A form of anxiety
Sexual performance anxiety
When the fear that something will not work is exactly what stops it working.
I am already thinking about it beforehand, and precisely because I am thinking about it, it doesn't happen.
What sexual performance anxiety is
It is the form performance anxiety takes in intimacy: attention shifts from what is happening to how it is going. Experience turns into assessment.
What makes it particular is that monitoring is especially counterproductive here, because sexual response is not voluntary: it does not answer to effort, and watching it interrupts it.
The self-feeding loop
A single occasion where something does not work can have any number of incidental causes: tiredness, alcohol, a heavy day, a new relationship. What happens afterwards matters more than the occasion itself.
If it becomes a precedent, the next encounter begins with a question — will it go like last time? — and the question puts attention where it does not help. At that point the difficulty confirms itself, and one precedent becomes two.
From there the problem is no longer the original one. It is the anticipation.
It is not only about men
In men it often presents as erectile difficulty or as control over ejaculation. In women more often as difficulty with arousal, loss of desire, or pain during sex — where the muscular tension anxiety produces has a direct effect.
The form changes; the mechanism does not. Monitoring attention interferes with a response that cannot be produced on command.
Medical assessment comes first
Erectile difficulty, loss of desire and pain during sex all have possible organic causes, and a doctor needs to rule them out before or alongside psychological work.
Causes can also be mixed: an organic component and a psychological one feeding each other, where anxiety maintains a difficulty that began for another reason. Medical assessment therefore does not postpone the psychological work — the two often proceed together.
When it starts organising the couple
At some point avoidance enters the relationship: things get postponed, reasons get found, intimacy contracts. The other person often reads the withdrawal as disinterest, and that reading adds a second problem to the first.
It becomes hard to talk about at precisely the point where talking would help most. A session together can be useful here — it is assessed rather than assumed.
How the work goes
We start from what is happening now, not from an account. What is needed is the clinical information required to understand the mechanism — when it happens, in what circumstances, for how long — and the pace is whatever is sustainable.
The work concerns shifting attention and reducing avoidance, gradually and by agreement. Reticence is the norm in this area rather than the exception, and it does not obstruct the work.
Frequently asked questions
It can be both, and often is. An organic cause can trigger the difficulty, and the anxiety that follows can maintain it even after the original cause has been resolved. Medical assessment and psychological work are therefore not alternatives: organic causes get ruled out, and if the difficulty remains, the mechanism is where the work goes.
No. What is needed is the clinical information required to understand the mechanism, not an account. I ask the questions, and answering a specific question is different from having to find the words unaided. The pace is whatever is sustainable.
"Stop thinking about it" is the most common advice and the least workable: trying not to monitor is still a form of monitoring. What the work addresses is not stopping the thought but moving attention onto what is actually happening — and that is something trained rather than decided.
Dr. Giuseppe Iannone — Psychotherapist
FIRST STEP