Understanding the Mind-Body Erection Connection: A Man’s Guide to Conquering The Fear of Erectile Problems
(First of a series of 3)

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Despite every man’s wish to be completely potent throughout life, occasional erectile problems are a commonplace but upsetting event. By age 40, probably as many as 90% of men experience at least one erectile failure. This is a normal occurrence, not a sign of chronic erectile dysfunction. However, some men experience continuing erectile instability, leading to feeling depressed, anxious, or like a failure.

Statistics show that up to 30 million men in the United States may be affected with erectile problems (ED). If you experience ED, the first step is always get evaluated by a physician. ED may signal serious underlying disease, such as hypertension, cardiovascular disease, or diabetes. While researchers now feel that up to 80% of erectile problems are organically based (ie. they are based in some physical problem), 20% of erectile problems are purely psychologically based. Certainly, there are men with medical problems, which explain 100% of their erectile problems. But most sexologists now feel that even some predominantly medically-based ED has a psychological or a psychological/relational component.

With help from sexual health professionals, medications, and new medical treatments, most erectile problems can be successfully treated. However, if you are having erectile instability, there are things you and your partner can change in your behavior, whether or not you use medications or other medical treatments, which will increase chances of having more enjoyable sex and better and more reliable erections. Partner’s emotional and behavioral reaction to erectile instability can make a problem better–or worse!

Performance Anxiety

The role of anxiety in hindering erections has been long known. In 1970, Masters and Johnson highlighted the "profound role played by fears of performance." (1970, p 84). It is only recently, however, that we have become more clear about how erections occur in the body and how anxiety hinders the process on a physiological level. One behavioral phenomenon of performance anxiety is called "spectatoring." Men who have suffered with ED, undoubtedly have had the spectator experience. It refers to a problematic process where instead of being inside your body, enjoying all the sights and sounds of lovemaking and becoming aroused, you split off and become a spectator, worrying about failure and obsessively monitoring the firmness of your penis. And, the more you stop attending to arousing stimuli and focus on fear-provoking ones, the more limp the penis gets! David Barlow PhD, and his colleagues (1983 and 1984) have performed fascinating and ingenious studies proving cognitive interference and negative feelings such as anxiety are central facets of the psychology of ED. For example, Barlow et. al. found that men who experience erectile failure tend to underestimate the amount of erection response they are actually achieving, whereas functional men are more accurate in their estimation of their erections. Also, men who experience erectile failure tend to decrease their erection response when demands to get aroused are made, whereas men with no erectile problems experience the opposite.

With advances in medical treatment of ED many men who have psychological or mixedphysiological/psychological erectile problems have experienced increased confidence in their ability to maintain an erection. However, if your physician evaluates you and feels that any portion of your problem is psychological, it is worth addressing the psychology of your erectile fears. As we will discuss, when ED has a psychological component, your sexual functioning can be helped or hurt by you and your partner’s reaction to it.

This is particularly true if you are young and physically healthy. Young, healthy men need to learn to deal with their performance fears. Normal erect penises are not always rock hard. Normal penises get more and less firm during the course of a single lovemaking session. By using Viagra as a crutch or "insurance" with a new partner, you will never learn to become friends with your own, normal penis, and to deal with its ups and downs! Viagra is a godsend for the men who need it, but some men with perfectly normal erections are turning into long term Viagra users. What follows is a kind of "users guide" for having a friendly relationship with your penis. It should prove useful to both you and your partner.

The Mind-Body Connection

Once you understand the psychology and physiology of erections, you will understand what we will call the mind/body erection connection. You and your partner need to thoroughly understand the mechanics of erections, and why losing an erection does not mean a lack of love or sexual attraction. Once you understand this important information, we can begin talking about how to make any sexual situation less anxiety provoking and create a more erotic and successful sexual life for you together. Forget the notion that if a man is attracted, erections are "automatic"

The process of getting and maintaining an erection is a complex process which isn’t under a man’s conscious control. The body/ mind erection connection is crucial. In order to be successful with an erection, a man has to be sexually aroused but not worried. When a man gets worried, his "fight or flight response" kicks in, he gets tense, and his body gets bathed in adrenaline. The "fight or flight" response can be turned on unconsciously and automatically. It is part of what is called our sympathetic nervous system. The man’s tension and the adrenaline released in his body are a response to danger, and this physically makes it impossible to attain or keep an erection.

