Performance Anxiety and Erectile Dysfunction: Why the Problem Is Rarely What Men Think It Is
Dr Ben Davis | MRCGP · MRCP · FECSM · RegCOSRT · PhD (Men's Health) GP, Men's Health Physician and COSRT-registered Psychosexual and Relationship Therapist Central Health London, Devonshire Place, Marylebone
Performance anxiety affects men of all ages — and is almost always treatable
The man in his late 20s who loses his erection the second things get serious. The man in his 40s who is fine on his own but can't reliably perform with a partner. The man who has tried Viagra, tried abstaining, tried watching less porn — and still finds himself caught in the same loop, each failed encounter making the next one feel a little more loaded than the last.
I see men like this regularly. Performance anxiety is one of the most common things I work with — and one of the most misunderstood, both by the men experiencing it and, often, by the clinicians they've already seen.
If you recognise yourself in any of the above, I hope this is useful. It's an attempt to explain what is actually happening, why conventional approaches often fail to resolve it, and what genuinely tends to help.
What Performance Anxiety Actually Is
Sexual performance anxiety is not simply nervousness before sex. It is a self-sustaining psychological loop in which the fear of not performing becomes the primary cause of not performing.
It works like this: a man has a difficult sexual experience — perhaps an erection that fades at the wrong moment, or a first encounter that goes badly. The experience is uncomfortable enough that he approaches the next encounter monitoring for it. That monitoring — the mental stepping-outside-oneself to watch and evaluate — is precisely what disrupts the conditions that allow arousal to develop naturally.
Masters and Johnson, whose work on human sexual response remains foundational, named this process spectatoring: the tendency of anxious men to become observers of their own penile function rather than participants in the sexual experience.1 Once a man is watching himself, he is no longer in the experience — and arousal, which depends on presence, begins to fade. The erection falters. The fear intensifies. The loop tightens.
What makes this particularly difficult is that the loop is self-validating. Each difficult encounter becomes evidence that the problem is real and worsening, which increases the vigilance that caused the difficulty in the first place. Men often describe it as a split between two versions of themselves in bed — the one trying to have sex, and the one standing in judgement of how it's going. I hear this described in different ways, but the shape of it is almost always the same. That internal division, not any physical failing, is usually what is sustaining the problem.
The Role of Shame
Shame is not the same as embarrassment or guilt. Embarrassment and guilt are about what you did. Shame is about what you are.
It's a distinction that matters enormously in this context. When erection problems develop, most men do not think I had a difficult experience. They think something is wrong with me. That shift — from event to identity — is the move into shame, and it changes everything about how the problem is held and whether a man seeks help.
Brené Brown's research on shame identified a consistent pattern in men: the central organising fear is not being perceived as weak.2 Sexual difficulty — particularly anything involving the penis — activates this directly. The result is that men tend to carry erection problems in isolation, often for months or years, before speaking to anyone. The shame drives secrecy. The secrecy prevents help. The problem deepens.
Shame also shapes what happens in the room when men do seek help. Many arrive having prepared a carefully clinical account of their symptoms — because presenting it as a medical problem feels safer than presenting it as something that has made them feel inadequate or frightened. I notice this often in first appointments: a man who is clearly articulate and self-aware, describing his difficulty in terms that keep the feeling at arm's length. Getting past that — to the actual impact on self-worth, on relationships, on how he feels about himself — is often where the most important work begins, and it tends to happen once he realises the room is genuinely safe enough for it.
Shame Containment: Why "Just Relax" Doesn't Work
A common response to performance anxiety — from partners, from friends, from some clinicians — is to suggest that the man simply relax, worry less, or take the pressure off. This is rarely helpful and sometimes actively harmful.
The reason is that shame cannot simply be reframed or reasoned away. It operates below the level of conscious thought, in the part of the nervous system that monitors threat and regulates safety. When a man is caught in a shame loop around sexual performance, telling him to relax activates the very self-monitoring it is meant to dissolve. He is now watching himself trying to relax, aware that he is failing at that too.
Shame Containment Theory, developed from clinical research into shame and sexual difficulty, reframes shame not as a deficiency or a personal failing but as a protective response — something that developed for comprehensible reasons, often rooted in early experiences of exposure, judgement, or inadequacy, and that has persisted because it has never been given space to be understood differently.3 The therapeutic task is not to eliminate shame but to change the relationship with it — to create a space in which it can be acknowledged without it becoming overwhelming or defining.
