Can't Get or Keep an Erection?
Understanding What's Really Going On
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, London W1
Most men who come to see me have been dealing with erection difficulties alone for longer than they should have to. There is almost always a way back to sexual confidence and pleasure — and finding it starts with a proper assessment.
I'm Dr Ben Davis — a private men's health GP, physician and COSRT-registered sex and relationship therapist based in central London, with over 15 years of clinical experience. I hold dual medical training as both a GP (MRCGP) and physician (MRCP), a specialist fellowship in sexual medicine (FECSM), and registration as a psychosexual and relationship therapist — all with a dedicated focus on men's health. To my knowledge, I am the only clinician in the UK who combines all four.
That means I can assess and treat both the physical and psychological dimensions of erectile dysfunction within the same consultation, with the same clinician — without the gaps that come from seeing a GP, a urologist and a therapist separately, none of whom has the full picture.
Is My Erectile Dysfunction Psychological or Physical?
This is the question I am asked most often. The honest answer is that it is often both — and sometimes relational too.
Erection problems are rarely caused by just one thing. They usually involve contributions from three interacting areas:
Biology: Blood flow, hormones, nerves, cardiovascular health, medications, and metabolic factors.
Psychology: Anxiety, stress, low mood, self-pressure, sexual confidence, and your erotic world.
Relationships: Connection, safety, desire, communication, and the dynamics between you and a partner.
Many men have contributions from more than one area — and sometimes from all three reinforcing each other.
There are useful pointers. If your erections during masturbation are reliable and you still get spontaneous or morning erections, the difficulty is more likely psychological in origin. If erections are fine in some situations but not others, or with one partner but not another, that points towards psychological or relational factors. If erection problems have gradually worsened over time and affect you regardless of partner or situation, a physical or biological component becomes more likely.
That said, these distinctions aren't always clear-cut — which is why a proper assessment matters more than a quick guess.
Psychological Causes of Erectile Dysfunction
Can anxiety cause erectile dysfunction?
Yes — and performance anxiety is one of the most common presentations I see, particularly in men in their 20s and 30s.
If you can get hard on your own but not with a partner, or you find yourself losing your erection during sex despite wanting to have it, this is what happens when anxiety pulls you out of sexual presence and into monitoring and self-judgement.
Sexual pleasure relies on three things:
Mindful presence (being in the moment, in flow, not in your head)
Physical responsiveness (what feels good to your body)
Psychological turn-on (desire, safety, connection, erotic alignment)
Anxiety disrupts all three, but mindful presence is often the key one. When anxiety takes over, you’re pulled out of the moment — and sexual pleasure, including erections, often fades.
This is why sudden erectile dysfunction in your 20s or 30s is often psychological, particularly if erections are reliable during masturbation but difficult with a partner.
Many men try Viagra at this point, which helps partially but not completely. They then try changing masturbation habits, abstaining, or searching for the right fix — often increasing pressure rather than relieving it. Without addressing the loop itself, the problem tends to persist.
Can depression and stress cause erectile dysfunction?
Yes. Depression and erectile dysfunction frequently go together. Antidepressants can reduce sexual function — but so can untreated depression, and working out which is driving the problem matters because the treatment is very different. I work closely with a team of consultant psychiatrists, and for men where mental health and sexual difficulties overlap, we can review the picture together where needed.
Porn, Masturbation and Erection Problems
Whether pornography causes erectile dysfunction is a controversial topic. Men with erectile difficulties may watch more porn or masturbate more — often because these feel less pressured than partnered sex when a difficulty has developed.
Men with a healthy sexual relationship and good sexual self-understanding also masturbate and watch porn. Context matters.
When The Problem Is Relational
Sometimes the most important question is: who actually has the problem?
Many men arrive having had the difficulty placed squarely on their shoulders. But erection problems are often relational — maintained by the couple's dynamic, unspoken tensions, communication patterns, or mismatched desire. A man who is fine alone, or was fine in previous relationships, but struggles consistently with one partner, is often dealing with something relational rather than individual.
Losing an erection during sex — or struggling to stay hard with a partner — may have nothing to do with your body, and everything to do with anxiety within the relationship.
Medical Causes of Erectile Dysfunction
Erectile Dysfunction as an Early Warning Sign of Heart Disease
Here is something many doctors — and online Viagra pharmacies — do not tell you: erection problems can be the earliest sign of underlying cardiovascular disease, and this matters enormously.
The blood vessels supplying the penis are small — around 1 to 2mm in diameter. As vascular damage develops, these smaller vessels are affected first. The coronary arteries are larger — around 3 to 4mm — and by the time significant coronary disease is present, penile blood flow has often been compromised for years. In men in their 50s and 60s with gradually worsening erections, vascular change frequently underlies the problem, sometimes three to seven years before any cardiac symptoms appear.
