Answered: can anxiety cause erectile dysfunction?

The modern world is accelerating at such a dizzying pace that it’s almost impossible not to feel anxious. Whether your anxiety is caused by modern-day job hunting, social media, existential anxiety or society’s diverse pressures, it can have a significant effect on your sex life. 

Anxiety can make it difficult to get and maintain an erection. Both general anxiety and more specific kinds of anxiety like performance anxiety (the worry that you won’t be able to sexually satisfy your partner) can tank your sex drive and make it harder to get aroused. ¹

But don’t worry. Sexual performance anxiety affects somewhere between 9% and 25% of men, so if it feels like something that only happens to you, it isn't.¹

How anxiety stops an erection

An erection needs the smooth muscle inside your penis to relax. When it relaxes, blood flows in and stays there. That's the whole mechanism.

Anxiety does the opposite. It switches on your sympathetic nervous system, the fight-or-flight response, which floods your system with noradrenaline. Noradrenaline makes that same smooth muscle contract. So the tissue that needs to relax for an erection is being actively told to tighten.¹

Which is why willing it harder doesn't work, and often makes it worse. The effort itself is the problem. Your body can't run the fight-or-flight response and an erection at the same time, and in that argument fight-or-flight wins every time.

The cycle, and why it feeds itself

It usually starts with one night that didn't go to plan, and there are a hundred ordinary reasons for that. Too much to drink. Exhausted. Distracted. New partner. Not really in the mood but going along with it anyway. Sound familiar?

Then the next time, part of your attention is on whether it'll happen again. That's enough. You've moved from being in the moment to monitoring yourself from the outside, and monitoring is an anxious activity. So the thing you're worried about becomes more likely, which gives you more to worry about next time.

Sexual performance anxiety isn't formally recognised as a diagnosis in its own right, but it's understood to cause, worsen, and maintain most of the common sexual difficulties men experience.¹ Maintain is the important word. The cycle keeps itself going long after whatever started it has gone.

Is it anxiety, or is it something physical?

Erectile dysfunction is a recognised early sign of cardiovascular disease. The arteries in the penis are considerably narrower than those in the heart, so they show the effects of vascular damage earlier, and problems with erections can precede a cardiovascular diagnosis by several years.²

The pattern gives you a hint - difficulty that comes on suddenly, happens only in some situations, varies between partners or between sex and masturbation, and leaves your morning erections intact tends to point towards a psychological driver. Difficulty that came on gradually, happens every time regardless of situation, and comes with your morning and overnight erections fading or disappearing tends to point towards a physical one.

However, normal morning erections don't rule out a physical cause, and the two frequently overlap. A physical problem starts it, anxiety keeps it going.³ So the pattern is a useful thing to notice and describe to a clinician. It isn't a reason to skip the conversation.

If it's been happening consistently for a few months, get it checked properly. An at-home blood test checks for key physical markers that are related to erectile dysfunction, including low testosterone, high cholesterol, and diabetes.

What helps in the moment

Take the outcome off the table: Not as a mindset exercise, as an actual agreement. Deciding in advance with your partner that sex doesn't have to end a particular way removes the thing you're monitoring for. It's the single most useful change most men make.

Come back to sensation: Anxiety lives in your head, and it's very hard to be in your head and body at the same time. Attention on touch, sound, physical sensation is attention that isn't available for self-monitoring. This is the principle behind mindfulness-based approaches, and it's the one with the most evidence behind it.^1,4

Say something: Silence lets your partner fill the gap with their own explanation, which is usually worse than the truth and adds pressure you don't need. Most partners are far less concerned about it than you are.

Look at the alcohol: Drinking to take the edge off anxiety works on the anxiety and works against the erection. It's a common combination and it's often the whole story.

What helps longer term

Cognitive behavioural therapy: A talking therapy that works on the thought patterns keeping the cycle going. The evidence base for CBT in anxiety disorders is substantial,⁵ and it's recommended in UK guidance as a first-line treatment for anxiety.⁶ You can refer yourself to NHS talking therapies without going through your GP.⁷

Mindfulness-based therapy: Structured training in attention and awareness rather than an app you open twice. Studies put it as a moderately effective treatment for anxiety,⁴ and it's been identified as one of the approaches with genuine potential specifically for sexual performance anxiety.¹

Medication for the anxiety itself: UK guidance generally recommends trying psychological treatment first, but medication is an option and it works for plenty of people.⁶ That's a conversation with a doctor rather than a decision to make from a website.

Sex therapy or couples therapy: Worth considering if the cycle has been running long enough to affect the relationship, which it often has by the time someone starts searching.

Where ED medication fits

PDE5 inhibitors, the group that includes sildenafil and tadalafil, are effective in erectile dysfunction with a psychological cause, not only a physical one.¹

They work on the blood flow side of the equation regardless of what started it.

What they don't do is treat the anxiety. If anxiety is the driver, the medication addresses the symptom while the cause carries on, which is why it's usually most useful alongside one of the approaches above rather than instead of them. For some men, having a few reliable occasions is enough to take the monitoring away, and once that's gone the cycle loses its fuel.

They aren't right for everyone, particularly alongside certain heart medications. But that's what the assessment is for.

The numan take

Anxiety and erections run on opposite systems. One needs your body relaxed, the other has it braced for a threat, and they can't both have the floor.

The frustrating bit is that the cycle keeps going on its own. Whatever started it usually stopped mattering a long time ago, and what's left is the monitoring.

Which is also the hopeful bit. Cycles that maintain themselves can be interrupted, and this one responds to several different approaches. Get it looked at physically too, then pick a route and give it more than one attempt.

References

^{1 Pyke RE. Sexual performance anxiety. Sex Med Rev. 2020;8(2):183-190.}

^{2 Yannas D, Frizza F, Vignozzi L, Corona G, Maggi M, Rastrelli G. Erectile dysfunction is a hallmark of cardiovascular disease: Unavoidable matter of fact or opportunity to improve men’s health? J Clin Med. 2021;10(10):2221.}

^{3 Zou Z, Lin H, Zhang Y, Wang R. The role of Nocturnal Penile Tumescence and rigidity (NPTR) monitoring in the diagnosis of Psychogenic Erectile Dysfunction: A review. Sex Med Rev. 2019;7(3):442–54}

^{4 Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78(2):169-183.}

^{5 Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.}

^{6 National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline CG113. NICE; 2011, updated 2020.}

^{7 National Health Service. NHS talking therapies for anxiety and depression. NHS.}