You need to understand a little bit about erections to understand the mind/body erection connection. One superb description of the complicated process of getting and keeping erections is found in Dr. Irwin Goldstein’s 1995 book, "The Potent Male." As Dr. Goldstein, a preeminent erectile dysfunction expert, notes, in most mammals, the shaft of the penis contains a slender bone which keeps the penis in a constant state of semierection. However, men do not have such a bone. Mens’ erections are achieved when the smooth muscles surrounding the spongy bodies inside the penis relax, and the spongy bodies are filled with blood. And to keep an erection, the smooth muscles must stay relaxed and the spongy bodies must store the blood until the sexual act is over . (At that point, the brain sends a message and the blood drains out.). In order for the erection to happen, a man has to be aroused sexually, but not worried.

In a male without a medical impairment, he will experience psychological confidence and lack of anxiety, paired with sexual arousal, and the parasympathetic nerves will cause a relaxation of the smooth muscle in the penis. The arteries expand, and blood flow into the corpora cavernosa increases enormously. The blood is trapped in the spongy bodies of the penis, holding the erection, because veins running through the tough sheath (the tunica) are compressed, trapping blood within the corpora cavernosa. The internal blood pressure in the penis increases, and the flow of blood into and out of the penis slows, creating a firm erection.

If a man is anxious or becomes distracted (and also after ejaculation) the sympathetic nerves take over from the parasympathetic nerves. Constricting neurotransmitters are released into the smooth-muscle cells, these muscles contract, and blood flow into the penis is pinched off, and so the erection is lost.

I always tell my patients this story, which may help you to remember the importance of the fight or flight response to erectile problems. Man’s tendency to lose an erection in the face of danger probably evolved as a strategy for survival. Imagine a two cave men, happily having intercourse, when a sabre-tooth tiger, snarling at the thought of a meal, ambles into the cave. The cave man, who kept his erection and kept on having sex, and his mate, were eaten by the tiger, and so no descendants!!

Once you understand the psychology and physiology of erections, you will understand what we will call the mind/body erection connection.

But imagine a cave man whose fight or flight response got turned on when the tiger walked in on him having sex with his cave lady. He got scared out of his mind. His body automatically made his penis go limp, so that he detached himself from his partner. His sympathetic nervous system then sent all of his blood into the large muscles of his legs and thighs, so that he could run like hell, away from the tiger. We can only surmise that the tiger chased him, sparing the lady, and not catching this cave man.
Of course, we are all descendants of the cave man who had the well-developed fight or flight responses. If you are having erectile problems which are in part psychological, you can see that being descended from the caveman with the well developed fight or flight response sometimes has its problems. Clearly, being eaten by a tiger is a life-threatening danger. But as we evolved into having bigger and bigger brains, our ability to worry about smaller things and to view them as perilous seems to have expanded.

Men who are having erectile problems no longer worry about being lunch for a big, wild animal, but they do worry about the size of their erect penis, it’s relative firmness, whether it will be firm enough to put on a condom. They worry about a partners’ disappointment, rejection, humiliation, or various other personalized inner dramas of past sexual distress. Any of these fears is enough to turn on that very same fight or flight response that helped our caveman forefather run away from the frightening, dangerous tiger. Thinking about this image of the two cavemen may help you remind yourself to try to avoid anxious thoughts during sexual interludes.

Dr. Goldstein’s Sponge Analogy

Dr. Goldstein paints this clever image as a simple way to remember how anxiety defeats erectile stability. It is an very effective image of important erectile mechanics, and an accurate way to think about why it is important for you and your partner to do things to minimize your anxiety during sexual and sensual encounters: If you want to make love, your goal is for the spongy bodies in the penis to fill up with blood. When everything is working well physically and emotionally, this is what happens automatically. But what happens to a man when there is fear or tension while making love?

Think about the fact that for a sponge to absorb water, it must be open, not squeezed tight, right? Now ask yourself, what happens to the muscles in your body when you get tense? They contract, right? (Many people feel tension as neck or back spasms, for instance.) Well, when a man gets anxious, the smooth muscles around the spongy bodies in the penis contract, and they squeeze all of the blood out of the spongy bodies of the penis. Lo and behold, the penis becomes flaccid!

(October 2001)