Erectile dysfunction or performance anxiety? This is not about sex, it is about shame

All men struggle to get an erection at some point in their lives

It was just as things were getting serious in the bathroom at a house party that an off-hand comment ruined the mood for Toby. The woman the 32-year-old was with remarked that he wasn’t hard enough for them to have sex. “It made me feel super-shit,” he says. “I’ve always had a bit of anxiety about my performance, so she hit a bit of a bedrock there, because I had been thinking about it before.”

Their encounter ended; he could no longer perform. That was in November 2017, but even after Toby started dating someone else, the problem persisted. “Every time I went to see my girlfriend, I’d be freaking out,” he says. “In my head I’m telling myself it’ll be fine, but there’s always a voice saying: ‘What if it does happen?’ Then it becomes a physical thing, and my body gets all hot and I feel startled inside. That’s usually a sign things won’t work out.”

Many believe erectile dysfunction (ED), also known as impotence, is becoming more prevalent in young men. According to the Irish Heart Foundation, 18 per cent of men aged 50 to 59, 38 per cent of men aged between 60 and 69 and 57 per cent of men aged over 70 suffer from the condition.

However, Nicole Prause, a neuroscientist who specialises in sexual behaviour, says there is little scientific and statistical evidence of a growth in the prevalence of ED. "When you look representatively, there has not been an increase in erectile dysfunction. I see stats all the time reading, 'It's increased 1,000 per cent in young men'. But there's no paper that says that."


What does seem to have increased is young men’s performance anxiety.

More men believe themselves to have ED, when they are actually anxious about their sexual performance. Under enormous social pressure to be smooth sexual performers, they are mistakenly self-diagnosing with ED after a few failed attempts to have sex. "If you look at the rise of easily accessible pornography, people have an expectation that men are going to be great performers," says Raymond Francis, a psychotherapist.

Nobody tells you how to have sex

"We are raised in a culture where men do not talk authentically about sex," says Paul Nelson, founder of Frank Talk, an online support group for men with ED. "Nobody tells you how to have sex – you just figure it out yourself from other teenage boys and porn."

Medical professionals report that many more young men are coming to them complaining of ED. "I have been treating patients for 30 years, and there's no doubt that we're seeing more young men today than we used to," says Dr Douglas Savage of the Centre for Men's Health, based in London and Manchester. "Often, these are men who appear to be super-healthy: they're slim, they exercise, they're young, and you think, 'why on earth have these people got sexual difficulties'?"

Whether it is as a result of drinking, stress or tiredness, the inability to get or maintain an erection will happen to most men at some point in their lives. Prause says that party drug culture and Viagra marketing have led men to pathologise occasional erection issues as something more sinister. “Everyone has erectile problems from time to time. It would be weird if you didn’t,” she says. “But with the drugs companies in the 90s, they started pushing the idea that any erection trouble is unacceptable.”

She mentions evidence that men who get Viagra prescriptions don’t refill them. “They’ve had a couple of bad experiences, so they panic. But then they don’t refill the prescription because they come to realise they’re fine.”

The problem with ED is that men can literally think themselves into having it: a few fumbled experiences can, over time, create a cycle of ongoing ED. “I see an increasing number of men under the age of 35 developing performance anxiety,” says Francis. “Shortly before the man finds himself in bed with his partner, the anxiety builds. The more he imposes a demand on himself, and the more that demand is not met, the more disturbed he becomes. It’s a self-fulfilling prophecy.”

I’d think: “Next time I see her, is it going to happen?”

It became a running joke in my life

Bradley, (24), used to worry every day about his ability to perform. Three years ago, in the course of a year-long relationship, he remembers sitting in front of the TV with his partner, unable to concentrate on what they were watching because a voice had begun in his head. It would say: “We’re going to try to have sex in about an hour,” and he wouldn’t be able to stop thinking about what would happen if he couldn’t get an erection. “I’d think: ‘Next time I see her, is it going to happen?’” he says. “It became a running joke in my life. Not one I found funny, though.”

Initially, Bradley’s ED developed because he felt anxious about his inexperience. “It was like: am I doing it right?”

His problems persisted, in part, because his partner had told him that she wasn’t looking for long-term commitment, but for a more casual relationship. “A part of me thought, in quite a disturbing and manipulative way, that if we could just be intimate, maybe I could win her over.” He sought treatment from the NHS, but this in itself was an unhappy experience. “No one ever takes the time to stop and recognise this is something that’s upsetting to you.”

One doctor told him, in effect: “Think happy thoughts and you’ll be fine.” Another was squeamish and didn’t want to talk about it. After a six-month wait, Bradley was referred to a psychosexual counselling service for therapy, which he found helpful, but by then it was too late: his relationship had crumbled under the strain.

Afterwards, the ED went away. “When it wasn’t a desire to be intimate with someone you loved, it helped a lot.”

ED can, perhaps counter-intuitively, be more of a problem in a committed relationship than in a casual encounter. It is the difference between having to give a speech in front of all the people you most respect in the world, or a group of strangers – which is going to make you more nervous?

