This article originally appeared as a commissioned contribution to Choosing Therapy.
Sexual anxiety affects people of all ages and genders. When present, it may manifest in the form of various physiological or psychological symptoms, but often both. The duration of sexual anxiety can be either short-term or long-term depending on the circumstances and idiosyncratic factors. Treatment options typically include behavioral and/or pharmaceutical interventions. The nature of sexual anxiety is that many factors contribute to its presence, such that an evaluation by a trained clinician or medical provider is often encouraged.
Signs of Sexual Anxiety
Sexual anxiety will frequently manifest with physiological symptoms that impact sexual functioning. One might experience an inability to achieve an erection, or the erection may be weak and inconsistent. Some may experience near immediate ejaculation upon stimulation or lack of ability to ejaculate, particularly with a partner. Vaginal lubrication may be insufficient to allow for penetration, or penetration may result in pain or discomfort.
Many of the physiological symptoms described above may be a function of an undiagnosed medical condition, hormonal changes, or typical aging; therefore, standard of care often dictates a medical evaluation to rule out a possible medical explanation for the concern. Even with a medical antecedent, however, psychological concerns will often emerge around the problem, such as issues with self-esteem or self-image.
Sexual anxiety does not always present with physiological symptoms and can instead rest purely with psychological symptoms impacting behavior. For example, fears around performance may lead to a retreat from sexual activity altogether rather than face the possibility of a negative experience. Alternatively, one may restrict the sexual repertoire to only certain activities, often those that provoke the least anxiety. Body image concerns may be camouflaged by insisting on complete darkness during sex. Some may fear shame or embarrassment and remedy that by engaging exclusively in one-time sexual encounters with strangers rather than risk having to face those fears with a consistent partner.
Symptoms of Sexual Anxiety
Sexual anxiety can cause physiological symptoms; while physiological symptoms can cause sexual anxiety. Whether sexual anxiety is a cause or a symptom can be determined by a trained clinician.
It is also necessary to determine whether the symptoms emerging from sexual anxiety are situation-specific or global. Using erectile dysfunction as an example, it would be situation-specific if the inability to achieve an erection occurs only when with a sexual partner, but the individual experiences no difficulty during masturbation or with spontaneous erections. By contrast, a global presence would mean erectile dysfunction is persistent regardless of the situation. Treatment will vary based on this determination.
Symptoms may also be short-lived resulting from a variety of factors, such as an acclimation period to a medication change, stress unrelated to sexual activity, and relational discord. Long-term sexual anxiety tends to be persistent and reoccur even when life circumstances and sexual partners change. The duration of symptoms is typically elongated because people often are reluctant, afraid, or embarrassed to seek treatment. Waiting too long for treatment solidifies unhelpful beliefs and attitudes around the problem and conditions the body to respond in undesired ways.
Sexual Anxiety and Erectile Dysfunction
When the mind wanders from a focus on stimulation and excitement to a focus on anxiety around fears, doubts, and preoccupation with pleasing others, this transition of thought can be a cause of erectile dysfunction. These anxieties may also cause the individual to focus on extraneous qualities, such as a reflection in the mirror, distracting noises and sounds, and a partner’s expressions, such that the individual disconnects from the body. The more disconnected you are from your body, the more difficult it is to maintain an erection.
Several studies have cited pornography use as a factor in the increasing rate of individuals who report erectile dysfunction, including among adolescents and young adults. Pornography can be used as a means of healthy sexual expression both alone and with partners; however, problematic use requires some consideration regarding erectile dysfunction. It may create unrealistic performance expectations in the viewer, not only of themselves but of their partners, which can increase anxiety around abilities and prowess. Frequent use can also lead to an escalating need to increase the intensity of the type of pornography, much in the same way one builds tolerance around drug use. When tolerance builds, increasingly higher doses are required to obtain the same effect. The same is often true for pornography use. When the threshold required for sexual arousal becomes too high, individuals will find it difficult to achieve adequate arousal from routine sexual activities.
