One of the commonest reasons men come to see me, and one of the most treatable. It is also one of the few symptoms that tells you something important about the rest of your health.
Erectile dysfunction is common. Accurate numbers are hard to come by, but as many as one in two men over fifty are affected. An erection needs blood vessels, nerves, hormones, desire and how you are feeling, all working at once. A problem with any one of them can be enough on its own, and often more than one is involved: blood flow that is slightly reduced, say, plus the anxiety that arrives the first time it happens. Finding out which is what a proper assessment is for. Without one you are throwing treatments at a problem nobody has identified.
Your erection is an honest signal. It reports on your arteries, your hormones, your history, your fear and how safe you feel with the person beside you. What it does not do is make clear which one is the problem.
Anxiety, stress, low mood, self-pressure, confidence, and your erotic world.
Relationships
Connection, safety, desire, communication, and the dynamic between you.
Socio-cultural
Sexual scripts, cultural and religious norms, ideas about masculinity, and what you were taught about sex.
The usual contributors are cardiovascular and metabolic health, testosterone, the side effects of medication you are already on, sleep, alcohol and mood. Alongside those sit the ones that get asked about least: whether you actually want sex, what your erotic world is and whether the sex you are having resembles it, and what is going on in your relationship. None of them are character flaws, and all of them are things a doctor can look into.
For gay and bi men the biology is the same and the picture around it often is not. Receptive and insertive sex make different demands, and a man may find one affected and not the other. Recreational drugs, PrEP and recovery after prostate cancer treatment come up more often. You shouldn't have to explain the basics of your sex life before getting to the clinical question.
Is it physical, or is it in my head?
It's the question I'm asked most, and it can be almost entirely one, almost entirely the other, or some of each. Some pointers: if you get reliable erections alone and still wake with morning erections, the psychological side is doing more of the work. If they have worsened gradually and happen in every situation, a physical component is more likely. Plenty of men do have elements of both, and where they do, the way the two feed each other is usually what keeps it going. None of that gets settled by guessing from a description.
01Can erection problems be a sign of heart disease?
They can, and it is the thing men are least likely to have been told. The blood vessels supplying the penis are smaller than the ones around the heart, so vascular damage tends to show there first, sometimes three to seven years before any cardiac symptoms appear.
The penile arteries are around 1 to 2mm across and the coronary arteries around 3 to 4mm, so by the time coronary disease is significant, penile blood flow has often been compromised for years. Men with erectile dysfunction have a 59% increased risk of heart attack and a 34% increased risk of stroke. The evidence has been clear for decades and is still rarely passed on.
So in men over forty whose erections have been getting gradually worse, I assess cardiovascular risk as a routine part of the consultation.
What I check:
Blood pressure, waist circumference and BMI
Extended lipids, including LDL, lipoprotein(a), ApoB and hsCRP
Where it's warranted, a CT calcium score or CT coronary angiogram, which show what is actually happening inside the vessels rather than estimating it
If significant heart disease is found, it can always be treated. That isn't a reason to be alarmed. It's a reason to act, and acting early makes an enormous difference.
Genetic and other differences in sexual development. Klinefelter's is the commonest, affecting around 1 in 600 men
And medication, where the usual culprits are:
Antidepressants, the SSRIs in particular: fluoxetine, sertraline, citalopram
Antipsychotics
Blood pressure medication, particularly bendroflumethiazide and the beta blockers
Anti-androgens: finasteride, dutasteride, and androgen deprivation therapy, used for prostate cancer, benign prostate enlargement and male pattern hair loss
Anabolic steroids
Nicotine and cannabis, cocaine, GHB and GBL, crystal meth, MDMA and mephedrone
One point worth making on its own, because it gets lost in the list: penises age as the rest of us does. Even with none of the above, erections become less strong and less sensitive to stimulation over the years. That is not a disease and it is not the end of anything.
Could it be my testosterone?
