- Physical versus psychological causes -

Today’s estimates indicate that in the USA alone approximately 10-20 million men suffer from various degrees of impotence at some point in their life.
In spite of the widespread believe that erectile problems are mainly caused by psychological factors, since the 1980’s it is revealed that perhaps about 80% of the erectile dysfunctions start with a physical factor. These could be surgical trauma, accident, diabetes, circulation problems, neurological problems, drug or alcohol abuse or as a side effect to medication.
However it is important to consider the interaction between the psychological and physical causes as a maintaining factor of this problem.

- Performance anxiety- the vicious circle -

One should also make a clear differentiation between erection problems which are persistent, and those which are present in some situations but not in others.
In sex therapy it is described as situational erectile dysfunction - and is referred to it in an enormously rarefied tome- the DMS IIIR (Diagnostic Manual of the American Psychiatric Association) - as a “…persistent or recurrent partial or complete failure in males to maintain erection until the completion of sexual activity”.
If a man fails to perform for any reason which, in certain circumstances, is quite common, he may well start worrying. Later on, the specific cause of his failure may be sorted out, but the anxiety remains, setting a vicious circle in motion: he worries because he cannot perform, and he cannot perform because he worries.
This kind of anxiety can interfere with the man’s excitement level and as a consequence he will lose his erection.
The more often he worries about his erections the more likely he is to lose them.
Most negative emotions like anger, resentment towards the partner, guilt and negative past emotional experiences can interfere with the excitement level. It is because it is not just a biological dynamo that powers sexual activity (like hormone level etc.) but also the processing of information in the brain.
Both biological and emotional factors can negatively and positively influence sexual arousal. A useful analogy in this instance would be that of a circuit, the point of which could equate to the brain (fantasy, sexual thoughts), perception (sight, hearing, smelling etc.) touch and emotions towards the sexual partner.
If a certain stimuli is negative at any given point on this circuit (e.g. painful stimulation, undesirable appearance of the partner) then the person would lose his or her sexual excitement; rather like turning the light on and off. If a man feels anxious or guilty during sexual activity, then it matters little how willing and pretty his partner is. Click, out goes the light.

- Feelings towards each other -

The most common secondary problem that arises is how the partners cope with this problem. Most people desire to please their partners, and it is fine until this desire gets out of hand. The person could become a victim of his own feelings; that of wishing to please the partner at any cost, and the expense of his or her own needs.The result could be lack of confidence in self.
If the partner is unsatisfied she may well react with anger, and in turn both feel unloved and rejected. These are obviously not ideal conditions for love making.
From the above explanation it is obvious that relationship issues play a complex part in performance anxiety. Erectile problems, as in most sexual problems, cannot be treated independently. They have to be managed in the context of a relationship. That is the reason why relaxation and experimentation with tranquilizers alone are often times in vain though in some instances they can help.
Most of the time it is advisable to seek professional help to unravel the underlying psychological issues of the problem.

- The possible cure -

When the relationship problems are resolved and communication is reestablished between the partners, then the sexual problem can be targeted.
The most common technique used is called sensate focus: this involves teaching the couple to focus on their own feelings and sensations, and to participate together on homework assignments.
The idea behind this is to allow people to become relaxed with each other both physically and mentally, thereby allowing them to recognize their own feelings. In order to reduce stress and performance anxiety, the couple is advised to refrain from intercourse for an initial period of a few weeks. The couple is told to caress each other, but not in a sexual context. This hopefully reestablishes sensuality and intimacy in the relationship; both partners do not worry about penetrative sex, as they are not allowed to have it. There are different stages in this therapeutical process and the couple goes through them gradually. Most of the time guidance from a qualified therapist is essential, giving important feedback to the couple as they progress.