Erection Problems: A Different Approach with Dr Ben Davis
Why Can’t I Get an Erection? Understanding What’s Really Going On
If you’re reading this, you’ve probably typed something like “why can’t I get hard” or “can’t stay hard during sex” into a search engine at 2am, feeling alone with a problem you’ve not told anyone about.
Maybe you can get hard alone but not with your partner.
Maybe you still get morning erections but lose your erection during sex.
Maybe your erection goes away when you put on a condom.
Maybe it used to be fine — and now it isn’t — and you have no idea why.
You’re not alone. And more importantly: there is almost always a way forward.
Starting to talk about erection problems
Most people who come to see me have been completely on their own with this problem. Many haven’t told their partner. Some haven’t told anyone.
The first thing I do is create a genuinely safe, non-judgmental space where you can talk freely. I listen carefully, without embarrassment, rushing, or assumptions. The moment the problem is shared, the burden usually eases — because you’re no longer carrying it alone.
I know the courage it takes just to book an appointment. Reaching out is a meaningful first step, and often the most difficult one.
A Different Kind of Consultation
Many men tell me that their previous experiences of seeking help have been dismissive — “here’s a few tablets, off you go.” Often there was barely a chance to talk about the problem, let alone have a proper assessment.
They may have met a clinician who felt embarrassed talking about sex, didn’t really know what to do, or wanted to shut the conversation down because it felt uncomfortable.
As a sexual medicine doctor and sex & relationship therapist, there is very little you could say that I haven’t heard before. Erectile difficulties are common — and they deserve thoughtful, skilled care.
Is My Erectile Dysfunction Psychological or Physical?
This is one of the most common questions I’m asked. The short answer is that it’s often both — and sometimes relational too.
Erection problems usually stem from three interacting areas:
Biology – blood flow, hormones, nerves, medications
Psychology – anxiety, stress, mood, self-pressure, erotic world
Relationships – connection, safety, desire, dynamics
Most men have contributions from more than one area, and sometimes from all three interacting with each other.
There are some key ways of telling whether a difficulty is more psychological or more physical, although this isn’t always clear-cut. If your erections during masturbation are reliable, and you have spontaneous or morning erections, the cause is more likely to be psychological. Similarly, if erections are fine with one partner but not another, this again points towards psychological or relational factors.
If erection problems have gradually worsened over time and affect you regardless of partner or situation — whether alone or with someone else — a physical or biological component becomes more likely.
Medical treatments like Viagra can help even when the cause is psychological. However, they often stop working if the underlying biological, psychological, or relational issue isn’t addressed.
Psychological causes of Erection Dysfunction
There are many psychological contributors to erectile dysfunction — including anxiety, low mood, depression, relationship difficulties, or having sex that doesn’t align with what genuinely turns you on.
Can anxiety cause erectile dysfunction?
Yes, absolutely. Performance anxiety–related erectile dysfunction is incredibly common. If you’re asking:
“Why can I get hard alone but not with my partner?”
“How do I stop overthinking and stay hard during sex?”
- you’re describing what happens when anxiety pulls you out of sexual presence and into monitoring, worry, and self-judgment.
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.
The Anxiety Loop – What to Do When Viagra Stops Working
Many men have tried Viagra (sildenafil) or Cialis (tadalafil) bought online. It often helps initially — but only partially.
They may then try changing masturbation or porn habits, abstaining from sex, or endlessly searching for the “right” solution. This often increases pressure rather than reducing it.
The result is a loop of worry, monitoring, and disappointment, which takes people further away from sexual ease and pleasure. Without addressing the loop itself, the problem tends to persist.
Stress, Low Mood and Depression
Can stress cause erectile dysfunction? Yes. Can depression cause erectile dysfunction? Absolutely. Depression and erectile dysfunction often go hand in hand. Antidepressants can cause erectile dysfunction but so can untreated depression. It's a complex picture.
Porn, Masturbation and Erectile Dysfunction
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.
