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  • Writer's pictureFiona O'Farrell, LMFT

Everything You Need To Know About Erectile Dysfunction

Updated: Dec 16, 2023

By Jessica Leith & Fiona O'Farrell

There are few topics men like to discuss less than erectile dysfunction (ED). Scratch that, there may not be anything more embarrassing than confronting the reality that erections are not a sure thing every time you engage in sexual acts with your partner or with yourself.

The stigma associated with this issue runs counter to the masculine perceptions of what “real men” should be: strong, confident, and ready to go at any moment. Exactly why most ads for treating erectile dysfunction run during football games. It’s the dirty elephant in the room that no one wants to talk about.  

Well, we’re here to address this elephant. We will discuss everything you need to know about erectile dysfunction, including:

  • Stigmas surrounding it

  • What it is

  • Its causes

  • Its symptoms and warning signs

  • How common it is

  • How to treat it

  • How to remain sexually active

  • How Pepper Together can help

Stigmas surrounding penises and erectile dysfunction.

The shame that is often attached to erectile dysfunction is central to the problem. And the way we talk about erections, particularly the language we use, just raises unrealistic expectations for all involved. So, let’s start with some general rules before doing a deep-dive into the world of erections to start adjusting our expectations, and keep these four pointers in mind as we delve into the variety of causes and options for penis-owners and their erections.

ED terms matter

And anytime we hear “dysfunction” we automatically attach negative sentiment to it. We will use the term “erectile dysfunction” throughout this article because it is the most common term we collectively use to describe the variation a penis-owner experiences in relation to their erections. Note: the dysfunction is attached to the erection and not the penis. Generally, a penis is perfectly functional whether it is erect or not. 

So let’s keep in mind that penises are totally functional in their non-erect form and all penises vary in size, shape, length and levels of rigidity. Moving forward we can start to lean towards the idea that an erection is something that is “experienced” instead of thinking of it like a light switch that is either on or off and we can move away from using the term “dysfunction” altogether to describe variance in erection experiences. 

An erect penis is not required for pleasure

Even if you suffer from erectile dysfunction or have a hard time getting and keeping an erection, an erect penis is not required for pleasure. The penis, testicles, perineum and anus are full of nerve endings and pleasure sensors. A lot of penis owners are socialized from a young age to depend on an erect penis to signal to them that they are experiencing pleasure. 

However, an erection is typically the result of pleasurable stimuli, and not the cause of it. Once you start paying attention to the pleasure instead of the penis’ response to it, you’d be surprised at how much you can enjoy. Particularly, the corona of the penis (the ridge that forms where the shaft of the penis meets the head) is jam packed full of pleasure sensing nerve endings and is primed for intimate play. 

A soft penis can penetrate

You will discover a whole new world of sexual experiences once you let go of waiting for an erection to start the show. Make sure to use lots of lube and discover the ways both you and your partner respond to playing with a soft penis. The skin to skin action alone will release a ton of feel-good endorphins and a soft penis can totally be inserted as long as everyone is relaxed and having a fun time exploring one another. 

Penises change over time 

Just like the rest of our bodies, the penis also changes as we age. The common misunderstanding is that erection frequency decreases much later in life, however many men report changes in penis rigidity starting in their mid-late twenties and onwards. 

What is erectile dysfunction?

Erectile Dysfunction is the inability to experience and/or maintain an erection during sexual activity and may or may not include a marked decrease in overall erectile rigidity (DSM V, APA). Some people are able to get one but are unable to maintain it for more than a short period of time, while some can become erect in certain contexts (e.g. while watching porn), but are unable to experience one in others (e.g. with a partner). 

Erectile dysfunction tends to be more common in older males, especially for those 60 and older, though it can affect penis owners at any age. Finally, erectile dysfunction is only diagnosable if the decrease in erections lasts for six or more months and cannot be explained by some other explanation (medication, drug/alcohol use, injury, etc.)

Causes of erectile dysfunction.

Causes of ED vary from medical (e.g. hypertension), to psychological (e.g. stress, anxiety). 

In order for a penis to become fully erect and stay erect, a series of coordinated events must happen. Often, we simplify this process since erections are so plentiful and often unwanted when men first experience erections during puberty. 

The process of a fully erect penis is actually quite amazing when you look at all the events that need to align for it to occur. Erections start in the brain, usually there is some kind of stimulus that tells the brain to signal to the body for blood to flow freely and fill the chambers of the penis. Not only do the arteries and veins that fill the penis need to be fully open to fill, but the veins responsible for preventing back flow out of the penis must also function well enough to close and restrict the blood from emptying. 

Essentially, issues associated with erectile dysfunction can occur at any of these phases: 1) The brain signal, 2) the in-flow of blood, or 3) the restriction of backflow. Next time you or your partner experience ED, consider the many factors that may be contributing to the issue.

Physiological/Medical Causes 

Erectile dysfunction can be linked to many health considerations such as diabetes, rapid weight gain, smoking, chronic health disorders, heart or kidney disease, and numerous others. It’s important to make sure to rule out any potential medical condition at the onset of ED, by visiting your health provider.

Difficulty experiencing an erection and maintaining it may be physiological or psychological in nature or, in some cases, a combination of both. Many penis-owners hesitate to acknowledge erectile dysfunction or choose not to address it, which can unfortunately lead to further stress and challenges down the road.