Sometimes, though less often than many venture capital clinics suggest. Testosterone does affect erections, but it needs to be assessed as part of a wider picture rather than as the answer on its own. Diagnosing deficiency properly needs total testosterone, SHBG, calculated free testosterone, pituitary hormones and metabolic markers, taken before 11am, rather than a finger-prick kit. Plenty of men arrive having been told by an online clinic that their level is low when it is normal.
Where a man is overweight and his testosterone is low, choosing between weight loss medication and testosterone therapy is a clinical judgement rather than a rule. It depends on the whole picture, on what matters to him, and on whether fertility is in question. No trial has compared a GLP-1 against testosterone head to head as a first treatment, so anyone telling you the answer is obvious is telling you something the evidence does not.
Is this just my age?
Age changes the likely cause rather than the outlook. In younger men it's usually psychological or lifestyle. From the fifties on, vascular and metabolic causes become more likely and cardiovascular assessment matters more. Erectile dysfunction is rarely permanent at any age.
How it tends to differ by decade:
20s and 30s: usually performance anxiety, stress, low mood, alcohol, cannabis or a medication side effect
40s: the decade this stops being only about sex. Gradually worsening erections over forty are a strong predictor of a heart attack or stroke in the next five years, and hormonal and psychological factors are often in play alongside
50s and beyond: vascular and metabolic causes more likely still, and cardiovascular assessment becomes the priority
70s and 80s: the tissue itself changes, holding blood less well, and there is still almost always something that helps
Few men arrive saying they have a psychological erection problem. Most say the problem is in the body: they feel turned on, they want sex, and their body does not respond the way it used to. That feeling of disconnect is real, and it does not mean the cause is biological, because what is happening genuinely is physical.
An erection needs the parasympathetic nervous system in the driving seat, the rest-and-digest side, which only happens when you feel safe. It is always in balance with the sympathetic system: adrenaline, fight or flight, fear. When fear is driving, the parasympathetic side shuts down and so does the blood flow. Some men describe sex as going into battle, full of threat and risk, and when that is the experience the sex is rarely good and the erection rarely holds.
When you're running from a lion, you don't need an erection.
Often an old memory is doing it. The situation itself is not frightening, but a memory network from the past gets triggered, usually with a belief attached: I am not man enough, there is something wrong with me, my penis is broken. You may not notice the memory at all. The body responds anyway, and the thinking part of the brain cannot easily talk the fear part out of it.
Underneath that, almost universally, is a harsh internal critic. It is at the root of a great deal of both sexual difficulty and mental health difficulty, and compassion-focused therapy, which is central to how I work, exists to address exactly that.
Anxiety is the commonest cause I see in men in their 20s and 30s. It pulls you out of the moment and into watching and judging yourself, and once that loop is running it feeds itself. Most men try Viagra at this stage and find it helps partly. Then they change their masturbation habits, or abstain, or hunt for the right fix, and the pressure goes up rather than down. The loop is the thing that has to be addressed, and it responds well to being worked on.
Sex relies on three things, and anxiety disrupts all of them:
Being present, in the moment rather than in your head
Physical responsiveness, what actually feels good to your body
Psychological turn-on: desire, safety, connection
Depression and antidepressants are often both involved. Antidepressants reduce sexual function, and so does untreated depression, and which one is driving it matters because the answers are completely different. Stopping the medication is rarely the right move. A change of drug, of dose, or something added is more often it.
Where it does turn out to be psychological, you don't get sent anywhere else. I'm a COSRT-registered psychosexual and relationship therapist as well as a physician, so both sides can be worked on in the same place by the same person.
Is porn part of this?
Sometimes, and less often than men assume. Plenty of men arrive certain that porn is the cause, and it usually isn't. What tends to do more harm is the belief: once a man has decided his porn use is damaging him, he takes that into sex as shame and self-watching, and both of those will affect an erection on their own. Men with erection difficulties also often watch more porn or masturbate more, frequently because it feels less pressured than sex with a partner once a difficulty has started, so the direction of cause is rarely as obvious as it looks. Men with good sex lives watch porn too. What matters is the context it sits in.
