A men’s doctor and a sexologist share solutions.
Erectile dysfunction is one of the most common health issues men deal with, especially as they age, but talking about this often-fraught topic is another story entirely.
Penis problems are a major taboo for men, and many of them will do just about anything to avoid confronting the issue. But that’s not good for anyone — including their partners — and things will never get better unless they’re addressed directly.
To clear up this complicated situation, we spoke to two professionals with ample experience in this arena to get the scoop on the medical problems behind erectile dysfunction, how they’re treated, how to navigate ED within your relationship, and more.
What are the health implications of erectile dysfunction?
According to Jesse Mills, MD, director of the UCLA Men’s Clinic and author of A Field Guide to Men’s Health, a patient’s erectile capabilities tell a much bigger story than simply how they’re performing in the bedroom.
“One question I ask every man who walks into my office is: Are you still getting up in the morning with erections?” Dr. Mills says. “That’s a very good indication of overall men’s health. We know that for an erection to happen, a guy has to have a good cardiovascular system, a good hormonal system, a good nervous system, and a good psychological system.”
It’s especially informative in terms of cardiovascular health. Many men who deal with erectile dysfunction, especially if they’re under 50, may also have an underlying cardiovascular condition that hasn’t yet been diagnosed.
“If you have a problem like cholesterol, it affects arteries everywhere,” Dr. Mills explains. “The artery that supplies the penis with an erection is a little bit smaller than the artery that supplies the heart, and the smaller the pipe, the quicker you’re going to have a problem. So if a guy has erectile dysfunction in that pipe, it could be that his coronaries or his brain aren’t too many years behind having a problem themselves.”
How does a doctor investigate erectile dysfunction?
Dr. Mills begins with an interview to learn more about the frequency and intensity of the erectile issues: Is the patient totally unable to achieve an erection, or is the problem that it’s not as strong or long-lasting as it used to be? The answer informs how a physician will approach treatment moving forward.
Then it’s on to the physical exam, which will include a heart check, blood work to assess risks for issues like high cholesterol or diabetes, and possibly a prostate exam, depending on age. (Dr. Mills says prostate screenings are generally recommended to begin between 45 and 55, depending on risk factors and family history.)
Testosterone levels are another important piece of the puzzle, and they can be affected by issues you may not realize are related, like the quality of sleep. “If someone’s not sleeping, then their brain won’t send the signal to the testicles to make testosterone, so guys that have poor sleep almost always have low testosterone,” Dr. Mills says.
The doctor will also conduct a genital exam, checking on testicular health and assessing any abnormalities. One thing Dr. Mills looks for is scar tissue on the penis, which could be a sign of a condition called Peyronie’s disease. If he finds anything, he may conduct an ultrasound to get more information.
What are the mental effects of erectile issues?
Erections may be a physical response, but an inability to maintain them has a substantial effect on the mind, too. Simply starting a discussion about it is delicate, says sexologist Shamyra Howard, LCSW, who frames the condition with her clients as “erectile dissatisfaction.”
“When people have issues with their penis, one of the stigmas associated with it is the word ‘dysfunction,’” she says. “When they hear ‘dysfunction,’ it makes the erectile issues they’re having feel compounded.”
In Howard’s experience, the mental effects can include issues with depression, anger, lack of confidence, and guilt about being unable to perform. Many men experience deep shame around what they perceive to be a personal shortcoming, which can also cause them to withdraw emotionally from not only their partner, but also their male friends. In fact, the concerns about how their issues will make them look to other men even extends to therapists.
“Men will go to a woman to talk about their erectile issues in therapy before they go to a man, and that’s been my experience and other colleagues’ experience as well,” Howard tells us. It all traces back to the way men are taught to define themselves by the size of their penis and how well (or how often) they use it. “They feel embarrassed talking about their penis issues with another man because a lot of them were taught to wear their egos in their underwear. So talking to a woman feels less threatening.”
One of the most common emotional effects is a feeling of inadequacy, and that doesn’t only apply to the person who’s having trouble getting erect.
“Their partner may think, ‘Oh my God, he’s not able to maintain an erection and it’s because of me. He doesn’t want me. What can I do to make his erections last longer?’” Howard says. “So now we have both people in the relationship feeling inadequate for the same reason.”
How should you talk to your partner about erectile dysfunction?
Whether the obstacles to erectile bliss are physiological, psychological, or some combination, the single biggest factor in successfully working through this as a couple is clear, open, and shame-free communication.
For the person who’s experiencing erectile dysfunction, one option is to state it plainly: “You can say, ‘Hey, I’m having an issue. I think I need to get it checked out, and I wanted to let you know,’” Howard says. “That opens up the conversation.”
It’s also helpful to connect it to how those issues may be affecting your significant other, too: “You can say, ‘I don’t know if you’ve noticed, but I’ve been a little distant from you sexually, and I want to talk to you about why.’”
On the flipside, if you’re looking for a way to bring up erectile problems with a partner who you suspect is dealing with them, Howard says it’s important to use “I statements” that center your own experience rather than “you statements” that put blame onto your mate.
“Saying ‘You have been rejecting me for sex’ is the wrong thing to do. You want to say, ‘I’ve been feeling a little distant from you sexually, and I want to talk about what’s going on with that,’” Howard explains. “Tell them you’ve noticed things are different and you want to discuss what you can do to help the sexual relationship.”
But you don’t have to jump blindly into such a complicated conversation. Howard says anyone whose partner is struggling with their erections could benefit greatly from speaking to a sex therapist themselves, to get support on what kind of language to use in your specific situation.
And while many couples may think the inability to maintain an erection means the end of their sex lives, Howard strongly disagrees. In fact, she frequently works with clients to redefine sex beyond a simplistic understanding that’s limited to penetration.
“Sex is a mental, physical, emotional, spiritual, erotic connection, so it can literally be whatever you want it to be,” she says. “It’s a big-game changer for people to explore other forms of sex like, outercourse or oral sex. Look at mutual masturbation or find different places in the house to be intimate. Do something in a different place that might feel risky. It’s all about increasing eroticism while decentering penetration.”
What is the treatment plan for erectile dysfunction?
The treatment most of us know of is ubiquitous for a reason, says Dr. Mills.
“The little blue pill is still an amazingly well-prescribed drug,” he explains. “Viagra has been around since 1998, and it’s generic, so you can go to your local superstore and get it for about 20 cents a pill.”
While Viagra is Dr. Mills’s “first-line therapy for anybody,” he adds that it doesn’t work for everyone, and if that’s the case, there are other options.
“One of the main things I do surgically is what’s called a penile implant, which is kind of like getting a knee replacement,” he says. “We make a small incision into the penis and insert two cylinders that inflate with saltwater. I hook it up to a reservoir and put a little pump in the scrotum, so every time he wants to have sex, he just pumps this little device, and magically his penis comes to life. It’s a great way to restore intimacy in men who have no other options that work conservatively.”
Unfortunately, medical intervention — whether it’s a pill or a procedure — can sometimes intensify men’s feelings of inadequacy because they bristle at the idea that they need help to perform. But Howard has a simple approach for helping patients deal with that concern.
“If a doctor said you need medication to keep your heart beating, would you say, ‘Oh man, I don’t want to take that because I want my heart to be able to beat on its own’? This is the same thing — it’s a body part, and we are going to experience a lot of issues with different body parts as we age and grow.”