Understanding erectile disorder

By Madeleine Castellanos, M.D.

Picture this: You're in the middle of a fierce make-out session and reach down to grab what you expect will be a hard, throbbing erection. Instead, your hand is met with a disappointingly soft penis. Or maybe he's got an erection now, but loses it before you can actually get busy. Sure, what goes up must, eventually, come down, but so soon? Your first thought is probably, "Why can't he get it up? Isn't he attracted to me?"

But it's not that simple. As I discuss in my book, A Woman's Guide to Men and Their Penis Problems, erectile issues are actually incredibly common. According to the results of the Global Better Sex Survey, published in the April 2008 issue of the Journal of Sexual Medicine, 65% of men aren't satisfied with the quality of their erections (and neither are 63% of women).

It's no wonder erection issues are so widespread: They can have any number of causes, and very few of them have anything to do with your attractiveness. So before you start taking it personally, take a look at some of the reasons why he may have trouble getting hard: 

• Physical causes: Most cases of erectile problems are caused or influenced by physical issues, particularly those that limit blood flow to the penis or damage the nerves in that organ.
• Psychological causes: The brain plays an important role in sexual arousal. It is, after all, our biggest sex organ! What's going on outside the bedroom, whether at work or at home, and issues such as depression, anxiety, stress, fatigue and relationship issues all influence a man's ability to get or keep an erection.

Want to know if the cause of his erectile problem is physical or psychological? Work with him to understand how his body responds in various situations by trying these tricks:

• Do the tape test: Normally, a man can develop an erection during the night or upon awakening. This body response is known as nocturnal penile tumescence and is proof that he's physically able to have an erection. If your guy isn't sure, he can wrap a very thin and narrow piece of tissue paper around his flaccid penis, secured with a little bit of scotch tape. It's likely that if he has an erection when he's sleeping the paper will break to some degree. If he easily gets an erection during sleep, but not in other situations, the cause is likely psychological. If not, the reason is likely physical.
• Let him give himself a hand: If a guy can get aroused when he's alone (and masturbating, for example) and not when he's with a partner, the cause is psychological.

While these are only two basic facets of physical and psychological causes, they can help determine what type of expert to contact in an effort to understand what is going on and who to see for help.

While many people think of ED as an older guy's issue, there are some common causes of erectile problems in healthy young men:

• Performance anxiety: Perhaps the most common cause of erectile problems among younger guys is performance anxiety. Many cultures place pressure on men to be the "experts" when it comes to sex, which can make men feel like they have to be responsible for sex or know how to please their partner every time. This pressure can be stressful and make it more difficult to get or maintain an erection.
• Alcohol: A couple of drinks can loosen your inhibitions and help you relax, but alcohol can also impair sexual functioning. Alcohol works on the nervous system by slowing down brain function, breathing and pulse.
• Porn: The Internet has made porn more accessible than ever before. As a result, many men are using porn more often and masturbating more frequently--and that means they may have trouble climaxing, ejaculating or even getting an erection with real women.
• Condoms: It may sound like an excuse to get out of wearing a condom, but many guys have problems maintaining an erection when putting one on. The interruption of sex play is often distracting, as is the stress of putting on a condom.

If your guy complains that he can't stay hard during intercourse because of a condom, which often reduces sensitivity, he can try a thinner latex condom, like the Kimono brand, or a condom made from polyisoprene or polyurethane, which may provide even more sensation for many men.

Of course, most men have trouble getting or staying hard from time to time. That's normal, and you can usually trace it back to nervousness about a new relationship or a night out pounding back beers with the guys, for example. Try not to jump to conclusions: In many cases, it is a fleeting, situational event that shouldn't be cause for concern and doesn't indicate a lack of attraction to you or a loss of sexual function. So don't sweat it. The best thing to do is to move on to other enjoyable activities (such as kissing, breast stimulation, sensual massage, oral play) or call it a night.