When a difficulty is held in place by a memory rather than by an artery, talking about it often does not reach it. A man can understand perfectly well that he is safe, that his partner is not judging him, that one bad night years ago means nothing, and his body will carry on responding as though none of that were true. That is not a failure of insight. It is what a memory network with a belief attached to it does, and it is why so many men describe the problem as being in the body.
EMDR works on that directly. Eye Movement Desensitisation and Reprocessing was developed for trauma, and what it does is reprocess the memory so it stops carrying the same charge: the event stays, the alarm attached to it does not. In erectile difficulty the target is usually specific. The first time it happened and what that felt like. A partner's reaction. An assault. Shame absorbed from family, school or religion long before any of this started. Reprocessing it lowers the threat the body is responding to, and an erection needs the absence of threat more than it needs anything else.
It is not right for everyone and it is not a substitute for the medical side of the assessment. Where it earns its place is with the men who have done everything else. Tablets that worked partly, a course of therapy, sometimes thousands of pounds of shockwave, and a body still braced against something nobody has named. That is the pattern where EMDR tends to move things when nothing else has.
Sometimes the more useful question is who actually has the problem. Men often arrive having had it placed squarely on their shoulders, when erection difficulties are frequently held up by the couple: unspoken tension, how you talk to each other, mismatched desire. A man who is fine alone, or was fine in a previous relationship, but struggles consistently with one partner, is usually dealing with something relational rather than something of his own.
There is no single right treatment, and what works depends on why the problem developed, which is why the assessment matters more than the list. Most men I see have already tried tablets, testosterone, injections or shockwave therapy without anyone having established what started it.
The options, depending on what's driving it:
Lifestyle: exercise, a Mediterranean diet, stopping smoking, less alcohol, better sleep, particularly where the cause is cardiovascular or metabolic
Pelvic floor physiotherapy, which improves rigidity and control and is badly underused
PDE5 inhibitors: sildenafil, tadalafil, vardenafil. If one hasn't worked, that rarely means the class is wrong. Dose, timing and choice matter, and daily low-dose tadalafil behaves very differently from an on-demand tablet
Intraurethral alprostadil (MUSE, Vitaros), where tablets haven't worked
Injections such as Invicorp or Caverject, which are highly effective for many men tablets have failed
Low-intensity shockwave therapy for mild to moderate vascular ED. Six to twelve sessions, with effects lasting up to two years
A penile implant, usually once other treatments haven't worked
Psychosexual therapy for performance anxiety, sexual trauma, confidence and desire, which needs no separate referral here
EMDR, where a specific earlier experience is still anchoring the difficulty and talking about it has not shifted it
Couples therapy, where the dynamic between you is part of what's happening
Can it be cured, or only managed?
Often genuinely resolved, particularly when the cause is identified rather than the symptom treated on its own. Where it can't be, there's almost always a way to improve things substantially. "Cured" can be the wrong frame anyway: the aim isn't always to return things to exactly how they were, but to get to a place where sex is reliable and enjoyable again. For most men that's achievable.
Do you offer shockwave therapy?
Yes, where it's likely to help. I'm trained in it and refer to a men's health physiotherapist who does it to a high standard, so you get someone who does the procedure often, with me holding the wider picture and the plan.
Can it be treated after prostate cancer?
Usually yes, though the approach is different and recovery is measured in months rather than weeks. It often combines medication, devices, injections and psychological support, and the right mix depends on the surgery or radiotherapy you had and on what function matters most to you. For gay and bi men that means insertive and receptive function both, which is a conversation that too often doesn't happen at all.