More importantly, not seeking help with erectile dysfunction can prevent accurate diagnosis if the problem is related to more severe underlying health conditions such as heart disease or diabetes. Eventually, it can be difficult to tease apart what is an organic medical condition and what is psychological.

Psychological Causes & Impacts

There are a number of psychological conditions that are positively correlated with erectile dysfunction, including anxiety, depression, stress, sleep disorders, body image issues and low self esteem, to name a few. However, even if the cause stems from a medical condition, the impact of the distress related to this can be the real culprit. 

This is where the convergence of physiological and psychological manifestations of ED occur. Disappointing experiences in the bedroom can bring up a lot of negative self talk, which may impact feelings of anxiety and depression and thus becomes associated with the act of engaging in sex.

It can become a vicious cycle where men start to avoid anything associated with being sexy for fear that they aren’t going to be able to meet theirs or their partners sexual needs. We know that performance expectations alone can threaten the ability to have a satisfying sexual experience. Read more about “spectatoring” in our better sex guide

Symptoms and warning signs of erectile dysfunction.


Symptoms vary, depending on what is contributing to ED (e.g. organic or psychological, or more often, a combination of both). The primary red flag that sparks awareness that something may be up is the inability to get or maintain an erection. The medical community will often asses for this in the context of penetrative sex. This can occur suddenly or more gradually over time. Many of the psychological symptoms that accompany ED can be offset by a simple visit to your medical provider, in order to rule out any potential health conditions. Depending on other potential symptoms, they will be able to determine if further testing is warranted.  

Warning signs

The most common warning sign for erectile dysfunction is most likely major life transitions, dissatisfaction in your relationships or major changes in physical health. As a sex and relationship therapist, it is important to highlight that the penis is often the whistleblower of deeper relational issues. Erections often decrease when there is lack of trust or satisfaction in the relationship or a decrease in desire for sexual intimacy with your partner. 

Most people prefer to think of ED as a medical issue only, however it is a more holistic disorder, impacted by a variety of factors in your life. Changes in physical health, either sudden or gradual (including aging) are the other most common reason for ED. Erectile dysfunction is not hereditary but the medical conditions that can impact erectile function are hereditary such as heart disease and other cardiovascular issues. 

Finally, most of the medical literature cites the signs of erectile dysfunction in relation to penetrative sex, but contexts can vary. If this is something that has always been a concern, or begins to show up on a regular basis, it is important to get a physical examination with your primary care provider or a urologist or consider reaching out to a sex therapist.

How common is erectile dysfunction?

Erectile dysfunction is more common than most people think and affects about 30 million men in the United States. The Massachusetts Aging Study estimates that about 40% of men at age 40 have experienced ED and these rates go up with age, (remember your whole body changes, including your penis) with a reported 70% of men aged 70 and older going through it. Common reported experiences include reduced sexual desire to difficulty getting and maintaining an erection during penetrative sex. It’s quite common to experience an erection sporadically but not necessarily when you want to have sex, or it may not last as long as desired.

Treatments for erectile dysfunction.


The good news is that there are lots of ways to treat ED. The first step is to talk to your health provider to rule out any serious medical conditions that may be impacting this. Depending on the cause of the issue, your doctor may recommend simple lifestyle changes or medication, Viagra and Cialis being common options that you can discuss further with your health provider. It’s important to know that even these medications are about 60% effective so there will be variance using that little blue pill too. 


Other treatments such as injectables (yes, a shot right in the dick), penis pumps, pelvic floor strengthening with a board certified pelvic health physical therapist, mindfulness practices through meditation or yoga and acupuncture are all potential treatment strategies for ED.Many people often seek sex therapy as a last resort for treating erectile dysfunction after all other explanations have been ruled out. As a sex therapist, we strongly encourage you to consider reaching out sooner rather than later, research shows that therapy with a trained sex therapist (see for a list of certified sex therapists) is one of the most effective treatment strategies for ED.

Once medical concerns have been ruled out, you can focus on retraining the strongest sexual organ in the body – the mind. The mind is the control system of all sexual responses and training the mind is the best way to combat worries about erectile dysfunction. 

Is it possible to still have sex/be intimate with ED?

Yes, there is absolutely no reason why erectile dysfunction has to effectively end your sex life (see our four overarching rules above). As we mentioned in our section on getting creative, it’s really just accommodating to your needs. You can absolutely still have penetrative sex with penis’ that have varying levels of hardness and you and your partner can experience pleasure. In fact, one study with cis men who experienced severe levels of ED reported that they are still able to achieve an orgasm. 

If you are a partner of someone experiencing erectile dysfunction, then you can do your part by being just as interested in your partner’s penis whether it’s erect or not. Somatic Sex Educator Duo of Pleasure Mechanics have a great podcast episode about reclaiming the soft penis and other erotic touch practices that will expand your repertoire of sexy activities. 

Once we give the penis a break, there are many other bodily sensations that can be sexually intense and contribute to full body orgasm. Consider turning your attention to the other major player in penis-owning pleasure–the Prostate! The prostate gland is part of male sexual anatomy and when stimulated (most commonly via the anus) is considered to be full of satisfying sensation. Many men report deep intense orgasm through prostate stimulation. As we stated above, an erect penis is a part of the arousal experience, but not a requirement for sexual intimacy.

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