Relationship Causes of Erectile Dysfunction: When the Problem Isn’t Just Yours
A big part of assessment is working out who actually has the problem. Often the person who comes to see me has had the difficulty placed squarely on their shoulders — “go and sort yourself out.” But it’s often a relational difficulty.
That individual may be fine when they’re on their own, or have been fine in previous relationships, but in this one it’s become an issue, and the couple’s dynamic is maintaining the difficulty.
This is why losing your erection halfway through sex or struggling to stay hard during sex might not be about your penis at all — it might be about anxiety in the relationship, unspoken issues, or differing desires.
Medical Causes of Erectile Dysfunction: What Many Doctors and Therapists Miss
Here’s what many doctors — and online Viagra pharmacies — don’t tell you: erection problems can sometimes be the earliest sign of an underlying medical issue, particularly involving blood vessels.
Erectile Dysfunction and Heart Disease
Yes — erectile dysfunction can be an early warning sign of cardiovascular disease, and this is important.
In men in their 50s and 60s especially, vascular changes often underlie erection problems. These changes may appear in the penile blood vessels years before symptoms develop in the heart — sometimes three to seven years earlier.
This reflects changes in blood vessels more broadly, often showing up in the penis before the heart.
Assessing cardiovascular Risk
This is why I often investigate cardiovascular risk further, which may include:
Accurate blood pressure monitoring (sometimes using home devices such as a Hilo band)
Height, weight, waist circumference, BMI
Extended blood tests assessing cardiovascular risk (lipids, LDL, lipoprotein(a), ApoA, ApoB, hsCRP)
However, these tests only tell part of the story. They estimate risk, but don’t show what is actually happening inside the blood vessels themselves.
Imaging such as a CT calcium score or CT coronary angiogram can give a clearer picture of future cardiovascular risk by identifying whether there is significant narrowing of a coronary artery.
When narrowing becomes severe, blood flow to the heart muscle can be compromised, leading to a heart attack. The challenge is that this process can develop silently, without warning symptoms. In the right context, investigating further rather than relying on blood tests alone can therefore be important.
If a significant narrowing is found, it can often be treated with medication and, where appropriate, intervention via coronary angiography.
So if you’re wondering “Should I see a doctor about erectile dysfunction?” — the answer is yes. Not because you’re broken, but because your body may be signalling something important about your cardiovascular health.
Other Medical Causes
There are lots of other medical causes of erection problems. The most common are:
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
The Hormonal Picture (Including Testosterone)
Low testosterone can cause erection problems. Accurately diagnosing testosterone deficiency, however, can be nuanced. Understanding the cause of testosterone deficiency and whether it can be reversed is also crucial.
Low testosterone often relates to weight and obesity. Fat tissue converts testosterone to oestrogen, which lowers testosterone levels.
Proper assessment requires blood tests including total testosterone, SHBG, calculated free testosterone, pituitary hormones, thyroid function, and metabolic markers. A comprehensive hormonal picture is essential.
What is often missed in the rush to sign men up to TRT subscriptions is that treating metabolic syndrome and obesity can improve testosterone without testosterone. As weight reduces and physical activity increases, particularly with resistance training — testosterone levels may rise. Sleep often improves as sleep apnoea improves, and with this, erections, libido, and overall cardiometabolic health can improve.
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 Erection Problems
The age at which erection problems first appear has a strong influence on likely causes.
In younger men, ED is common and usually psychological or lifestyle-related. Performance anxiety, stress, depression, medication side effects, alcohol, cannabis, and other substances are frequent contributors.
In men in their 30s and 40s, factors often overlap — stress and anxiety often still play a role, but hormonal and relationship factors become more relevant.
In men in their 50s and beyond, vascular and metabolic causes become more likely.
Some men in their 70s and 80s have no major medical conditions but experience erectile difficulties because penile tissue becomes less elastic with age, making it harder for blood to remain held in the penis.
