Erectile Dysfunction (ED) – Processing the Self as a Sexual Object?

What is Erectile Dysfunction?

Erectile dysfunction, impotence, or an unreliable erection, is a biopsychosocial problem for people with a penis. It's defined as a consistent and/or recurrent inability to maintain an erection sufficient to satisfy a sexual encounter in solo or partnered sex. Approximately 58% of people with a penis in the UK experience ED, and 40% would feel uncomfortable seeking help (Kessler et.al, 2019). 

Multiple interacting factors can lead to unreliable erections, such as fitness, diet, diabetes, and obesity, to name but a few. There is evidence that the prevalence of ED increases with age. 

If you're experiencing unreliable erections, it's strongly advisable to see your GP as this may be an early indicator of cardiovascular disease. It may also be helpful to have your testosterone level checked, as it may be low.  

The Impacts of Erectile Dysfunction

Erectile dysfunction can be supported via several biological interventions, such as PDE5 inhibitors (e.g. Viagra), penile implants and vacuum erection devices.  

For our purposes, though, I'll focus on the psychological and social aspects of ED and its impact. Nobre (2010) developed a cognitive-emotional model of erectile dysfunction and surveyed over 300 participants. He identified the importance of beliefs about virility and machismo, for example, a participant stated, "a real man has sexual intercourse very often," and, "I am condemned to failure.”

He also noted that sexual beliefs are based on past experiences of sex and that ‘self-concept’, or how we see and what we believe about ourselves, was the most sensitive dimension for the participants. Overall, Nobre (2010) found that macho beliefs about (sexual) incompetence, a lack of experiencing erotic thoughts, sadness and erectile function were the interacting features that predict erectile functioning. 

Erectile dysfunction can lead to embarrassment, shame and avoidance. Partners may feel rejected and confused, especially if it's difficult to communicate about the ED together. Additionally, for people who experience ED and have not had a sexual relationship for some time, there may be a fear of intimate relationships. This is just the start of understanding the impact that ED has on people and their partners.  

In my clinical practice, in both mental health and sexual difficulties, I have found some similarities in the signs and symptoms of social anxiety and the anxiety that may be contributing to the experience of ED. 

Processing the Self as a Social Object

Central to the Cognitive Behavioural Therapy (CBT) model for social anxiety is ‘processing the self as a social object’ (Clark and Wells, 1995). This somewhat scientific and wordy phrase relates to paying attention to how ‘the self’ (you or me) is coming across to others in social situations. This process is a safety behaviour, which is intended to try and make sure we're being received well in a social setting. Unfortunately, this cognitive strategy turns our mind inward, to monitor ourselves as observers, rather than being engaged in conversation and interactions with other people. 

There's a whole host of strategies that people implement while they're processing themselves in a social situation. A key behavioural strategy is damage limitation by, for example, attempting to avoid feared negative evaluations from others, which then often leads to people avoiding social situations as much possible. This strategy would have worked initially, but then inevitably it keeps the problem going. The solution becomes the symptom. 

Processing the Self as a Sexual Object

In my work with people with ED and sexual performance anxiety, I've noticed that the processes in sexual anxieties have some very similar processes and behaviours to social anxieties. These are potentially social and psychological aspects of ED. From what I've observed and gleaned over the years, the anxiety people experience about an unreliable penis leads to monitoring the rigidness of their penis, or attempting to avoid their sexual partner knowing about a flaccid penis by changing sexual activity or position. 

Most poignant is where the person's attention is. It's likely they're experiencing penile self-consciousness. Similar to social anxiety, this means that sexual focus is on ‘performance’, rather than pleasure and connectedness. The person’s attention is inward, rather than being engaged in the sexual experience, thus they're processing themselves as a ‘sexual object’.  

Imagery Rescripting

Another, later, key feature in the development and treatment of social anxiety is imagery rescripting. This intervention was initially designed to process childhood abuse memories (Arntz & Weetman, 1999). The rescripting of a memory creates a change in the meaning and feeling of the experience. The imagery rescripting also allows for the instillation of an alternative ending to a memory, where the person feels safe and may have a companion. This all occurs in the mind's eye. Imagery rescripting allows for a different modality of describing the event, rather than it just being a cognitive ‘wordy’ perspective.  

Humans are adept at self-criticism and rumination, which can reinforce negative and challenging beliefs. Imagery rescripting provides the opportunity to process the memory from different perspectives. The cognitive model of imagery rescripting developed by Wild & Clark (2011) uses some exposure therapy, as the process is completed three times from different perspectives.  

• The first is imagining and describing the event as if it were happening in the here and now.
• Second, the person goes through the memory from a different perspective, where they're observing the event and their younger self.
• The last perspective allows for the younger self and the self now (or to invite a safe person) to go through the memory together and be given what they needed (e.g. care and compassion) at the time of the traumatic or challenging/shaming event (e.g. being humiliated by a sexual partner, or a flaccid penis.) This aligns with Nobre’s findings that early memories of sexual experiences influences sense of self. 

I have usefully used imagery rescripting with clients who feel ashamed or humiliated during a sexual liaison. The clients I've worked with have found this intervention very helpful. Please reach out if you think this therapeutic approach would be something you'd like to explore.  

I have an ambition to develop a series of case studies using the self as a sexual object, and for this to be published. Please get in touch if you'd like to be involved. I would extend my hypothesis to all people and genders, but let’s find out. 

Bibliotherapy

The global prevalence of erectile dysfunction: a review 
https://bjui-journals.onlinelibrary.wiley.com/authored-by/Kessler/Anna 

Arntz & Weertman (1999). Treatment of childhood memories: theory and practice. https://pubmed.ncbi.nlm.nih.gov/10452174/ 

Clark D.M., Wells A. A cognitive model of social phobia. In: Heimberg R., Liebowitz M., Hope D.A., Schneier F.R., editors. Social phobia: Diagnosis, assessment and treatment. Guilford Press; New York: 1995. pp. 69–93.

Nobre, J. 2010. Psychological Determinants of Erectile Dysfunction: Testing a Cognitive-Emotional Model. J Sex Med 2010,7:1429-1437

Imagery Rescripting of Early Traumatic Memories in Social Phobia. 
https://pmc.ncbi.nlm.nih.gov/articles/PMC3267018/  

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