Gay Men’s Sexuality: Three Types of Erectile Dysfunction and Their Interventions
[Warning: This is an adult clinical discussion of sex therapy topics provided by a licensed clinical social worker and trained sex therapist. It is not restricted adult content, nor is it literary erotica or “pornography,” but reader discretion is advised if you are sensitive to frank discussions of sexual health topics.]
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:
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Erectile dysfunction in gay men is often more specific—and more situational—than most people realize.
Many men I work with are not dealing with a total inability to get an erection.
They’re dealing with something more frustrating—and more confusing:
- You can get hard… but not when it matters
- You’re fine alone… but not with a partner
- You start strong… but lose it during sex
At that point, the question becomes:
“What exactly is going wrong?”
Because not all erectile dysfunction is the same.
And if you don’t understand which part of the process is breaking down, it’s very difficult to know how to fix it.
In my work as a specialist in therapy for gay men and an AASECT Certified Sex Therapist, one of the most useful ways to understand erectile dysfunction is to break it into three distinct phases—each with its own causes, patterns, and solutions.
This framework often helps men move from confusion and self-blame to something much more useful:
clarity.
In my long (28 years) career as a specialist in therapy for gay men, and with my emphasis on sex therapy, one of the most common complaints I hear involves erectile dysfunction. In simple terms, this refers to a (cisgender) man’s ability to get “hard” and remain erect long enough to complete a full sexual cycle, whether oral or anal intercourse.
It’s important to remember that many gay men do not prefer anal intercourse—and that is perfectly valid. However, many men do want to engage in the Top role and enjoy the physical and psychological pleasures associated with penetration for both partners.
Three Phases of Erectile Function
Erectile dysfunction can be understood in three phases:
- Getting erect upon arousal or stimulation.
- Getting erect enough to penetrate.
- Staying erect through intercourse.
In the case of my client “Paul” (details changed for confidentiality), we explored how the term “erectile dysfunction” can be imprecise. For Paul, getting an initial erection was not the issue. The difficulty was staying hard enough to penetrate his partner and sustaining the erection long enough to complete intercourse to mutual orgasm.
Working with Paul clarified how ED can occur at different points in the sexual sequence. Each phase may require a different intervention.
Medical providers such as urologists or endocrinologists often evaluate these phases as well. Sex therapists frequently collaborate with MDs because ED can have both medical components—such as blood flow, hormonal balance, testosterone levels, estradiol levels, and circulation—and psychological components. (I have written separately about cognitive causes and cures of ED, as well as the fear of topping and the fear of bottoming.)
What many men don’t realize at this stage is that identifying which phase is breaking down is only part of the picture.
For most men, the next question becomes:
“Why is this happening in the first place?”
That’s where things often become more complex—because erectile difficulties are rarely just mechanical. They are usually influenced by performance anxiety, self-monitoring, relationship dynamics, and the broader psychological context of sex.
If you want a deeper look at how those factors interact—and what actually helps interrupt the cycle—you can read more here:
Erectile Dysfunction in Gay Men: Causes, Anxiety, and What Actually Helps
Assessment of the ED Situation
If you are experiencing ED, it helps to break it down precisely. Are you struggling with desire and libido at the early stage? Do you have initial erectile response at all? Or does your penis remain flaccid despite sexual desire and stimulation?
Alternatively, do you achieve partial erection that is short-lived and not sturdy enough to penetrate the mild resistance of the anal sphincter?
Or can you penetrate but not maintain erection long enough for a reasonably satisfying duration of intercourse?
For Paul, Cialis (Tadalafil) helped him achieve initial erection. However, he “psyched himself out” when attempting penetration with his relatively new boyfriend, Lorenzo. A general practitioner prescribed the medication.
When we unpacked what “psyched himself out” meant, Paul described getting in his head about whether he could satisfy Lorenzo. Lorenzo had a long history of enthusiastic bottoming. Paul also reflected that in his previous long-term relationship, penetrative anal sex was rare. He and his former partner were satisfied with oral sex, mutual masturbation, massage, and touch.
Now Paul felt pressured. Lorenzo considered Paul’s sexual repertoire “under-developed.” That comment left Paul feeling criticized and defensive. Resentment and performance anxiety began to interfere.