This is why the relationship with the clinician matters as much as the technique being used. Shame cannot be addressed in a clinical vacuum. It requires a space that is genuinely safe — not just professionally appropriate, but warm, non-judgemental, and experienced enough with male sexuality to understand what is being communicated beneath what is being said.
Compassion Focused Therapy and the Threat System
One of the most clinically useful frameworks for understanding performance anxiety is Paul Gilbert's model of three emotion regulation systems: the threat system, the drive system, and the soothing system.4
The threat system evolved to detect danger and mobilise a response — fight, flight, or freeze. It is fast, involuntary, and not easily overridden by conscious reasoning. In men with performance anxiety, the sexual encounter itself has become a threat stimulus. The body responds accordingly: adrenaline rises, attention narrows, and the parasympathetic conditions that allow erections to develop are actively suppressed. This is not weakness. It is the nervous system doing exactly what it has been trained to do — which is also why telling someone to "just relax" is so unhelpful. You cannot reason your way out of a threat response.
Compassion Focused Therapy (CFT), developed by Gilbert specifically to address shame and self-criticism, works by activating the soothing system — the neurobiological circuitry associated with safety, warmth, and connection — as a counterweight to that chronic threat activation.5 In the context of performance anxiety, this means developing a genuinely different relationship with the experience of difficulty: one characterised by curiosity and self-compassion rather than self-surveillance and judgement.
CFT has a growing evidence base across presentations involving shame and self-criticism, and I find it particularly useful in psychosexual work where those patterns are central.6 What I like about it clinically is what it doesn't ask men to do: it doesn't ask them to think positively, or push through, or reframe their way to confidence. It asks something more honest — that they relate to their own struggle with the same understanding they might offer to someone they care about. For many men, that is genuinely novel.
When the Past Is Present: EMDR for Sexual Anxiety
Not all performance anxiety is rooted in a straightforward anxiety loop. For some men, the difficulty is connected to earlier experiences — a humiliating sexual encounter, a shaming response from a partner, a childhood or adolescent experience that attached fear or shame to sexuality before it had a chance to develop naturally.
When that is the case, the anxiety in the present is not primarily about what is happening now. It is the past intruding into the present — a conditioned response that developed at a specific moment and has been generalised ever since. Standard therapeutic approaches that focus on the present-day loop may help partially, but they do not reach the original experience that is driving it.
Eye Movement Desensitisation and Reprocessing (EMDR) is a structured therapeutic approach, originally developed for trauma, that works by facilitating the reprocessing of distressing memories that have become stuck and continue to intrude into present experience.7 In the context of sexual performance anxiety, EMDR can be used to target the specific memories — the first failed encounter, the partner's reaction, the moment of humiliation — that have become the anchors of the current difficulty.
The aim is not to erase the memory but to change its emotional charge: to allow it to be held as something that happened, rather than something that is still happening every time a man enters a sexual situation. Men who have tried conventional sex therapy without lasting improvement sometimes find that EMDR reaches something that talking-based approaches did not.
Who You See Matters
There is something practical worth saying here, even if it is difficult to quantify.
Shame lives in the gap between how we feel and how we think we are supposed to appear. For some men, that gap is wider in certain rooms than others. I have had men tell me — sometimes in a first appointment, sometimes only after several sessions — that they had wanted to seek help for years but couldn't find a clinician they felt certain would genuinely understand. Not just clinically, but in terms of what male sexual experience actually feels like from the inside: the pressure, the way identity gets tangled up in performance, the particular weight of feeling like your body has let you down in a specifically male way.
I can't make a general evidence-based claim about which kinds of clinician are easier to speak to for which kinds of man. What I can say is that comfort matters — because shame cannot be worked with if it cannot first be spoken, and whether a man feels able to speak honestly depends significantly on whether he trusts the space he's in.
What I offer is a space that is medically rigorous, psychotherapeutically informed, and genuinely comfortable with male sexuality in all its complexity — without judgement, and without the need for anything to be explained or justified. Many men find that enough to say things they have not said anywhere else. That, in my experience, is usually where things begin to move.