Men with erectile dysfunction have a 59% increased risk of a heart attack and a 34% increased risk of a stroke. This is not obscure research — the evidence has been clear for decades. Yet it remains poorly communicated, largely because sex and medicine make uncomfortable conversation partners.
This is why I assess cardiovascular risk as a routine part of any consultation for erection problems — blood pressure, waist circumference, BMI, and extended lipid tests including LDL, lipoprotein(a), ApoB and hsCRP. Where appropriate, imaging such as a CT calcium score or CT coronary angiogram gives a clearer picture of what is actually happening inside the blood vessels, rather than relying on numbers that only estimate risk.
If a significant narrowing is identified, it can often be treated. If your erection problems are pointing to cardiovascular risk, that is not a reason to feel alarmed — it is a reason to act, and acting early makes an enormous difference.
Other Medical Causes of Erectile Dysfunction
Common Medical Causes:
Diabetes (type 1 and type 2)
Hypertension (high blood pressure). Some blood pressure medications can make things worse, but untreated high blood pressure is damaging to erections in the long term
Smoking and alcohol
Prostate cancer treatment (surgery, chemotherapy, radiotherapy)
Medications — from finasteride for hair loss to antidepressants
Testosterone and hormonal health
Low testosterone can contribute to erection difficulties, but accurately diagnosing genuine testosterone deficiency requires comprehensive testing — not a home finger-prick kit. A proper assessment includes total testosterone, SHBG, calculated free testosterone, pituitary hormones (LH and FSH), thyroid function and metabolic markers.
What is often missed in the rush to sign men up to testosterone subscriptions is that treating the underlying metabolic picture — improving weight, sleep and physical activity — can restore testosterone naturally. As weight reduces and activity increases, testosterone often rises, sleep apnoea improves, and with it erections, libido and overall cardiometabolic health.
There has not yet been a head-to-head trial comparing GLP-1 medications with testosterone therapy as initial treatment for testosterone deficiency, but weight loss benefits multiple health markers.
Age and Erectile Dysfunction
Age shapes the likely cause significantly.
In younger men, ED is common and usually psychological or lifestyle-related — performance anxiety, stress, depression, alcohol, cannabis, or medication side effects.
In men in their 30s and 40s, causes often overlap — psychological and hormonal factors both become relevant.
In men in their 50s and beyond, vascular and metabolic causes become more likely, and cardiovascular assessment becomes particularly important.
In men in their 70s and 80s, penile tissue changes with age, reducing elasticity and blood retention — but even here, there is almost always something that can help.
Erectile dysfunction is rarely permanent. There are almost always ways to improve erections once the underlying causes are properly understood.
Treatment for Erectile Dysfunction — What Actually Works
There is no single right treatment for erection problems. The most effective approach depends on why the problem developed — which is why assessment matters more than any treatment list.
Many men I see have already tried tablets, testosterone, injections, shockwave therapy, or other interventions — often without a clear understanding of why their difficulty started. My approach is different: understand the cause first, then treat it appropriately.
Lifestyle changes: Regular exercise, a Mediterranean-style diet, stopping smoking, moderating alcohol, improving sleep, and managing stress can all make a meaningful difference — particularly where cardiovascular or metabolic health is involved.
Pelvic floor physiotherapy: Specialist physiotherapy targeting pelvic floor muscle function can improve erectile rigidity and control, and is underused in many ED treatment pathways.
PDE5 inhibitors (Viagra, Cialis, and related medications): Sildenafil (Viagra), tadalafil (Cialis), vardenafil — remain highly effective for many men. If one has not worked well for you, this does not mean the class is wrong — dose, timing and choice of drug often matter, and daily low-dose tadalafil works very differently from an on-demand tablet.
Treating underlying medical conditions: Cardiovascular disease, testosterone deficiency, diabetes, thyroid problems, and raised prolactin levels can all contribute directly to erectile dysfunction. Addressing them can improve both erections and overall health.
Penile pumps: Vacuum erection devices draw blood into the penis and support erections. These can be effective alone or alongside other treatments.
Intraurethral alprostadil: Medications such as MUSE or Vitaros, placed into the urethra to stimulate an erection — an option when tablets haven't been effective.
Penile injections: Injections such as Invicorp or Caverject, administered directly into the penis. These can be highly effective for men where tablets haven't worked.
Low-intensity shockwave therapy (Li-ESWT): Uses sound waves to stimulate blood vessel growth. For men with mild to moderate ED related to vascular disease, this can be effective. A course typically involves 6 to 12 sessions, with effects lasting up to two years.
Penile implants: A surgical option, usually considered when other treatments have not been effective.
Psychosexual therapy: Addresses performance anxiety, sexual trauma, confidence, desire and arousal — and because I am a COSRT-registered therapist as well as a physician, this does not require a separate referral.