Erectile dysfunction is rarely permanent. There are almost always ways to improve erections once the underlying causes are understood.
Treatment which works: what’s the best way of treating erectile dysfunction?
There are many different ways to treat erection difficulties, and no single approach is right for everyone. The options below work in different ways, and the most effective treatment depends on why the problem has developed.
Lifestyle changes
Regular exercise, a Mediterranean-style diet, stopping smoking, moderating alcohol, improving sleep, and managing stress can all make a meaningful difference — particularly when erections are affected by cardiovascular or metabolic health.
Pelvic floor physiotherapy
Specialist physiotherapy can help improve pelvic floor muscle function, which plays an important role in erectile rigidity and control.
Tablets (PDE5 inhibitors)
Medications such as Viagra (sildenafil), Cialis (tadalafil), and vardenafil.
If one hasn’t worked well for you, it doesn’t necessarily mean these medications aren’t right — dose, timing, or choice of drug often matters.
Treating underlying medical conditions
Including cardiovascular disease, testosterone deficiency, diabetes, thyroid problems, and raised prolactin levels. Addressing these can improve erections and overall health.
Penile pumps
Vacuum erection devices that help draw blood into the penis and support erections. Some men find these helpful on their own or alongside other treatments.
Intraurethral alprostadil
Medications such as MUSE or Vitaros, placed into the urethra to help stimulate an erection.
Penile injections
Injections directly into the penis, such as Invicorp or Caverject. These can be very effective for some men when tablets haven’t worked.
Shockwave therapy
Focused Low-intensity shockwave therapy (Li-ESWT) uses sound waves to stimulate blood vessel growth. For some men with mild to moderate erectile dysfunction related to underlying cardiovascular disease this can be effective. A course of treatment is usually 6 to 12 sessions, and the effects can last up to 2 years.
Penile implants
A surgical option, usually considered when other treatments haven’t been effective.
Psychosexual therapy
Talking therapies that address anxiety, confidence, sexual trauma, or difficulties with desire and arousal. Approaches may include sex therapy or trauma-focused therapies such as EMDR.
Couples or relationship therapy
Helpful where relationship dynamics, communication, or mismatched desire are contributing to erection difficulties.
Making sense of the options
This can feel like an overwhelming list. The key point is that these treatments work in different ways and are effective for different underlying causes.
Many men try several treatments with mixed success because they haven’t had a clear assessment of why their erection difficulties started in the first place.
Once the underlying cause is properly understood, treatment can be much more focused and effective. For example:
If significant cardiovascular disease is present, psychological therapy alone is unlikely to be enough.
If testosterone levels are genuinely low, this needs to be addressed directly.
Many men who come to see me have already tried tablets, testosterone, injections, shockwave therapy, PRP (“P-shot”), or other treatments — often without a clear plan. I offer a different approach: one that focuses on understanding why the problem developed, so treatment is appropriate, proportionate, and genuinely helpful.
Should I See a GP, a Urologist, a Sexologist, or a Sex Therapist?
It can be confusing working out who to see and where to begin.
Urologists are excellent for structural problems, prostate disease, and surgical conditions. If you have prostate cancer, significant urinary symptoms, or need surgery, a urologist is the right specialist.
Erection problems, however, are often not purely structural. They commonly involve cardiovascular, hormonal, psychological, and relational factors. For an initial assessment, it can be helpful to see someone who can look at the whole picture and guide you appropriately.
Some men see a sex therapist, which can be very helpful where anxiety, confidence, or relationship dynamics are central. However, without medical input, this can miss underlying health issues or future risks.
Some GPs, including myself, have additional training in men’s health and sexual medicine — but many do not. I regularly see men in general practice whose erection problems in their 50s were treated intermittently with Viagra, only for them to go on to have major, preventable heart attacks in their 60s or 70s.
There are also clinics offering treatments with limited evidence, or medical interventions where the underlying difficulty is primarily psychological or relational. My approach is to integrate medical assessment with psychological and relational understanding so that treatment is appropriate, proportionate, and genuinely helpful.