The Erotic World: Why What Turns You On Matters Clinically
Performance anxiety is almost always discussed as if the problem is purely mechanical — a failure of arousal in a context where arousal is expected. But arousal is not a generic response to sexual opportunity. It is highly specific, shaped by each man's erotic world — the particular set of desires, images, dynamics, and conditions that actually generate his arousal.
Jack Morin, in his foundational work The Erotic Mind, proposed the concept of the Core Erotic Theme: the underlying pattern of conditions that reliably produces a man's most intense arousal, often consistent across his lifetime and traceable to formative experiences.8 His erotic equation — attraction plus obstacles equals excitement — captures something important: that arousal is not simply the absence of anxiety, but the presence of something that specifically ignites it. Men are not aroused by sex in the abstract. They are aroused by specific things, in specific contexts, with specific emotional textures.
This matters clinically for several reasons.
Research consistently shows that male sexual arousal is more category-specific than female arousal — more narrowly organised around particular stimuli, less context-dependent, and more tied to visual and psychological triggers that are relatively fixed.9 This is not a moral observation. It is a psychophysiological one, with implications for how erection difficulties develop and how they are treated. A man whose erotic world is not present in a particular encounter — because the dynamic is wrong, the partner is wrong, the context feels unsafe, or the conditions that usually ignite him are absent — may find that erections are unreliable regardless of how relaxed he is. That is not performance anxiety in the conventional sense. It is an erotic mismatch, and treating it as anxiety will not resolve it.
Erotic conflicts add another layer. Many men carry internal tensions between what arouses them and what they believe they should be aroused by — conflicts rooted in shame, moral frameworks, relationship expectations, or the gap between fantasy and lived experience. Morin identified that these tensions are not incidental to arousal; in many cases they are central to it. Guilt, transgression, and emotional risk frequently intensify erotic experience rather than diminishing it. But when a man cannot acknowledge or integrate what actually arouses him — because it conflicts with his self-image, his relationship, or his values — the result is often a kind of erotic deadening: desire that cannot fully arrive because it has nowhere safe to go.
In my clinical work, I regularly see men whose erection difficulties are less about anxiety in the conventional sense and more about an erotic world that has become constricted — by a relationship that has lost its charge, by sexual scripts that no longer fit, by desires that feel unacceptable, or by a growing gap between what is happening and what they actually need erotically. These are not conversations that happen easily. But they are often the conversations that make the most difference.
What a Proper Assessment Looks Like
Performance anxiety is a clinical diagnosis, not a default when nothing physical is found. It requires a proper assessment — one that distinguishes it from physical causes, identifies what is sustaining it, and understands its history.
Some practical signposts that suggest anxiety is the primary driver:
Erections during masturbation are reliable, but consistently fail or fade with a partner
Morning erections are present and normal
Erections are fine in some situations or with some partners, but not others
The problem began suddenly following a specific experience rather than gradually over time
Attempts to manage it — Viagra, abstaining, watching less porn — have brought temporary improvement but not resolution
That said, these distinctions are not always clean. Many men have both physical and psychological contributions to their difficulty, and the psychological loop often develops on top of an initial physical problem — medication side effects, a period of stress, a cardiovascular change — that has since resolved. By the time they seek help, the original cause may be less relevant than the self-sustaining anxiety that has developed around it.
A proper assessment will explore all of this — through blood tests where indicated, a detailed sexual and psychological history, and honest conversation about what has and hasn't worked. At my clinic in Marylebone, this typically takes a 60-minute first appointment, and most men leave with a significantly clearer picture of what is actually driving their difficulty.
What I Do — and Why It Matters for This Presentation
Performance anxiety sits at the intersection of medicine, psychology, and relationship — and the reason it is so often inadequately treated is that most clinicians are trained in only one of those areas.
A GP without psychosexual training may offer Viagra and refer onward. A sex therapist without medical training may not investigate whether there is a physical component or co-occurring condition that needs addressing. Neither has the full picture.
I came to this work with dual training: as a physician and GP with a specialist fellowship in sexual medicine, and as a COSRT-registered psychosexual and relationship therapist. I work with CFT and EMDR alongside established sex therapy approaches. I also trained in the Developmental Model of Couples Therapy, which is relevant when performance anxiety has become embedded in the relational dynamic and a partner needs to be part of the work.