It depends on what's driving it, which is the awkward part, because that is the thing you don't yet know. As a rough map:
A urologist is the right person for structural problems, prostate disease and anything surgical
A sex therapist helps where anxiety, confidence or the relationship is central, though without medical input the health risks underneath can be missed
A GP has ten minutes, and sexual medicine barely features in general practice training. I say that as a GP. I regularly see men who were given four Viagra a month in their 50s and had a preventable cardiac event in their 60s
Erection problems are rarely purely structural. They involve vascular, hormonal, psychological and relational factors at the same time, so an initial assessment is best done by someone who can look at all of it
I'm a GP and a physician, a sexual medicine specialist and a registered psychosexual therapist, which means the cardiovascular risk, the hormones, the performance anxiety and the relationship get assessed in the same hour by the same person. Nothing has to be handed between two clinicians who never speak, and nothing falls into the gap between them.
An hour. We go through what's happening, when it started and what was going on in your life at the time. I take a medical history, look at any medication you're on, and examine you where that's useful. I arrange the blood tests directly, usually cardiovascular, metabolic and hormonal. Then I tell you what I think is going on and how I got there, and we decide together what to do.
You don't need to have the right words ready. Most men have rehearsed a sentence before they arrive and it rarely comes out the way they planned. That's fine.
How long does treatment take?
If it's mainly medical, often quickly: two or three appointments once there's a clear plan. If it's mainly psychological or relational, meaningful change usually comes within about six sessions, particularly where an anxiety loop has formed and you're willing to work with it. Where there's trauma it can take longer, and I'd say so. Where a relationship is involved I may suggest some sessions with your partner.
Can you arrange scans and refer me on if I need it?
Yes. Night-time erection monitoring, home blood pressure monitoring, sleep apnoea assessment, and cardiac investigations including ECG, echocardiogram, CT calcium score and CT coronary angiogram. I work with cardiologists, urologists, pelvic health physiotherapists and psychologists and refer where it's in your interest. Nothing is arranged without me explaining the reasoning first.
The clinic is at Central Health London, 23 Devonshire Place, Marylebone, a quiet and discreet address a short walk from Regent’s Park. Most men arrive anxious and leave relieved. You will be welcomed by reception, offered tea or coffee, and given time to settle before we start.
A first consultation is usually an hour. We go through your symptoms, your medical and family history, and your sexual experience, relationships and lifestyle: the medical, psychological and relational picture together rather than one at a time.
I will ask you a lot of questions. You do not have to answer any of them: saying "I would rather not answer that" is a complete answer and nothing follows from it. A physical examination is sometimes useful, particularly for erection problems, and it is always optional. You stay in control of the appointment throughout.
If you have had recent blood tests, send them ahead. If not I will arrange them, and I will tell you which ones need taking before 11am.
The waiting room at 23 Devonshire Place.
Who tends to benefit most from seeing me
Men in midlife who have not engaged much with healthcare
If you are in your fifties or sixties, have no GP you know well, do not much like going to the doctor, but recognise it is time to take your health seriously, this is a reasonable place to start. I often find things that matter and have been missed.
Gay, bisexual and queer men
If you want help but are wary of seeing someone who is not comfortable talking about gay or queer sex, you can come to someone who does not need it explained, and who will not judge or shame you.
Men who want a thoughtful, whole-person assessment
Men who have tried quick fixes, or had a purely medical or purely therapeutic approach that did not help. I see a lot of men for second opinions. And men of any age and in any kind of relationship who want to understand what is going on rather than be handed a prescription.
About Dr Ben Davis
I am a GP, a sexual medicine specialist and a COSRT-registered psychosexual therapist, working at 23 Devonshire Place, Marylebone, central London, alongside NHS general practice in Hackney.
Most men reading a page like this arrived from a search rather than my homepage, so this is probably the first you have heard of me. The short version: I hold the medical, the psychological and the relational picture together in one appointment, rather than sending you to three people who each see a third of it.
