How Psychologically Troubling Is Erectile Dysfunction (ED)?

Erectile dysfunction (ED) is widely considered men’s most psychologically devastating sex problem. The evidence? All the publicity for the several erection drugs, notably Viagra, the 1998 introduction of which still ranks as the most headline-generating drug launch in history. Yet two aspects of ED remain controversial—its prevalence, and the depth of psychological distress it causes.

Recently, researchers at the University of Minnesota, Indiana University, and the California School of Professional Psychology in Los Angeles addressed these two issues in a methodologically rigorous investigation.

The Study

The researchers recruited 1,822 men involved in the 2021 National Survey of Sexual Wellbeing. Demographically, they formed a reasonably representative sample of American men. The researchers informed participants of a standard measure of erection, the International Index of Erection Function, then surveyed them about theirs, awarding gift cards when the men completed the survey. The investigators followed up the survey with telephone calls and emails to check the accuracy of replies.

One-Quarter of Men

At first glance, it shouldn’t be difficult to determine the prevalence of ED. After all, men can either raise erections or not. But the devil is in the details, and for ED, there are two difficult details: the definition, and how researchers ask men about it.

Defining ED is problematic. The World Health Organization defines it as “inability or marked reduction in ability over at least several months to attain or sustain an erection of sufficient duration or rigidity to allow sexual activity despite desire and adequate stimulation, and causing significant distress.” That sounds good, but it’s vague. How many months? Is solo sex included, or just partner sex? And how much emotional distress is “significant”?

Meanwhile, surveys vary. Some gauge severity, others don’t. Some aggregate self-sexing and partner sex, others don’t. Some consider age, others don’t. Some explore the role of medical conditions, but others don’t.

Consequently, previous studies have yielded prevalence estimates all over the map, from 13 percent of men to 71 percent.

In the recent study, approximately one-quarter of the men (24 percent) met criteria for ED, but severity differed.

These findings are consistent with other methodologically rigorous research.

Everyone knows that ED risk increases with age. After age 35, that’s true, but the study showed a J-shaped curve—modest risk among men 18 to 24, lower risk for those 25 to 34, then after 35, steadily increasing risk.

Until 35, the survey showed no men with severe ED. After 35, mild and mild-moderate ED predominated, but moderate and severe ED steadily increased. After 74, mild ED decreased as mild-moderate, moderate, and severe ED increased.

Less Psychologically Upsetting Than Many Imagine

In the recent report, the men expressed reluctance to mention ED to doctors. Of the 24 percent who reported ED, only 17 percent told health professionals.

This is troubling. Even if men opt not to treat ED, doctors should hear about it. ED may be an early symptom of potentially serious conditions: depression, diabetes, anxiety disorders, high cholesterol, high blood pressure, heart attack, and congestive heart failure.

Corroborating previous reports, in this study, only 25 percent of the ED sufferers took erection medication. Why so few? Researchers cite three reasons:

• If financed out of pocket, erection medications are costly.
• The drugs don’t work as well as advertised.
• Unpleasant side effects are possible.

Only one-third of men chose to treat their ED. Two-thirds preferred to live with it.

Why are men so unlikely to seek treatment? Most commentators mention two reasons:

• Compared with women, men are more reluctant to consult doctors for any reason.
• Men are also less likely than women to take prescribed medication.

Both are true, but they miss the real point. The major reason most men prefer to live with ED is that older couples stop having intercourse. For aging couples, intercourse becomes problematic. Older men become increasingly likely to suffer ED, and older women become increasingly prone to vaginal dryness or tissue thinning (vaginal atrophy) that can make intercourse difficult or painful, even with lubricants. So, older couples who remain sexual usually jettison intercourse for what sexologists call “outercourse,” all the other marvelous ways to enjoy satisfying sex: hugging, kissing, etc.

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If couples don’t have intercourse, men don’t need erections. Meanwhile, under the right conditions, they can still enjoy intense orgasms. Those conditions include an erotic context, an alluring partner, and more. Meet those conditions, and men with flaccid penises can still enjoy a pleasant sex life.

ED can be unnerving. Here’s what helps: Limit alcohol. Quit smoking. Enjoy regular exercise. Get at least seven hours of sleep per night. Weight control. A diet including at least five daily servings of fruits and vegetables while cutting down on red meats. And erection medications.

If lifestyle and medical approaches don’t provide sufficient relief, outercourse is always available, and can bring marvelous erotic enjoyment and satisfaction—even if men can't raise erections.