This is not mentioned to impress — it is mentioned because it is directly relevant to what men with performance anxiety need. Most men I see have already tried one kind of help. What they have rarely had is someone who can hold the medical, psychological, and relational picture together in the same space, and who is also comfortable sitting with the shame that is almost always at the centre of it.
If that is where you are, you are welcome to book a consultation or simply get in touch to ask whether this is the right place to start.
If This Sounds Familiar
Performance anxiety, in my experience, responds well to the right kind of help — often within a handful of sessions when the anxiety loop is the primary driver, sometimes more where shame is deeper or earlier experiences need processing through something like EMDR.
What most men need first is not a technique. It is a space in which the problem can be spoken about honestly, without the additional weight of managing how they appear while they speak. If you have been carrying this alone — working around it, avoiding certain situations, hoping it might resolve on its own — it is worth knowing that it very rarely does without being addressed directly. But when it is addressed, it usually does resolve. I have seen men who had been stuck in this for years move through it in a matter of months. That is not exceptional — it is fairly typical when the right things are being worked with.
My clinic is at Central Health London, 23 Devonshire Place, Marylebone — quiet, discreet, a short walk from Regent's Park. Initial consultations are 60 minutes. If you would like to book, or just to ask whether this is the right place to start, you're welcome to get in touch.
Book a consultation | Get in touch
Summary
Performance anxiety operates as a self-sustaining loop: the fear of not performing becomes the cause of not performing, sustained by spectatoring — the process of mentally observing and evaluating oneself during sex rather than being present in the experience.
Shame is almost always central: men typically experience erection difficulty as a statement about who they are, not just what happened. This drives secrecy and delays help-seeking, often for years.
Shame Containment Theory reframes shame as a protective response rather than a personal failing — changing the relationship with shame, not eliminating it, is the therapeutic task.
Compassion Focused Therapy (CFT) addresses the chronic threat-system activation that underlies shame-based performance anxiety, by cultivating the soothing system as a neurobiological counterweight.
EMDR can be particularly valuable where earlier experiences — humiliation, trauma, or shame-laden sexual encounters — are anchoring the current difficulty in ways that present-focused work does not reach.
Male arousal is more category-specific than female arousal and organised around a Core Erotic Theme. When the conditions that generate a man's desire are absent from an encounter, erections may be unreliable not because of anxiety but because of erotic mismatch. Erotic conflicts — between what arouses a man and what he believes should arouse him — can further constrict desire in ways that relaxation alone will not resolve.
A proper assessment distinguishes performance anxiety from physical causes, identifies what is sustaining the loop, and understands its history — rather than defaulting to tablets or reassurance.
References
Masters WH, Johnson VE. Human Sexual Inadequacy. Boston: Little, Brown; 1970.
Brown B. Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead. New York: Gotham Books; 2012.
Etherson L. Shame Containment Therapy: a new framework for understanding shame in psychosexual difficulty. Developed from PhD research into shame and compulsive sexual behaviour. See: lisaetherson.com/therapy/shame-containment-theory/
Gilbert P. The Compassionate Mind. London: Constable; 2009.
Gilbert P. Compassion focused therapy: distinctive features. Psychotherapy Research. 2014;24(3):263–279.
Leaviss J, Uttley L. Psychotherapeutic benefits of compassion-focused therapy: an early systematic review. Psychological Medicine. 2015;45(5):927–945.
Shapiro F. Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. 3rd ed. New York: Guilford Press; 2018.
Morin J. The Erotic Mind: Unlocking the Inner Sources of Passion and Fulfillment. New York: HarperCollins; 1995.
Chivers ML, Rieger G, Latty E, Bailey JM. A sex difference in the specificity of sexual arousal. Psychological Science. 2004;15(11):736–744.
Dr Ben Davis is a private men's health GP, physician and COSRT-registered psychosexual and relationship therapist based at Central Health London, Devonshire Place, Marylebone. He holds MRCGP, MRCP, FECSM and a PhD in men's emotional and sexual health, and is to his knowledge the only clinician in the UK who combines dual medical training with registered psychosexual therapy and a dedicated focus on men's health. He works with CFT, EMDR, and the Developmental Model of Couples Therapy alongside established sex therapy approaches. Book a consultation.
