What actually helps—beyond pills, injections, and panic
Ken Howard, LCSW, CST, is a gay men’s specialist psychotherapist and AASECT-Certified Sex Therapist with over 30 years of experience working with gay men, couples, and polycules. He provides psychotherapy to California residents and coaching to gay men worldwide, focusing on mental health, sexual confidence, performance anxiety, aging, relationships, trauma recovery, and long-term emotional well-being.
This article comes from my work with gay men around confidence, relationships, and sexual self-understanding.
If you want to see what working with me looks like:
Individual Therapy (CA) | Coaching (Worldwide)
Erectile dysfunction (ED) is one of the most common—and least honestly discussed—sexual concerns among gay men. I see it in men in their 30s and 40s who feel that “this shouldn’t be happening to me this young,” and in men in their 50s, 60s, and beyond who quietly fear it means something irreversible about aging, desirability, or masculinity.
Most articles about ED are either overly medical, painfully generic, or quietly shame-based. They reduce a complex human experience to blood flow, pills, or injections, while ignoring the psychological, relational, developmental, and cultural realities of gay men’s lives. When those realities are ignored, men are left feeling defective rather than understood.
I take a different approach.
What follows are practical, experience-based observations drawn from over three decades of clinical work as a gay men’s specialist therapist and coach. They are organized across the domains that actually shape erectile functioning in real gay men’s lives: medical and physical factors; intra-psychic processes; interpersonal dynamics; developmental and aging-related changes; and cultural and psychosocial pressures specific to gay men, including consensual non-monogamy and polycule structures.
Medical & Physical Factors
Medical and physical factors matter in erectile dysfunction, but they are not the whole story. Erections depend on physiology that includes cardiovascular health, nerve integrity, hormone balance (especially testosterone and estradiol, but also factors such as FSH and DHEA), sleep quality, medication side effects, alcohol use, and metabolic health.
There is a wide range of what is considered “normal” male sexual functioning. Some men masturbate several times a day and feel fine. Others are comfortable once a week. These patterns vary naturally and often change with age.
That said, I always encourage men experiencing ED to rule out or address underlying health issues first. This is why I often collaborate with MD urologists or endocrinologists.
A common online claim is that over-the-counter “testosterone boosters” resolve erectile dysfunction. There is no credible scientific evidence supporting this. These unregulated supplements often contain inconsistent ingredients, lack proper dosing standards, and may interact with medications or existing health conditions. When testosterone is genuinely a factor, it should be evaluated through blood testing and addressed under medical supervision—not through internet marketing.
The black market of anabolic steroids can also complicate erectile functioning. If you use these substances, it is essential to find a gay-affirmative and anabolic-educated physician. These providers are more often found in urban areas with large gay populations and are typically private-pay specialists in men’s sexual or hormonal health. While they can be expensive, even a single consultation can be educational and clarifying.
Telehealth can be a useful resource here. I have had positive professional experiences with Justin Saya, MD, of Defy Medical, who is nonjudgmental and well-informed. I would not tolerate a medical provider who is not explicitly affirming of gay male sexuality or dismissive of cultural considerations such as bodybuilding or aesthetics. I regularly hear stories of gay men having legitimate concerns invalidated by providers whose discomfort shows through an “ick factor” rather than clinical knowledge.
It is also important to remember that inconsistent erections are still erections. Erections naturally fluctuate, particularly under stress, novelty, or emotional pressure. Panic about variability often causes more difficulty than the variability itself. When fluctuation is interpreted as failure, the nervous system shifts into threat mode rather than erotic responsiveness.
Dr. Chris Donaghue, author and sex therapist, has long challenged the societal demand that men must “always” have consistent erections across all situations and stages of life. As he once said at a professional conference, when erections are absent, we still have fingers, toys, and tongues to play with.
Self-monitoring kills arousal. The moment sex becomes an internal diagnostic test—“Am I hard enough yet?”—attention moves away from sensation and toward self-surveillance. Desire does not thrive under scrutiny.
Alcohol is a larger factor than many men admit. Even modest drinking can significantly reduce erection reliability, especially with age.
Shakespeare captured this dynamic centuries ago in Othello (Act 2, Scene 3), when Iago says of alcohol:
“O, thou invisible spirit of wine,
if thou hast no name to be known by,
let us call thee—devil!
…It provokes the desire, but it takes away the performance.”
The fact that erectile medications such as Viagra or Cialis work inconsistently is meaningful information. When medication helps only sometimes, it often suggests that anxiety, pressure, or relational context—not just blood flow—are involved. Medication can be useful, but it rarely resolves ED that is rooted in fear, self-monitoring, or emotional conflict.
Intra-Psychic Factors
Intra-psychic factors describe what is happening internally during sex. Many men tell me, “I get all up in my head during sex.”
One of the most consistent patterns I see is performance-driven self-surveillance layered over deeper identity fears. Men may not voice these fears, but they often think them. Thoughts like “If I lose my erection, I’ve failed,” or “This means I’m not attracted enough,” escalate quickly into fears of judgment, rejection, or replacement.
For many men, ED becomes “proof”—however inaccurate—that they are aging, becoming irrelevant, or losing desirability.
A related set of myths involves pornography and masturbation. Some online movements claim that pornography causes erectile dysfunction. The best available scientific evidence does not support a direct causal link between typical pornography use and ED. Large studies that control for anxiety, depression, relationship satisfaction, and age show no reliable association between porn consumption and erectile functioning.