Sexual Anxiety and Premature Ejaculation
When anxiety is of a sexual nature, you might find your body seeking to flee the sexual encounter, and premature ejaculation is one avenue for departure. It’s the body’s way of saying, “get me out of this situation.” Estimates suggest prevalence rates of individuals who experience premature ejaculation are at 3% to 20% of the population. Studies vary as to what is considered an “average” ejaculation time; however, one to five minutes is considered within normal limits. Rather than worry about the time it takes others to ejaculate, focus on yourself instead. What makes sense for you in terms of ejaculation control, is it realistic, and what plan can be developed to work toward that goal?
Sexual Anxiety and Body Image
Does it strike you with fear: the idea of having sex with the lights on or in the unforgiving light of a bright, sunny day? People go through pains to not be seen during sex and will often attempt to reduce their anxiety by hiding out in darkness. These efforts are typically to conceal insecurities about the body, to decrease emotional intimacy, and to avoid being seen in positions that make them feel vulnerable.
Body image concerns are common across all demographics. In terms of sexual anxiety, these concerns may focus on weight; breast and penis size; vaginal appearance; physique; body hair; etc. These “defects” may be real, they may be exaggerated or misperceived, and sometimes they may be only imagined. The individual might insist on certain sexual positions that de-emphasize the body part of concern, for example, insisting on vertical positions to not allow the breasts to fall in a perceived-to-be unflattering manner. Some may find the “defect” so debilitating that they disengage from sex altogether.
Other Types of Sexual Anxiety
Relational: Sexual scripts develop extremely quickly between sexually consistent partners. As sexual relationships become more long-term, these scripts tend to center almost exclusively around the least anxiety provoking sexual activities. For most couples, this typically means kissing, penetration, manual, and maybe oral sex. The totality of a person’s true sexual identity becomes hidden behind the anxiety of being perceived as “gross,” “odd,” or “deviant.”
People will prefer anxiety-free sex, i.e., boring sex, in place of the more exhilirating sex that requires challenging the anxiety around revealing your true sexual desires. Instead, people are much more willing to admit their deepest sexual urges and fantasies to strangers. This can lead to routine, monotonous, and robotic sexual boredom in longer-term couples, creating anxiety around “having” to have sex you don’t want to maintain appearances that everything is “alright.”
Rather than challenge the anxiety around having difficult conversations about sexuality or initiating changes in the bedroom, partners will live in this perpetual state of chore-like sex for years. Sex can become such an anxiety-provoking activity that the sex stops altogether.
Substance-Related: It is not uncommon for people to turn to alcohol or illicit substances to manage anxiety around sexual activity. When people discover that this method helps them to distract themselves from their sexual anxiety, but the risk is that this strategy then becomes the sole means under which they will be willing to engage in sexual activity. It can then be difficult to transition from substance-fused sex to sober sex.
Many people will then struggle to regain enjoyment from sex without substances,, or they may lose their ability to perform entirely. This can almost always be treated and appreciation for sober sex can return, but depending on the substance(s) in question, duration of use, and other associated factors, it can be a long recovery. It is often encouraged to take a hiatus from sexual activity for a period of time, even if in a long-term committed relationship or marriage. Fortunately, most partners are more than willing to take a break from sex if the outcome will be a more functional relationship across sexual and other domains.
What Causes Sexual Anxiety
The psychological causes of sexual anxiety are highly nuanced. The same sexual problem facing two different people will likely have very different causes and etiologies. There is no one-size-fits-all reason for sexual matters such as anxiety, so it is important to be evaluated properly by a trained provider to help you determine possible causes.
Below are some examples of various potential causes that are explored in treatment:
Misinformed beliefs, maladaptive attitudes, and unrealistic expectations
Your belief system around sexual performance, such as “men must be the aggressor” or “women shouldn’t be too eager in bed,” etc., are often unnecessary limiters not only to sexual performance but to sexual pleasure. Treatment will help you sort out for yourself which of your beliefs make sense for how you want to live your sex life and which beliefs are no longer serving you.
