The pioneering work of Masters and Johnson in the 1970s shed significant new light on the possible causes of sexual dysfunction. Their publications emphasized the influence of religious orthodoxy, fear of failure, homosexuality, and maternal influence as contributors to erectile dysfunction (ED). Subsequent theories considered additional psychological factors such as the man’s “thinking” about sex, negative self-image and expectations, the partner’s needs and preferences, and the influence of marital conflict on sexual function. Recent studies have stressed the importance of not only anxiety, but also various physical conditions as major causal factors in ED. Although about two-thirds of the causes of ED are organic, psychogenic issues are still a critical part of male sexual dysfunction, and experts have not completely forgotten them. Psychosocial, lifestyle, demographic, marital, developmental, religious, and pharmacological factors may play a major contributory role in ED’s initiation or persistence, whether alone or, in a substantial number of cases, as a response to the sexual dysfunction. Emotional reactions to sexual dysfunction may be severe and should be addressed seriously in both the diagnosis and management of this devastating condition.
Erectile failure may occur at any time during a man’s development. He may acquire a poor self-image, low self-esteem, diminished sense of confidence, or desire to engage in perverted sexual practices. He may be overwhelmed by a domineering parental figure or influenced by religious fanaticism. A single episode of failure to perform may lead to a repetitive cycle of fear and failure, ultimately resulting in sexual dysfunction. Depression, anxiety, guilt, stress, worry, and relationship disturbances can affect sexual desire and may lead to ED. Additionally, psychogenic ED may be triggered by drug and alcohol abuse, or even (more rarely) by guilt and despair resulting from a vasectomy or by sexual abuse during childhood. Prominent psychologist J. LoPicollo (1991) groups psychogenic issues that could affect male sexual functioning into two overall categories. In the first, he lists factors related to a man’s personality, attitude, expectations, interest in sex, implicit or explicit demands for sex, attentional focus on erotic cues, sexual arousal, character, upbringing, psyche, and sexual behavior. Men having trouble with these factors include, for example, obsessive-compulsive individuals who have difficulty showing emotions during sex, those who find bodily secretions unpleasant, depressed men, those with sexual phobias or vaginal aversions, those who fear a loss of control over sexual urges and potential disastrous consequences, those with sexual deviations, and those who are concerned about aging. LoPicollo s second category encompasses disturbances in the relationship between the man and his sexual partner: marital conflict, loss of attraction, poor sexual skills, fear of closeness, so-called mismatched couples, domineering partners with excessive demands, and an inability to fuse feelings of love and sexual desire. The effect of sexual dysfunction on a relationship is devastating and destructive in most cases and affects both partners.
To better understand the various factors underlying psychogenic sexual dysfunction, we can apply, with some alterations, the model proposed by R. Basson et al. (2003), who divides predisposing, precipitating, and maintaining factors from contextual or immediate conditions that affect the outcome of a sexual encounter.
Predisposing factors involve sexual interest and desire, physical attraction, relationship dynamics, love and intimacy, and past life experiences. Constitutional factors, such as inborn anatomic, vascular, neurologic, and hormonal characteristics, as well as the individual’s personality and temperament also play an important predisposing role in future patterns of sexual function and behavior.
Additional developmental factors, which include gender identity development; past painful, humiliating, or traumatic sexual experiences such as rape or abuse; and hormonal imbalance causing premature or delayed puberty, may contribute as well to the shaping of future sexual function or dysfunction. Other important predisposing factors include religious, cultural, familial, social, and educational influences and personal views about sex.
Within that congenital and acquired physical and psychological framework, an individual may react negatively to certain precipitating factors, possibly impairing his or her sexual performance and desire. Among the most common psychogenic factors that may precipitate episodes of sexual dysfunction are performance stress, anxiety, depression, psychological disturbances, and relationship problems. These may all share a common pathophysiology such as a change in the inhibition of the parasympathetic nervous system, which normally stimulates the secretion of nitric oxide; alternatively, they may all lead to overactivity of the sympathetic nervous system, thereby constricting the penile arteries and precluding the development of normal erections.
Anxiety can produce cognitive distraction and reduce sexual arousal. Depression is generally linked with sexual dysfunction in a bidirectional way, which means that just as depression maybe responsible for sexual impairment, the sexual dysfunction itself may also exacerbate the depression—especially with the use of certain antidepressive medications, which may worsen the sexual symptoms. Other precipitating factors include recent childbirth, infertility, divorce, financial problems, adultery, unemployment, a poor relationship, a traumatic sexual experience, loss of a beloved family member, issues related to homosexuality, poor personal hygiene, physical repulsion, or the partners own sexual disturbances or ineptitude.
The most common factors in maintenance of sexual dysfunction beyond the original episodic disappointments are relationship disturbances, lack of intimacy, guilt feelings, performance anxiety, poor sexual education, and lack of communication. Other factors that play a pivotal role in the maintenance or persistence of sexual problems include lack of sexual experience, inadequate sexual stimulation, physical repulsion, fear of intimacy, psychiatric disorders, and loss of sexual chemistry.