Cognitive Versus Medical Causes of ED
Paul’s situation illustrates how ED often reflects more than physiology. Perhaps he unconsciously resented being pushed toward a sex act he did not strongly desire. Perhaps he still had unresolved feelings from his previous relationship. Lorenzo’s “bossy bottom” dynamic may have triggered performance pressure.
Age-related self-doubt may also have played a role. Ageism within the gay community can erode confidence. Feeling socially or sexually devalued can affect erection reliability.
Of course, medical factors must also be ruled out. Blood pressure medications, HIV antiretrovirals, hormonal imbalances, stress, trauma history, sexual abuse, and sleep deprivation can all diminish erectile response.
In Paul’s case, I wondered whether his GP’s prescription fully explored dosing or alternative medications. Other oral agents such as Viagra or Levitra might produce a different effect. He also experimented with mechanical options such as a cock ring, which slows venous outflow from the penis. That intervention provided only limited benefit.
Specialty providers sometimes offer additional options, including compounded injectable medications such as Tri-Mix or Quad-Mix. These are administered with very small insulin-style needles and can produce strong erections. However, they carry risks, including priapism (a prolonged erection requiring medical attention).
Paul had not been informed about these options. Many clients report that general practitioners do not always review the full spectrum of available treatments. In session, I provided psychoeducation about discussing these options with his physician. As a Licensed Clinical Social Worker, I defer medical decisions to licensed medical providers.
Self-Talk in ED
We also explored Paul’s internal dialogue during sex. What was he telling himself? Was he questioning his ability? Doubting whether he was “enough”? Fearing negative evaluation from Lorenzo?
While medication may support erection, negative self-statements can undermine it. Identifying and rewriting self-talk can significantly shift performance anxiety.
Sensate Focus
Sensate focus is another foundational intervention in sex therapy. It involves shifting attention away from performance and toward sensory experience.
Sometimes good sex requires a degree of selfishness. Focusing on your own pleasure—rather than monitoring your erection—can paradoxically make you a more responsive lover. As Esther Perel has said, equality belongs in most rooms of the house—but not necessarily the bedroom.
Sensate focus can include noticing what you see, hear, smell, taste, and feel. The gleam of light on skin. The sound of breath. The scent of cologne mixing with natural musk. The texture of touch. When attention anchors in sensation rather than anxiety, the penis often responds spontaneously.
Positive self-statements can also help. Internal messages such as “I can do this,” or “I’m confident,” support arousal rather than undermine it. Many Tops find that embodying confident erotic energy strengthens erection reliability.
These interventions apply across all three phases of erection: initial arousal, penetration, and sustained intercourse.
Putting It Together
Effective ED treatment often involves both medical and psychological components. Adjusting medication may help. So may cognitive restructuring, sensate focus, and improved communication between partners.
Sexual connection is always a dance between physiology and psychology. It is also shaped by relationship dynamics, cultural pressures, and individual history.
Becoming a better lover is a process, not a single event. It unfolds over time and experience. It also requires balancing responsibility with erotic freedom.
Gay men often grow up without affirming messages about their right to pleasure. Sexual self-empowerment means reclaiming that right. It means allowing yourself erotic abandon within the bounds of consent and respect.
For many men, this is the point where understanding the problem starts to shift into wanting to actually change it.
If you’re recognizing yourself in any part of this—whether it’s difficulty getting started, staying present, or maintaining an erection—you’re already closer to understanding the issue than you may have been before.
But most men find that insight alone doesn’t fully resolve the pattern.
Erectile difficulties tend to reinforce themselves over time: a moment of anxiety becomes anticipation, anticipation becomes pressure, and pressure becomes avoidance.
At that point, what started as a situational issue can begin to affect confidence, relationships, and how you see yourself sexually.
This is where more focused, structured work can make a meaningful difference.
In my practice, I work with gay men on exactly these patterns—helping them reduce performance anxiety, rebuild sexual confidence, and develop a more flexible, grounded relationship to sex that isn’t dependent on everything going perfectly.
If you’d like to talk through what’s happening in your specific situation, you’re welcome to reach out.
Text or Call: 310-339-5778
Email: Ken@GayTherapyLA.com
Or you can start by exploring more about this work here:
Sex Therapy & Sexual Confidence
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.