Comparison with others and with media / pornographic portrayals
Comparison is the enemy of joy. If you find yourself preoccupied with insecurities regarding your body, those insecurities may be triggering your sexual difficulty. Therapy can help you accept your body as it is, or it can help you develop healthy ways to address bodily concerns without succumbing to unreasonable expectations or unhealthy behaviors.
Fear that past performance is predictive of future performance
People sometimes let one sexual encounter set the expectations for years to come. It’s important to recognize each sexual encounter contains numerous variables that affect performance. For example, erectile dysfunction or vaginal pain with one partner do not necessarily mean it’s going to happen with all partners.
Mood and stress
When psychological conditions such as depression, generalized anxiety, and stress are present, these symptoms often interfere with sexual performance and desire. Many people who have experience with these conditions will often develop anxiety around sexual situations due to fears of the change in their sexual performance. It is very important to be communicative with sexual partners about any such changes due to mental health. It will ease your mind, and it will also prevent your partner from inventing (often suspicious or self-deprecating) reasons for the behavior change in absence of knowing the true cause.
How Sexual Anxiety is Treated
Sexual anxiety is often treated with therapy, such as by the implementation of cognitive-behavioral techniques. A frequent strategy of treatment is to address negative self-talk and false beliefs that contribute to the presence of the anxiety. These beliefs often create a self-fulfilling prophecy that perpetuates the problem. In treatment, you might also address harmful attitudes around sexuality and your body that may have been inculcated in childhood and adolescence. These attitudes often underlie fears and anxieties around sexuality.
Sensate focus treatment helps patients learn to concentrate on experiencing sensations of sex and touch without the burden of being preoccupied by sexual goals and objectives. With the pressure to perform removed, patients are often able to reset their mind and escape their concerns. Treatment is conducted under guidance by a clinician who assists you in working through various stages of escalating exercises conducted in private with a partner.
When physiological symptoms are present, medication may sometimes be used temporarily or long-term. For premature ejaculation, Selective Serotonin Reuptake Inhibitors (SSRI), such as those used for depression, may be prescribed by a medical provider. These medications have been found to increase latency between penetration and ejaculation. For erectile dysfunction, there are several types of phosphodiesterase (PDE) inhibitors that are widely successful. Hormonal treatments, such as vaginal estrogen, can be prescribed for vaginal dryness.
It is important to note, however, that when physiological symptoms are the result of an underlying psychological nature, medication alone may not be as effective. It is common for medical providers and mental health providers to work together on a treatment plan for a patient with physiological symptoms of a sexual nature.
Couples therapy can help increase communication around a sexual problem and decrease stigma around sexual activity, desire, and performance. A couple’s therapist can help both partners work through the symptoms, as sexual anxiety with one partner very frequently transmits anxiety to the other. For example, Partner A’s erectile dysfunction may activate fears of being unattractive or undesirable in Partner B, which can cause Partner B to develop separate problems with anxiety and sexual performance.
Proper self-care can sometimes reduce the presence or impact of sexual anxiety. Commonly suggested activities include exercise, participating in a healthy diet, and decreasing or eliminating smoking and illicit substances.
Sexual Anxiety Examples
Brian is a 20-year-old male struggling to achieve an orgasm with partners. He has no issue maintaining an erection and enjoys oral and penetrative sex; however, he finds he can never orgasm under these circumstances, and instead he always finishes through masturbation but then experiences emotional turmoil and shame. He begins to think of himself as inadequate and fears his partner questions his virility. After repeated and similar encounters, he finds himself no longer able to achieve an erection.
Thoughts: Brian’s difficulties with orgasm may be due to an idiosyncratic masturbatory method, i.e., he is habituated to orgasm through one specific method of masturbation, such that it is the only way he can climax. This is common for many people who have trained their body to respond only to certain stimulation patterns. His preoccupation with his performance decreases sexual arousal and increases anxiety, thus resulting in erection difficulties.