I must emphasize the importance of a solid personal relationship and intimacy between partners for the success of their sexual relationship. The sexual disturbances of one partner may cause sexual problems for the other, compounded with loss of desire, feelings of guilt, anger, loss of self-confidence, and sometimes the urge to seek extramarital experiences or divorce. There may, of course, be some cultural and even gender discrepancies regarding the importance of love in sexual satisfaction and marital success, but in the Western world, the majority of men and women believe that deep affection, respect, emotional intimacy, and feelings of love are essential ingredients in optimal sexual pleasure and satisfaction.
Immediate contextual conditions that may affect the success of a sexual encounter include privacy, motivation and receptivity for sex, lack of sexual skills, environmental constraints, financial difficulties, physical or mental disease, emotional disturbance, anger, disrespect, ignorance or disregard of the partner’s sexual preferences, premature ejaculation, and painful sexual intercourse.
Different schools of thought consider the psychological factors underlying male sexual dysfunction in a variety of ways (Hanash et al. 1994):
Psychoanalytic theory proposes that during the period of psychosexual development (mental, emotional, and behavioral) between the third and fifth years of life, a boy wants to possess his mother, views his father as a rival, and fears that discovery of his feelings by his father would result in severe punishment. Therefore these sexual desires are repressed and kept subconscious as the child tries to identify with his father. This is called the Oedipus conflict. According to this theory, these early incestuous wishes and desires are carried into adulthood, along with fear and guilt, when the conflict is not successfully resolved in normal psychological development and maturation, and therefore a man’s sexual disturbance or dysfunction is believed to be a defense against what he perceives as unacceptable childhood feelings. Psychoanalytic theory also contends that exposure to strict religious precepts condemning sexuality as sinful, shameful, and dirty eventually creates sexual difficulties. A psychiatrist of this school of thought would work with a patient to resolve these inner conflicts through interpretation and insight therapy.
Learning theory contends that psychogenic sexual dysfunction is related to faulty learning and upbringing. For example, a boy who fears sexual expression because of the Oedipus conflict mentioned previously may later become impotent as a man; a boy who was punished for having sex may become impotent when he is exposed to a subsequent sexual experience; or a man who fears his sexual partner may learn to deal with that fear by avoiding sex. In other words, men who have negative experiences associated with sexual expression unconsciously try to avoid the anxiety engendered by such experiences, and ED or other sexual dysfunction can result.
System theory, on the other hand, proposes that male sexual dysfunction is the result of a destructive relationship between the sexual partners. One of them may have a powerful urge to inflict pain, hurt, or humiliation on the other. Or, if a woman is feared to he “castrating” by her partner, or if her sexual needs are not met, her attitude and behavior can trigger insecurity, fear, and feelings of inadequacy in her partner, which can lead to anxiety and give rise to his ED.
Although there are legions of psychological causes for ED, four principal factors can be clearly identified: stress, anxiety, depression, and marital conflict. Stress is how we react physically and emotionally to situations around us, how we respond to the changes, challenges, and unexpected events in our lives. Stress can be positive or negative. Positive stress helps us focus our energies, concentrate, and be productive but it is positive only as long as we feel in control of the situation and as long as we can balance our stress with relaxation. Stress becomes negative when it is so constant, overwhelming, frustrating, or out of control that we cannot achieve the relaxation necessary for maintaining good mental and physical health. Uncontrolled stress can produce problems such as muscle tension, heart disease, stroke, high blood pressure, headache, backache, gastrointestinal problems, and sleep disorders; it can also cause either organic or psychogenic sexual dysfunction.
Anxiety’s physiological manifestations, and the failure of the man’s defenses to prevent or control it, may lead to sexual dysfunction that persists until the mental or intrapsychic conflicts producing the anxiety are resolved. Anxiety is a major cause of psychogenic ED. Although it is hard for women to understand it, many men are scared during the sexual act with fear of not being able to perform adequately and to match up with other men or to provide maximum pleasure to their partners, or to fail to develop or maintain an erection or to ejaculate quickly. This stress may preclude the expression of emotions and romantic feelings on his part, except maybe after the completion of a successful intercourse, when he feels relaxed. In contrast to women, who enjoy caressing and fondling all over their bodies for sexual excitation, a man needs reassurance about the quality of his erection, which is usually provided by direct caressing of the penis, which would also increase its firmness.
So-called performance anxiety, which differs from general anxiety, is also considered a major cause of psychogenic ED. In cases of performance anxiety and male sexual dysfunction, the man’s concern about his sexual performance and fear of failure produces a state of anxiety, to which other intrapsychic conflicts are not significant contributors. (This distinction is important for the therapeutic approach.)
Depression is common to almost everyone. Most of us have sometimes felt down or blue, especially if we have had a particularly hard day or if we have been under pressure. It usually passes, though, and with a new day comes a brighter mood. Some people, however, cannot just snap out of it, and for them, depression can become a real and serious psychological disorder. It can also be a major cause of sexual disturbances, which in turn can worsen the depressive state.
