The most frequent question asked by men suffering from erectile dysfunction is whether the problem is medical or psychological. It may help to know that it is also the first question a doctor will try to determine. If you are experiencing difficulty maintaining an erection during intercourse, it is always a good idea to get an evaluation from a urologist first. Even when it is clear that there are psychological aspects to the problem, an evaluation by a urologist can find and treat medical problems which may be contributing to impotence. After sorting through the possible medical causes for the problem, the doctor may ask you certain questions about your erections. The following are some questions which can be very helpful in determining how much of the problem is physical and how much is psychological:

• Do you have erections while asleep or upon awakening?
• Do you have erections while on vacation, but not at home?
• Are you able to have sex on weekends but not during the week?
• Are you able to get an erection when alone, but not with a partner?

If you answered "yes" to any of these questions, it is possible that psychological factors are playing a central role in the problem. This problem can be due to a variety of concerns such as stress, anxiety, or problems in your relationship. Your doctor can give you the name of a competent therapist who specializes in the treatment of sexual dysfunction and couples therapy.

Performance Anxiety

Everyone is familiar with the term "performance anxiety." However, most people believe it is a reaction which occurs only in front of a large audience. The reality is it could happen in almost any situation in which a person feels that others have expectations of him that he must meet.

A performer experiences stage fright when others are waiting to be entertained and expect a good show. This, of course, places a great burden on the performer who had better give the audience its money's worth if he values his career!

What happens when a man feels the same type of pressure to perform sexually?

There may not be a large audience, but you can imagine the anxiety that is sure to result. In a way, it is even worse than the anxiety of an entertainer, because a man has no direct control over his erection. A natural erection is caused only by sexual arousal, which directs blood flow into the penis, thereby causing an erection.

If a man is preoccupied by anxiety for whatever reason, he is not likely to get aroused. If he's busy thinking about whether he'll get an erection, then he won't be focused on the activity that is sexually arousing. This distraction is almost certain to prevent the erection he is so concerned about.

If instead, one can focus on enjoying the process of sex, the performance will follow naturally. The best way to do this is to have sex without intercourse for a period of time. This is what sex therapists call "sensate focus" exercises, or "non-demand stimulation." Briefly, it consists of exercises done at home, preferably two or three times a week, in which the couple take turns gently and sensuously massaging each other. The key at first is to avoid genital touching in order to take the focus and pressure off of getting aroused and the enjoyment of physical intimacy. When the couple has become accustomed once again to the experience of mutual pleasure without the expectation of arousal, genital touching can be included. Eventually, intercourse can be included in the experience as well, but only as an optional part of the couple's sexual repertoire -- not as an expected (demanded?) part of sex.

Developing Control

Premature ejaculation is perhaps the most common of all sexual dysfunctions. The good news is that it is also the most treatable.

One of the foremost leaders in the field of sex therapy, Dr. Helen Singer Kaplan, once wrote, "Premature ejaculation is the favorite dysfunction of sex therapists because ... it is extremely easy to treat with sex therapy in most cases, yet it is resistant to other forms of treatment."

Although erections cannot be brought under voluntary control, orgasm can -- but only if you can tell when it will happen. The key to control of ejaculation is to become more aware of the sensations which signal that orgasm is about to occur.

This awareness is best developed through homework exercises done by the couple together. This partnership has the added benefit of allowing the couple to communicate with each other about the problem, which may otherwise be avoided out of concern or embarrassment.

The couple is asked to practice foreplay and penile stimulation just prior to the point of ejaculation. At that point, the male signals his partner to stop stimulation until his level of arousal subsides. The couple then resume stimulation, and the process is repeated at least three times until ejaculation is allowed to occur.

With sufficient practice, the man can learn to predict the "point of no return." With this awareness, control soon becomes second nature.

The 10 Most Common Causes of Low Sexual Desire

• Boring sexual routine
• Anger towards partner
• Work stress/fatigue
• Performance expectations
• Anxiety
• Certain medications
• Discomfort with body
• Guilt about sex
• Depression
• Endocrine disorder

Alcohol and Sex

As the porter said to Macduff in Shakespeare's Macbeth, concerning drinking and sex, "...it provokes the desire, but it takes away the performance." As with most things he wrote, Shakespeare was right on target. The key to understanding the effects of alcohol on sexual functioning is to separate arousal and performance.

A moderate amount of alcohol may work just fine for loosening inhibitions and enhancing arousal without impairing performance. Beyond that level, which differs among individuals, alcohol still gets you in the mood quite effectively (arousal), but it has a negative effect on your ability to get and maintain an erection (performance). It also inhibits orgasmic functioning in women.

Long-term use of alcohol can have much more serious consequences on sexual functioning. Because of its potential effects on the liver (cirrhosis) and testicles (testicular atrophy), alcohol dependence can result in a decrease in the level of the hormone testosterone, which can cause the loss of sexual desire and problems with erections. After giving up long-term drinking, a man may experience sexual problems too, but these tend to be psychological in nature and are therefore treatable. This is often related to the psychological adjustment one makes in dealing with reality once again without the help of alcohol.

Fighting Fairly: Improving Communication Skills

• Do you and your partner engage in shouting matches in which neither of you actually listens to the other?
• Do you find yourselves reopening old wounds because -- what the heck -- you're both already letting it all out over some other issue?
• When your partner gets you angry are you afraid that if you say something, it will only make matters worse?

These are typical of the patterns that couples engage in when fighting unfairly. Communication breaks down when a fight defines the battle lines which each side has to defend while attacking the other.

Instead, a fight between a couple should be seen as a glitch in the otherwise cooperative relationship. Then each partner has an interest in the problem being worked out.

Think of a problem in a relationship as a hole in a boat with two people aboard. They would certainly gain nothing by blaming or screaming at each other. That way they simply sink together. Instead, they need to work cooperatively to stop the leak.

The key here is to listen to your partner's point of view without defensiveness and to respond without blame by stating your position. When you each understand both points of view, identify your mutual goal and be ready to compromise in order to achieve it.