Dan is 24 and he’s almost purple with embarrassment by the time he is sitting down in my consulting room. He can’t meet my eye. It takes every ounce of effort for him to finally mumble the reason why he has come: Dan struggles to get an erection.
It might sound surprising. After all, we often think of erectile dysfunction as something that happens in later life.
However, a shocking number of young men now struggle with the intimate issue.
The most recent data shows that roughly a quarter of young men – aged between 18 and 40 – suffer with some level of erectile dysfunction.
The reason this is so surprising is because, in many cases, erectile dysfunction is triggered by underlying chronic illnesses, such as high blood pressure, high cholesterol or diabetes.
These conditions lead to a narrowing of the blood vessels in the penis, making it more difficult to sustain an erection.
This is why when my older patients develop the issue I always check them for any hidden, potentially deadly, conditions.
However, Dan has none of these – he is in perfectly good health. His issue is something else entirely – and it is a problem I am now seeing with alarming regularity in men his age.
What Dan has is performance anxiety, driven by body image issues and, frankly, too much pornography.
We often think of body image worries as a women’s issue. But studies show that around a third of adult men feel anxious about their physical appearance.
The most recent data shows that roughly a quarter of young men – aged between 18 and 40 – suffer with some level of erectile dysfunction
It’s hardly surprising when we really think about it. Just as women have been sold an unrealistic standard of what they should look like physically by big fashion firms and reality TV, so too have men.
Adverts for something as innocuous as a package holiday often show men with impossibly sculpted muscles and a strong head of hair. Meanwhile, social media platforms such as TikTok and Instagram are filled with steroid-taking bodybuilding influencers who claim that their physiques are easily attainable.
This can all make going naked an intimidating proposition for young men – and leads to anxiety during sex.
Now add pornography to that mix, and the problem compounds dramatically.
The scale of pornography use among young men is extraordinary. The website Pornhub alone receives more than 100 million visits a day. Studies suggest that the majority of teenage boys watch pornography regularly, many from as young as 11 or 12, and research has found that a significant number of young men – some estimates suggest one in three – consider their own use to be compulsive or out of control.
This is causing real damage.
Pornography does not show ordinary bodies. It shows bodies at the extreme end of the scale, often with disordered eating and drug use, meticulously groomed to look even more extreme.
Dr Philippa Kaye say that worries about body image and sexual performance are at the heart of bedroom anxieties
The performances are not real – actors use medication and pumps, there are multiple takes, long breaks between scenes. None of this is disclosed. What young men absorb instead – often before they have any real sexual experience at all – is a template that bears absolutely no resemblance to reality.
Altogether, this causes men to feel self-conscious about their ability to perform during sex to the standard they see during porn, which in turn, makes it less likely that they will be able to keep it up during sex.
And I want to be very clear about something: this does not mean that this form of erectile dysfunction is ‘all in the head‘.
In fact, performance anxiety has a very real effect on the body. When you are anxious, your body goes into survival mode – it floods with stress hormones and actively redirects blood away from the genitals.
So the very worry about not getting an erection makes one physiologically less likely. Which then confirms the original worry. Which makes the next attempt worse. It is a vicious, self-reinforcing cycle – and it is biological, not imaginary.
What can be done? Quite a lot, as it happens.
Of course, there are medicines that can help. Viagra and Cialis are two cheap and effective erectile dysfunction tablets that can be bought over the counter in the UK.
However, they do not work for everyone – and won’t fix the underlying cause of the problem.
GP, author and broadcaster Dr Philippa Kaye
Instead, the first step is simply naming what is going on. I saw this with Dan. Once he was able to voice his worries, I was able to explain to him how normal his feelings are – and how he was setting unrealistic, punishing expectations for himself. This lessened his anxiety a lot. So it’s always worth raising the issue with your GP – I appreciate it feels embarrassing to you but we have seen and heard it all before.
However, there are other steps.
For men with high pornography use, it’s important to cut back. This may help anxiety, but it will also help in other ways. There is good evidence now that overconsumption of porn desensitises the body to sexual stimulation – meaning that physical intimacy with a partner may not be enough to arouse them.
Avoiding porn where possible will almost certainly increase libido and make erections more likely.
Staying present also helps. Not as a vague wellness concept, but for a specific reason: arousal requires attention, and if your attention is focused on watching yourself perform – mentally stepping outside your body and criticising everything – arousal collapses.
Psychosexual therapy can help with this. Through a series of structured exercises, couples learn to take penetration and orgasm entirely off the table, focusing only on touch and physical sensation. It sounds counterintuitive. But it works. The brain learns to associate intimacy with pleasure rather than pressure. The script gets rewritten.
It might feel intimidating – or embarrassing – to see a sex therapist. But you would see a physiotherapist for a knee injury, so why should this be any different?
Dan left my consulting room looking considerably less purple than when he’d arrived. He had an explanation. He had a plan. And he had the reassurance that there was nothing fundamentally wrong with him.
There isn’t. But the culture telling young men what sex should look like? That’s a different matter entirely.