Couples and relationship therapy: Where relationship dynamics, communication, or mismatched desire are contributing to erection difficulties, couples work can be an important part of the picture.
Should I See a GP, a Urologist, a Sexologist, or a Sex Therapist?
It can be genuinely confusing knowing where to start.
Urologists are the right specialist for structural problems, prostate disease, and surgical conditions. If you have prostate cancer, significant urinary symptoms, or need surgery, a urologist is where you should be.
Erection problems, however, are usually not purely structural. They involve cardiovascular, hormonal, psychological, and relational factors — often simultaneously. For an initial assessment, it helps to see someone who can look at the whole picture.
Sex therapists can be very helpful where anxiety, confidence, or relationship dynamics are central — but without medical input, underlying health issues and cardiovascular risks can be missed entirely.
Many GPs have limited training in sexual medicine. I regularly see men whose erection problems in their 50s were treated intermittently with Viagra, only for them to have significant, preventable cardiac events in their 60s or 70s.
If you're looking for an erectile dysfunction specialist in London who can bring all of these strands together — medical, hormonal, psychological, and relational — that remains relatively uncommon. I offer exactly this: specialist men's health medicine combined with psychosexual therapy in London, with the one doctor.
Frequently Asked Questions
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In many cases, yes — particularly when the underlying cause is properly identified and addressed rather than the symptom treated in isolation. Where a complete resolution is not possible, there is almost always a way to improve things significantly. Erectile dysfunction is rarely permanent, and most men I see make meaningful progress once we understand what's actually driving the problem.
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It can be, and this is one of the most important things men don't know. The blood vessels supplying the penis are smaller than those around the heart, so vascular damage often shows up there first — sometimes three to seven years before cardiac symptoms appear. In men in their 50s and 60s with gradually worsening erections, I routinely assess cardiovascular risk as part of the consultation. Finding a problem early, if there is one, makes an enormous difference.
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If your erections during masturbation are reliable and you still get morning erections, the difficulty is more likely psychological in origin. If erection problems have gradually worsened over time and affect you in all situations — alone and with a partner — a physical or biological component is more likely. In practice, most men have elements of both, and the interaction between them is often what sustains the problem. A proper assessment usually makes the picture much clearer.
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A sex therapist is typically a psychotherapist with additional training in sexual difficulties — their work focuses on the psychological, relational, and behavioural dimensions of sexual problems. A sexual medicine doctor is a medically qualified physician who specialises in the physical and hormonal causes of sexual dysfunction.
Many men with erection problems need input from both perspectives — but very few clinicians are trained in both. As a GP, physician, and registered psychosexual therapist, I hold both qualifications. This means I can assess and treat physical causes (cardiovascular risk, testosterone deficiency, medication effects) and psychological causes (anxiety, performance pressure, relationship dynamics) within the same consultation, without splitting your care across two separate practitioners. -
Yes, and it is one of the most common causes I see, particularly in men in their 20s and 30s. When anxiety takes over during sex, it pulls you out of the moment and into monitoring and self-judgement — which is usually incompatible with erections. Once this pattern establishes itself, it tends to be self-reinforcing. The good news is that it responds well to the right kind of assessment and support.
The word "cure" can be misleading — the goal isn't always to restore things to exactly how they were, but to reach a place where sex is enjoyable, confident, and reliable again. For most men, that is entirely achievable.
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Yes — and this is one of the things that makes my approach relatively unusual. Because I am a COSRT-registered psychosexual and relationship therapist as well as a physician, I can address both the medical and psychological dimensions of erectile dysfunction within the same space, without you needing to see separate specialists. For many men, this integrated approach is what makes the difference.
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A GP without specialist training may miss underlying cardiovascular or hormonal factors, or focus only on prescribing tablets. A sex therapist without medical training may miss physical causes or future health risks — and I regularly see men whose erection problems in their 50s were managed with occasional Viagra, only for significant cardiovascular disease to emerge years later. I bring medical assessment, sexual medicine and psychosexual therapy together in one consultation, so nothing falls through the gap.
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Yes, where it is clinically indicated and properly diagnosed. Accurately identifying genuine testosterone deficiency requires comprehensive testing — not a home finger-prick kit — including total testosterone, SHBG, calculated free testosterone, pituitary hormones and metabolic markers. Many men arrive having been told by online clinics that their testosterone is low when it is in fact normal. I take a careful, evidence-based approach and never prescribe testosterone unless I believe it is genuinely likely to help.
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Yes. Where further investigation is helpful, I can arrange 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 a network of cardiologists, urologists, pelvic health physiotherapists, psychologists and other specialists, and refer where appropriate. Nothing is arranged without explaining the reasoning to you first.
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Yes — shockwave therapy is part of my treatment toolkit, and I am trained in its use. For men where it is likely to help, I refer to a trusted men's health physiotherapist who specialises in this treatment and delivers it to a high standard. This means you benefit from dedicated expertise in the procedure itself, with my oversight of the wider clinical picture and treatment plan.