If you’re looking for an erectile dysfunction specialist, you’re likely looking for someone who can bring all of these strands together — which is still relatively uncommon.
What to expect when you come to see me
Most people arrive anxious — unsure what will happen, worried about being judged, or wondering whether they’ll be able to talk openly, what an examination might involve, or whether they’ll be criticised for masturbating or watching porn. Almost universally, they leave relieved that talking things through with someone skilled was straightforward and helpful.
The Full Assessment
Once we have clarity about the problem, I carry out a systematic review of your medical history, family history, and relevant risk factors. I’ll usually ask about your current and past sex life, lifestyle, and relationships. We look at things from a medical, biological, psychological, relational, and cultural perspective.
Sometimes a genital examination is helpful; sometimes it isn’t necessary. Where it is indicated — particularly for erection problems — it’s usually worthwhile, but it is always optional.
If you’ve had blood tests before, you can send them ahead of the appointment. If not, we’ll usually arrange blood tests, which need to be taken before 11am.
I might suggest further investigations such as:
Night-time erection monitoring (ADAM sensor)
Home blood pressure monitoring (Hilo band)
Sleep apnoea assessment (WatchPAT)
Cardiac tests such as ECG, echocardiogram, calcium score, or CT coronary angiogram
Everything is discussed with you, and nothing is compulsory. I never suggest anything I don’t believe is evidence-based or genuinely helpful, and nothing I wouldn’t recommend for my own family member.
What I Hope You Gain From Working With Me
By the end of a few consultations, my hope is that:
You’re enjoying sex again, with a positive and realistic vision for your sexual life. You feel confident and at ease in your sexual self, with a deeper understanding of your sexuality and a fuller experience of pleasure.
You have a clear understanding of your physical health, alongside a practical plan to improve it in both the short and long term — whether that means significantly reducing future cardiovascular risk or treating an underlying medical condition contributing to your erection difficulties.
You feel taken seriously, understood, and no longer alone in dealing with the difficulty.
How Long Does Treatment Take?
If the issue is primarily medical, improvement can sometimes be relatively quick. Particularly if you haven’t tried much before, addressing underlying medical factors and adjusting medications can lead to noticeable improvements once a clear plan is in place — sometimes within just two or three appointments.
If the difficulty is primarily psychological or relational, progress can also be made relatively quickly. Meaningful change often occurs within around six sessions. When an anxiety loop has developed, and you’re willing to engage with the process — whether within a relationship or through ongoing sexual experiences — change tends to follow when you’re able to reflect on what’s happening and try things differently.
If you’re in a relationship, I may recommend one or two sessions with your partner to explore things from a relationship therapy perspective.
For many men, erectile dysfunction can be resolved — particularly when underlying causes are addressed rather than symptoms alone.
Who Tends to Benefit Most From Seeing Me?
1. Men in midlife who haven’t engaged much with healthcare
If you're a man in your 50s or 60s who doesn't have a relationship with a good GP, doesn't particularly like going to the doctor, but you realise you need to take your health seriously and want to improve your health
2. Gay, bisexual and queer men
If you want to seek help but are worried about seeing someone heterosexual who's not comfortable talking about gay or queer sex. You can come to someone who ‘gets it’, who doesn't need things explained, and who's non-judgmental and non-shaming
3. Men who want a thoughtful, whole-person assessment
Perhaps you’ve tried quick fixes, or had a very medical or therapy based approach which hasn’t helped. I often see men for second opinions or after they’ve seen several other specialists.
That said, I see men across the spectrum – all ages – from men in their 20s to late 80s,all relationship statuses, all orientations. If you're struggling with erection problems and want someone who'll actually work out what's going on rather than just handing you a prescription, you're in the right place.
That said, I work with men across the spectrum — from their 20s to their late 80s, across all orientations and relationship statuses.