These guys go on a date with Viagra in their pocket

Many see it as shaming to seek professional help for ED, so instead use Viagra as a judgment-free fix. “You find that these guys go on a date with Viagra in their pocket, as an insurance policy,” Francis says. But while carrying Viagra may prevent embarrassment in the bedroom, it can lead to other humiliations. Bradley was on a night out when he got searched by a bouncer, who discovered a Viagra pill in his pocket. “It was so mortifying, because the bouncer was like, ‘don’t worry – I know what this is’.”

When men feel like sexual failures, it can erode their identity. “Men are supposed to always want sex and be ready to go,” says Nelson. “When you don’t live up to that code, you’re excluded from the men’s club.”

In addition, those with ED are sometimes publicly pilloried. When prostate cancer survivor and former US senator Bob Dole fronted commercials for Viagra in the late 1990s, he was mocked mercilessly. Nelson says that, for young men in particular, ED can feel like "total humiliation. There's a profound feeling of being less than anyone else and broken. I hear that a lot."

Alex, a 22-year-old student, says it makes him feel empty. As a result, men who experience ED will often continue to speak about their sexual performance as if nothing is amiss. “It’s absolutely not something I would bring up with one of my mates,” says Toby.

Alex remembers sitting in a bar with his then-girlfriend and her friends, feeling paranoid. “You go out in town, and her mates are there and you think, ‘what if my girlfriend is telling her friends’?” He says he also became nervous about the possibility of his shame going viral online. “If it gets on social media, you’re screwed.”

Erectile dysfunction is, of course, not only a problem for straight couples. Luke is a 29-year-old marketing executive who has been in sexual relationships with men who have the problem. “ED is not spoken about at all in the gay community,” he says. “But it’s more prevalent than people think.”

He says men with erectile dysfunction sometimes turn to casual encounters facilitated via apps as a way to circumvent performance anxiety. “One partner I had was fully aware of his ED, but because apps are very transactional, he felt like he didn’t have to explain himself to me. It’s less embarrassing, because it’s someone you don’t know or care about. You don’t mind that person realising, because you’re just trying to satisfy a need.”

At the end of the day, a man is there to perform

Other gay men may deal with the performance anxiety by identifying as “bottoms”. “They can’t get it up, so they label themselves the bottom,” says Luke. “Just like how ED is emasculating in the heterosexual world, it’s the exact same in the gay scene. At the end of the day, a man is there to perform.”

As a bottom, his experience of erectile dysfunction – typically in casual encounters – has sometimes caused him to question his sexual desirability. “You think to yourself, ‘maybe I’m not attractive enough for the person’.”

At the same time, dating men with ED has had some unexpected positive side-effects. “If you really like that person, it allows the relationship to develop differently, in a good way,” Luke says. “It desexualises the relationship a bit, which is something that’s lacking in the gay world, where everything can be a bit, ‘wham-bam, thank you ma’am’.”

Still, the male omerta around ED runs deep. After we speak, Toby texts me, begging me to delete his number and never contact him again. Others will only speak to me in euphemisms. Many men find support in anonymous online communities: 50,000 men visit Frank Talk each month. Nelson says it is a space where men isolated by their ED can stop feeling “so alone”.

While psychotherapy can help with anxiety-related ED, in many cases there is, in fact, a physiological cause. If the ED is hormone-related, testosterone therapy is an option, and recent research has indicated there is a genetic component to some cases, raising the prospect of new, gene-based therapies in the future. On online forums, meanwhile, men talk about the psychological devastation of “pushing rope” (trying to have sex when the penis is not fully erect).

“Because you’re depressed, you’re thinking, why me?” Alex says. “Especially for someone my age (early 20s). You’re just a recluse in your bedroom, not getting anything out of life. My girlfriend was miserable. I just felt like I was letting everyone down.” Eventually, his girlfriend told him she wanted to meet other men on Tinder. “It just put my self esteem so low.”

At his lowest point, over Christmas 2017, Alex was desperate. “Watching your relationship fall apart, your education go downhill, you’re not working any more and contemplating going on benefits . . . I felt suicidal. I’m not going to lie: I was in a bad, bad place.”

He and his girlfriend eventually broke up. “I think she just had enough.”

As Luke points out, ED can be distressing for the partners, too. “It’s so hard to divorce yourself from the fact that they’re looking at you naked, and they can’t perform,” says Megan, (29), who dated a man with ED. “Girls are always insecure about their bodies anyway.”

She says, despite the worst fears of men with ED, she would never have joked about it with her friends. “I had such a sense of shame.”

Before I began researching this article, I expected it to be a story about sex – or the lack of it. But shame is the word that actually came up most often. For men, it seems that not being able to get an erection can feel like the most shameful thing that could happen to them. After psychotherapy and hypnosis to address the anxiety underpinning his sexual dysfunction, Toby’s ED is gone. “I do still worry it will come back, but things are great now and I’m having amazing sex.”

But even though he has recovered, he would still never breathe a word of it to his peers. Recently, at a wedding, a friend drunkenly cornered him at 5am. “He said he’d been struggling, he’d been freaking out, and he’d gone from using Viagra when he was a bit blasted, to taking it all the time.”

Toby sympathised and suggested that he speak to a professional. But did he mention that he’d had ED himself and knew a therapist who could help? “I know it’s pretty selfish,” Toby says, but he kept his own story to himself. “I just don’t want him to tell any of our friends.” – Guardian