Erectile Dysfunction or Erectile Unpredictability?

Sometimes male clients come to see me because they have trouble achieving and maintaining erections. That can be the primary reason they come in or it can be just one factor amongst several. Either way, we end up talking about a lot more than their erections.

Clients usually refer to the challenge as erectile dysfunction, or ED, but on the more progressive side of the sex therapy field, it’s more commonly referred to as erectile unpredictability. I also prefer the term, ‘erectile unpredictability.’ The word ‘dysfunction’ feeds the narrative that clients who struggle with erections are in some way ‘broken,’ a word I’ve heard several clients with erectile unpredictability use to describe themselves. A person may not have as much control over their ability to get an erection as they’d like, but they’re in no way broken. Experiencing erectile challenges may mean that a client needs to feel really comfortable with their partner in order to be intimate. It may mean that they are subconsciously protecting themselves from some perceived risk. And it may mean that they could use more practice sharing their sexual desires with a partner.

When a client comes to see me with erectile unpredictability, I often start out by coaching them on the more practical aspects of their experience. I sometimes urge them to take Viagra or Cialis to help them gain more confidence in the short-term. I always encourage them to engage in more ‘outercourse’ with their partner and to de-centralize the penis in their sexual encounters. But this is only the beginning of the work.

My general approach is psychodynamic and holistic; I explore the client’s previous sexual experiences, when they’ve had positive sexual encounters with partners, what their erections are like when they masturbate. Sometimes, non-sexual factors—traumatic experiences from their childhood, for example—play into their erectile challenges.

There’s a Yiddish proverb I like that goes: “Sleep faster! We need your pillows.” Working towards understanding and improving one’s erectile unpredictability has a similar quality as an attempt to ‘sleep faster’: one cannot will themself to having more consistent erections. It doesn’t come through direct effort. It comes from being open, self-accepting, curious, and exploratory. Success also comes from seeing the challenge as relational; erectile unpredictability often dissipates when a client has the warm support and cooperation of their partner.

A terrific book and resource on this topic is the edifying and highly readable The Existential Importance of the Penis in which renowned sex therapist Dan Watter applies the ideas of Irvin Yalom, creator of Existential Psychotherapy, to the practice of sex therapy.