Emily is a 40-year old female who was socialized to see sex as a vehicle primarily for men’s pleasure. She has internalized this belief and expressed it in bed with her partners by dismissing her desire for orgasm, never initiating sex, and focusing exclusively on the needs of her male partners. Emily has found herself shocked to be in a relationship with a man who wants an egalitarian bedroom and is just as eager to please her as he is himself. After he achieves orgasm, he consistently attempts to perform oral sex on her. Although she enjoys it, she finds herself plagued with thoughts of being a burden and that he is engaging in a sort of sexual chore. Rather than discuss this, she retreats from sex altogether or hurries the encounter to reduce flee the situation.
Thoughts: Emily might do well to explore how her sexual beliefs and attitudes are self-imposed and no longer serving her. She already has a partner with whom to work through her anxieties, so incorporating him into treatment would be beneficial for them both.
Tips for Overcoming Sexual Anxiety
Unless you are a porn star, you are not a porn star. You do not need to try to act like one, and don’t expect your partner to act like one either. Stop thinking of sex as though you are performing for an imaginary audience.
Be a little selfish. It’s okay when trying to overcome sexual anxiety to focus exclusively on your sensations and your feelings. Just let your partner know that’s your intention and why you think it might help. If you are in individual therapy for the issue and in a relationship, consider bringing in your partner for a session or two. You overcoming sexual anxiety also means better sex for them, too, which is a goal most partners are happy to embrace.
Challenge your anxiety around difficult conversations, such as letting your partner know about your insecurities. This is not the time for empty validation, however. You’re not telling them so they can caretake your ego and tell you how wonderful everything is. You’re letting them know so they can be supportive of how you actually feel. They may alert you to their own anxieties, as well.
Consider evaluating your porn usage. Does it seem excessive to you? If so, it might be a good idea to cut down or abstain temporarily to see if you notice any improvement in physiological or psychological symptoms of sexual anxiety.
If you have a sexual partner you trust, see if they will be willing to help you practice new sexual behaviors, e.g., sensate focus, start-stop methods, etc. Being able to practice these behaviors in a context without any sexual pressure or performance expectations will greatly expedite opportunity for improvement. It doesn’t need to be a romantic or committed partner, just a sexual partner with whom you can have some consistency and trust.
Decrease a focus on orgasm and penetration. Consider engaging in more foreplay and sexual playfulness in bed. If an unwanted orgasm does occur, that does not mean sexual activity needs to stop if both partners wish to continue.
Additional Resources
American Sexual Health Association https://www.ashasexualhealth.org/ ASHA provides education and advocacy on a variety of sexual health matters
National Coalition for Sexual Health https://nationalcoalitionforsexualhealth.org/ Endeavors to provide sexual health information and decrease stigma around these discussions.
Mayoclinic: Sex Therapy https://www.mayoclinic.org/tests-procedures/sex-therapy/about/pac-20384613 Fact sheet with additional information on sex therapy: how to prepare, what to expect, etc.
Sources
Behav Sci (Basel). (2016, September). Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039517/#B10-behavsci-06-00017
Cochrane Database Syst Rev. (2011, August). Psychosocial Interventions for Premature Ejaculation. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21833964/
Cornell Health. (2019, October). Sensate Focus. Retrieved from https://health.cornell.edu/sites/health/files/pdf-library/sensate-focus.pdf
Journal of Experimental Psychopathology. (2019, May). A Review of Experimental Research on Anxiety and Sexual Arousal: Implications for the Treatment of Sexual Dysfunction Using Cognitive Behavioral Therapy. Retrieved from https://journals.sagepub.com/doi/full/10.1177/2043808719847371
Mayo Clinic. (2018, September). Female Sexual Dysfunction. Retrieved from https://www.mayoclinic.org/diseases-conditions/female-sexual-dysfunction/symptoms-causes/syc-20372549
National Health Service. (2020, August). Erectile Dysfunction (Impotence). Retrieved from https://www.nhs.uk/conditions/erection-problems-erectile-dysfunction/
Transl Androl Urol. (2016, August). The Impact of Ejaculatory Dysfunction Upon the Sufferer and His Partner. Retrieved from https://pubmed.ncbi.nlm.nih.gov/27652218/