Researchers including David Ley, PhD, Marty Klein, PhD, and Nicole Prause, PhD, have repeatedly challenged the idea of “porn-induced ED,” noting that this narrative often reflects moral anxiety, performance pressure, sexual shame, or ideological extremism rather than physiology. Critics frequently conflate exploitation, trafficking, misogyny, and non-consensual acts with consensual adult sex work, obscuring the complexity of sexual expression and labor.
A related but distinct issue sometimes described clinically is “death-grip” conditioning. This is not a medical diagnosis, but a descriptive term for becoming accustomed to a very firm, specific style of masturbation. When intense grip pressure or friction becomes the norm, partnered stimulation may feel less stimulating by comparison. Because this pattern is learned, it is also modifiable.
Less commonly discussed—but often central—are unconscious emotional conflicts that undermine erectile functioning. Unacknowledged anger toward a partner, resentment about unmet needs, or chronic relational disappointment can quietly suppress arousal, even when a relationship appears functional.
Residual guilt about being gay or having gay sex can remain active long after conscious self-acceptance. This guilt often originates in religious upbringing, family rejection, or cultural shame. In these cases, ED reflects an unresolved internal prohibition against pleasure.
This pattern can also appear in obsessive-compulsive disorder, where extreme or irrational fears of STDs interfere with sexual engagement.
Neurodivergent individuals, including those on the autism spectrum, may experience unique challenges related to social interaction or sensory processing that affect erectile functioning.
Survivors of sexual assault or trauma may also struggle with ED. I have worked with many men on reclaiming their right to sexual expression after a perpetrator attempted to take that away.
Gay men who survived conversion or reparative therapy may experience erectile and sexual difficulties until they heal from those experiences. Ongoing political efforts to preserve or re-legitimize these practices continue to have real psychological consequences.
Chronic illness, neurological conditions such as multiple sclerosis, or injuries from combat, accidents, or athletics can also affect sexual functioning. Each of these requires its own thoughtful, individualized therapeutic approach.
ED can also emerge after the loss of a long-term partner. For some men, arousal with someone new feels like a betrayal of the deceased partner, and guilt blocks sexual response.
Other intra-psychic patterns include chronic self-criticism, imposter syndrome, negative body image, or a belief that one does not deserve pleasure or good things.
These conflicts produce spectatoring—watching oneself perform rather than experiencing sensation. Once this shift occurs, arousal typically drops quickly.
Therapy focuses on redefining sex away from erection maintenance and toward presence and connection. Changes in erection are reframed as signals, not verdicts.
If this is bringing up recognition or questions, start with curiosity — and let’s have a conversation about what might help.
Email: Ken@GayTherapyLA.com | Call/Text: 310-339-5778
Individual Therapy (CA) | Coaching (Worldwide)
Interpersonal Dynamics
Interpersonal dynamics include hookups, long-term partners, and polycules. ED can appear in any sexual context: hookups, open relationships, threesomes, group sex, and polycules.
Pressure to perform quickly, fear of disappointing partners, comparison, and avoidance after a prior difficult encounter all contribute. Chronic conflict avoidance or suppressed anger in relationships often manifests sexually.
I work with couples and multi-partner relationships on reconciling what happens in the living room with what happens in the bedroom. In these situations, the body becomes the messenger for what has not yet been spoken.
Normalizing non-intercourse sex as real sex, using calm language such as “I’m still turned on; let’s slow this down,” and staying present help interrupt pressure cycles.
Consensual Non-Monogamy, Open Relationships, and Polycules
In consensual non-monogamy, ED can intensify due to comparison and unspoken hierarchies. Explicit communication, slowing sexual escalation, and separating erotic worth from erection reliability help restore confidence.
ED may occur when someone compares himself to a newer partner, feels pressure to perform for multiple partners, or senses a lack of genuine attraction within a group dynamic. These interpersonal layers make ED complex and deeply contextual.
Developmental & Aging Factors (Especially Over 40)
With age, erections often require more time and stimulation. Many men recall adolescence, when spontaneous erections seemed constant and uncontrollable. Over time, spontaneous erections decrease, while responsive desire remains intact.
Anxiety about aging suppresses arousal more than aging itself. The task is adaptation—learning to move with developmental changes rather than fighting them.
Psychosocial Factors Specific to Gay Men
Early shame from authority figures, school bullying, body hierarchies among peers, and exposure to anti-gay political rhetoric all influence erectile functioning.
Some sexual trauma survivors struggle with topping if dominance feels unsafe. Others who are not trauma survivors may still associate consensual dominance with harm. Therapy helps cultivate healthy, negotiated dominance rather than reenactment.
What Actually Helps in Therapy
Effective ED work in therapy and coaching can include sensate focus exercises, addressing self-talk, expanding sexual repertoire, improving communication skills, relapse-prevention planning, and working directly with guilt, anger, trauma, and aging.
The goal is not perfect performance, but confidence, flexibility, and sexual self-trust.
Final Thoughts: ED Is Not a Verdict
Erectile dysfunction is not a commentary on masculinity or worth. It is a signal that something in the erotic system may need adjustment in that moment. Sensitivity, creativity, and playfulness often help more than medication alone.
If this topic resonates, you’re not alone — and this is exactly the kind of work I do with men who want real, practical change, not just insight. I help clients turn understanding into action — improving confidence, relationships, and quality of life in a thoughtful, sex-positive, and affirming therapy space.
About the author
Ken Howard, LCSW, CST is a psychotherapist and AASECT-Certified Sex Therapist with over 30 years of experience working almost exclusively with gay men. A former USC faculty member, he is also the host of The Gay Therapy LA Podcast, where he explores the psychology, relationships, and inner lives of gay men — and he brings that same depth and practicality into his work with clients through therapy (CA) and coaching (worldwide) via telehealth.