The clinician should try to encourage the man to be open and honest with his partner. This will allow the couple to identify together any anxieties or other issues that might be causing the problem. It is important to provide sufficient time for a psychosexual assessment and this is likely to be about 1 h. This will address predisposing, precipitating, and perpetuating factors.

Predisposing factors will include limited sexual education and childhood and pubertal sexual experiences including traumatic episodes of any kind and general life stressors. Environmental stressors may need addressing, such as financial, domestic, or children-related issues.

Common precipitating factors include deterioration in the general relationship; separation, divorce, or recent death of a partner; vocational failure; and onset of physical or psychiatric illness.

Sometimes there can be problems in their relationship. Couples therapy helps both partners to address the situation and this may be necessary before any specific psychosexual therapy. Issues may be limited to poor communication skills and ways of relating together but there may also be difficulties in other areas such as negotiating time apart (or together) or deciding the share of household duties. Systemic psychotherapy may be indicated.

There may be specific performance anxiety about recurrence of erectile disorder even after just one or two episodes (e.g., attempts at love making while intoxicated with alcohol), which maintains the problem. There may be fear of repeated failure with associated guilt and embarrassment. Once the problem has become established, a number of other maintaining factors may need addressing during therapy. Themes include loss of attraction to the partner, poor communication of likes and dislikes during foreplay and sex between the partners, limited sexual education and awareness, a fear of intimacy, and an impoverished self-image including concern about genital size (particularly penis size). There may be unrealistic expectations from sex as well as other lifestyle, cultural, and religious restrictions on sexual variety. Attraction towards others of the same sex may become evident.

Therapy is directed toward the relationship with agreed and realistic goals of therapy established fairly early in therapy. Specific techniques such as genital self-focus work and modified sensate focus may be helpful. Where therapy is successful, attention to relapse prevention work is recommended. A detailed description is provided elsewhere.

Comorbid sexual problems such as secondary early ejaculation or loss of desire as well as other psychological problems such as depression or social phobia and anxiety may be evident on assessment, which will require input from a sex therapist or mental health professional. Techniques including cognitive and behavioral therapy or psychoanalytical therapy may be indicated.