Hello and welcome to Healthcare Magic. Thanks for your query.

Your sexual problem, erectile dysfunction is, in fact, the most common sexual problem in men. Now, in your case, you have mentioned clearly that your erection problem is there only during certain situations, i.e. when you have actual sexual intercourse and not there when you masturbate. As you have rightly said such a situational problem, especially during the first few sexual experiences is most likely to be due to psychological causes and not any medical problems.

I would like to let you know that in more than 80% of cases of erectile dysfunction, psychological factors play a major role in causing or aggravating the problem. Some examples of such psychological factors which affect sexual functioning are performance anxiety, feelings of sexual indequacy, self-doubts, guilt, past negative sexual experiences, poor communication / understanding with the partner, etc. Often there is a mix of multiple factors which are involved.

So, the first and most important step in management is a comprehensive psychological assessment. This will include a detailed sexual history, past history and childhood history, personal and social history. This is both informative to the doctor and the patient, as well as serves as an opportunity to educate the patient and clarify his doubts. or misconceptions.

Secondly, treatment is targetted according to the findings on evaluation and depending on what psychological factors are contributing to the sexual dysfunction. Accordingly, removing the person's doubts and fears, helping him overcome his performance anxiety and improving his self-confidence levels will definitely help in improving sexual functioning.

Regarding performance anxiety, the following are the most common underlying causes which have to be dealt with:

- Fear that you won't perform well in bed and satisfy your partner sexually.
- Poor body image, including concern over your weight.
- Poor communication with your partner or difficulties in your relationship.
- Worries about penis size
- Concern about ejaculating prematurely or taking too long to reach orgasm.

Most importantly, performance anxiety soon becomes a "viscious cycle" That is, anxiety leads to poor performance and poor performance then leads to further anxiety and this keeps on increasing.

So, the key is to break this cycle at some point of time and take control of yourself. Some good tips to control this performance anxiety are:

1) First get rid of your thoughts that you may be sexually inadequate - in terms of looks or attractiveness or penis size or technique or experience or whatever reason. Remember that sex is not just a physical act but also an expression of emotions, intimacy and love. So, just involve yourself in those feelings and stop focussing on your penis.

2) Increase and spice-up your foreplay. One of the common reasons of poor erections is inadequate arousal. Good foreplay not only arouses you but also sparks off the mood in your partner. So, when she is also aroused and involved, then things keep flowing smoothly and effortlessly, and you don't have to be constantly wondering if you are satisfying your partner or not.

3) Improve your communication with your partner - this means both verbal as well as non-verbal communication. Each person has his or her own ways of getting sexually aroused or feeling sexual pleasure. So, this verbal and non-verbal communication will let each of the partners understand what the other finds more enjoyable and arousing.

4) Distract yourself- try putting on some romantic music or mild lighting while you make love. Think about the things that turn you on. Taking your mind off of your sexual performance can remove the worries that are stopping you from getting excited.

5) Most importantly, stop "monitoring" your performance. Remember, your partner is not conducting a test and evaluating you. She is also a part of the sexual relationship and wants to make you happy as well. So, there is no need to "prove" anything. If both of you actually get involved intimately and emotionally, then the physical part will automatically happen.

I would advise you to consult a psychiatrist and have a detailed psychological assessment done, so that he can give you more specific advise and counselling. Also, avoid alcohol, smoking or any unecessary medication and try to stay stress-free and positive.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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