What to Expect When You Come To See Me
My clinic is at Central Health London, 23 Devonshire Place, Marylebone — a quiet, discreet location a short walk from Regent's Park. Most people arrive anxious, and leave relieved.
The first consultation is typically 60 minutes. We cover your symptoms, medical and family history, relevant risk factors, and your current and past sexual experience, relationships and lifestyle — from medical, biological, psychological, relational and cultural perspectives.
A physical examination is sometimes appropriate — particularly for erection problems — but is always optional.
If you've had recent blood tests, you can send them ahead. If not, I'll usually arrange blood tests, which often but not always need to be taken before 11am.
Where further investigation is helpful, I may suggest:
Night-time erection monitoring (ADAM sensor)
Home blood pressure monitoring (Hilo band)
Sleep apnoea assessment (WatchPAT)
Cardiac investigations — ECG, echocardiogram, CT calcium score, or CT coronary angiogram
Ultrasound, MRI, or other imaging where indicated
Nothing is compulsory. I explain the reasoning behind every suggestion, and I do not recommend anything I do not genuinely believe is evidence-based — nothing I would not suggest to a member of my own family.
I see patients at Central Health London, 23 Devonshire Place, in the heart of London's medical district — with remote consultations available particularly for follow-ups.
Fees
Initial consultation (60 minutes) — £400
A thorough, unhurried first appointment covering your medical history, sexual health, relevant risk factors, and the psychological and relational dimensions of what you are experiencing. This is the foundation of everything that follows.DrBen1 Blood panel — £275
A comprehensive hormonal and metabolic blood panel forms part of the medical assessment for most men. This includes testosterone, SHBG, free testosterone, pituitary hormones, thyroid function, lipids and metabolic markers — taken before 11am as standard.Follow-up appointment — £125 to £220
For reviewing results, adjusting treatment, or continuing the work once a plan is in place.Further investigations Some men benefit from more extensive cardiovascular testing — a further cardiovascular risk profile blood test or a CT calcium score to assess arterial health directly. Where this is indicated, I will discuss the likely cost and reasoning with you before anything is arranged. You can also find more about fees on my Book Now Page
Psychosexual therapy - £235 per session
Where psychosexual and relationship therapy is indicated, we would typically begin with a block of six sessions at £235 per session, then review together. Some men need only a few sessions; others, where difficulties are more longstanding or entrenched, benefit from longer work. I will always be open with you about what I think is likely to be involved before we proceed.
Who Tends to Benefit Most From Seeing Me?
1. Men in midlife who haven’t engaged much with healthcare
If you're in your 50s or 60s, don't particularly like going to the doctor, but recognise it's time to take your health seriously — this is a good place to start. I often find things that matter, and that have been missed.
2. Gay, bisexual and queer men
If you're looking for someone who genuinely understands gay and queer sex — someone who doesn't need things explained, and who won't be uncomfortable — you can speak freely here.
3. Men who want a thoughtful, whole-person assessment
If you've tried tablets, testosterone, injections, or shockwave therapy without a clear plan, or if you've had a purely medical or purely therapy-based approach that hasn't helped, a proper integrated assessment often makes the difference.
That said, I work with men across the full spectrum — from their 20s to their 90s, across all orientations and relationship statuses.
If you want someone who'll work out what's actually going on rather than hand you a prescription and send you on your way, you're in the right place.
What I Hope You Gain From Working With Me
By the end of a few consultations, my aim is that:
You're enjoying sex again — confident, at ease in your sexual self, with a fuller experience of pleasure.
You have a clear picture of your physical health and a practical plan to improve it.
You feel taken seriously, properly understood, and no longer alone with something that has probably been with you for too long
How Long Does Treatment Take?
If the issue is primarily medical, improvement can be relatively quick — sometimes within two or three appointments once a clear plan is in place.
If the difficulty is primarily psychological or relational, meaningful change often occurs within around six sessions, particularly when an anxiety loop has developed and you're willing to engage with the process. Sometimes, for men with trauma, psychological change can take longer term work, and I can discuss this with you.
Where a relationship is involved, I may recommend some sessions with your partner as part of the work.
For many men, erectile dysfunction can be resolved — particularly when underlying causes are addressed rather than symptoms alone.
Watch Dr Ben talk about Erectile Dysfunction, with Jon Dean
Ready To Talk?
Dr Ben Davis
Men’s Health GP & Psychosexual Therapist
GMC & COSRT Registered | MRCGP | MRCP | FECSM | RegCOSRT | PhD (Men's Health)
15 Years Clinical Experience
Taking this next step takes courage. If you would like a thorough, unhurried assessment that looks at the whole picture — medical, psychological and relational — you are welcome to book below or reach out via the contact form.