Erectile failure produces psychological reactions in the male that cut across cultural, racial, and socioeconomic lines. A man’s self-esteem, confidence, sense of manhood, and feelings of virility rely heavily on his erectile ability. A man who experiences the loss of an erection often feels that he is no longer a man. This can create frustration, loss of self-confidence, anger, humiliation, and shame—and any ensuing depression may well lead, unfortunately, to the development of ongoing ED.
83 Types of depression range from a mild passing condition to complete debilitation. Symptoms and signs can overlap, but some are unique to each type. Depressed people are usually blue, hopeless, irritable, and often tired. They tend to avoid social encounters, have trouble sleeping, and have little appetite. Generally, they have a decreased interest in sex. Sometimes they cry for no apparent reason and may even have thoughts of suicide. Just because a person has trouble sleeping, however, does not mean he or she is depressed. A psychologist looks for several symptoms that occur consistently over time before making a diagnosis of depression. Research also notes that men with ED and diabetes have a higher incidence of depressive symptoms and a negative health perception.
Depression affects all areas of an individual’s life, including sexual interest and performance. Its treatment varies according to its nature and severity and may involve pharmacotherapy, psychotherapy, behavior modification, electroshock, or rational emotive therapy. Psychiatrists often prescribe antidepressant medications for patients with severe depression. Ironically, some of these medications may themselves cause sexual dysfunction.
Not surprisingly, research indicates that negative events, such as divorce, professional problems, financial difficulties, relationship difficulties, and marital conflicts, may contribute to psychogenic ED (“Proceedings of the First Latin American” 2003). Projections of self-doubt, inadequacy, and lack of trust carry over into a sexual relationship, and any negative perceptions that an individual carries about himself and/or his partner may contribute to poor sexual performance. A relationship charged with discord and deep conflict can be a major cause of male sexual dysfunction. Rejection of or by a partner is another common cause of ED. Conflicts occur in most close relationships, and marriage, as a long-term commitment, is not easy. Married couples often report reduced sexual desire, avoidance of sex, or erectile and ejaculatory problems.
Some reasons for conflicts in a marriage or relationship are unspoken expectations, inability to communicate effectively, jealousy, children and their demands, desire to change one’s partner, self-image, appearance, obsession with performance, or simply the realities of life’s day-to-day routine. Power struggle, sexual mismatch, dependency, distortions, financial problems, and lack of love, affection, and respect may all lead to sexual problems. Therapists and researchers often cite other causes for the development of sexual dysfunction within marriage, including alcoholism, infidelity, unfulfilled emotional needs, financial difficulties, and domineering or suspicious spouses. Any of these may lead to a marital breakdown, which in turn affects the couple’s sexual attitudes and behaviors with each other.
Many therapists claim that the relationship disturbance is not so much because of the conflicts themselves, but rather because of the couple’s lack of skills to handle them; that is, the real problem lies in the mode of interaction between the two people, rather than in either of them separately. An attempt by one partner, unskilled in effective communication, to bring about a behavior change in the other may severely strain the relationship. For example, a woman who wants to be flattered more by her husband may withhold sex until he complies. Her approach of punishing him to get her wish may be effective in the short term but ultimately harmful.
Other psychosocial factors that may diminish sexual performance and desire include feelings such as fear, blame, shyness, and hostility; drug abuse or side effects of certain medications; and dissatisfaction with one’s own body (as in cases of micropenis or marked obesity). A person’s feelings about his or her body and physical appearance certainly influence the nature of his or her sexual activity. Embarrassment over the shape, size, or look of the genitalia or breasts, for example, interferes with successful fulfillment and enjoyment of the sexual act.
Some men are unable to abandon themselves to erotic pleasure and sexual feelings. A man’s excessive self-observation and preoccupation with his sexual performance changes his role in sex to that of a spectator, rather than a full participant, which can impair his sexual functioning and may lead to erectile difficulties. Conflict about sexual identity, preference, and orientation may also impair sexual functioning.
A domineering or overly strict parent, a failure during early sexual encounters, and trying too hard to impress a partner are other contributors to psychogenic sexual dysfunction. In young men, homosexuality, religious orthodoxy, and sexual ignorance or misconceptions that may originate in a strict upbringing or misleading playground talk are among the most common psychogenic causes of ED.
Some young men may experience total or partial ED on their wedding night or during their honeymoon. This may have a devastating effect on the man and his partner. In the past, the majority of these cases were attributed to psychological factors such as deep anxiety, excessive masturbation, ignorance, and fear of failure. Recent studies, however, have demonstrated the presence of vascular causes in about a third of these cases. Treatment with the phosphodiesterase type 5 inhibitor Tadalafil or the self-intracorporeal injection of Alprostadil or Trimix has been highly successful.
A man’s ED can sometimes be related to a lack of emotional or sexual intimacy with his partner, or perhaps to his partner’s lack of sexual experience. Female sexual dysfunction, including poor libido, vaginismus, vaginal or intracoital disturbances or pain syndromes, urinary incontinence, comorbidities such as chronic systemic diseases, and overriding emotional or physical concerns, can contribute to her partner’s ED, but these possible factors are often neglected during the evaluation of male patients (Singer AJ 2006).