Is it Erectile Dysfunction or a Mental-Health Challenge? Insights From Psychologists

Abstract

Erectile dysfunction (ED) is increasingly recognized as a multidimensional condition in which psychological, relational, and sociocultural processes intersect with biological factors. While international research has documented strong links between ED and mental health, especially depression, anxiety, and stress, limited evidence exists on how these dynamics are understood within sub-Saharan African contexts. This study explores how psychologists in Tanzania conceptualize and respond to ED among adult male clients, with attention to the psychological, cultural, and relational factors that shape its presentation and management. A qualitative phenomenological design was employed to capture practitioners’ lived experiences and interpretive frameworks. Twelve (12) psychologists working in public and private facilities were purposively sampled based on their direct experience with clients presenting ED alongside mental-health concerns. Data were analyzed thematically following Braun and Clarke’s approach. Findings reveal that psychologists view ED as strongly intertwined with mental-health conditions, especially depression, performance anxiety, chronic stress, and low self-worth. Participants emphasized a bidirectional cycle in which psychological distress precipitates erectile difficulties, while ED intensifies emotional suffering and relationship strain. Cultural scripts of masculinity, expectations of male sexual competence, and stigma surrounding emotional vulnerability further shape help-seeking behavior and therapeutic engagement. Psychologists reported employing biopsychosocial formulations, psychosexual assessment, cognitive-behavioral interventions, couple therapy, and psychoeducation as central components of care. The study demonstrates that ED in Tanzania is a masked mental-health presentation requiring integrative, culturally informed psychological responses. Strengthening psychosexual services, embedding mental-health screening in sexual health settings, and addressing masculinity-related stigma are critical for improving men’s sexual and psychological wellbeing.

Introduction

Erectile dysfunction (ED) refers to the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance (Rosen et al., 1999; Yafi et al., 2016). Clinically, ED is typically diagnosed when such difficulties persist for at least 3 months and cause significant personal or interpersonal distress, in line with international diagnostic and sexual medicine guidelines. It represents a significant and multifactorial health concern among men worldwide (Rosen et al., 1999).

ED arises from a constellation of biological, psychological, and lifestyle-related causes. Common biomedical contributors include vascular insufficiency, endothelial dysfunction, diabetes mellitus, hypertension, obesity, hormonal imbalances (particularly low testosterone), neurological disorders, and adverse effects of medications. Increasingly, lifestyle factors such as physical inactivity, poor diet, smoking, excessive alcohol consumption, and post-infectious sequelae (e.g., post-COVID conditions) have been recognized as modifiable contributors to ED (Ismail, 2022; Ismail & Abd El-Azeim, 2022; Ismail et al., 2023). For instance, the available data estimate shows that in 1995, there were over 152 million men experiencing ED worldwide (Aytac et al., 1999). The authors projected that by 2025, the prevalence will equal 322 million men with ED. More so, epidemiological evidence indicates that the global prevalence of ED varies considerably across populations, with reported rates ranging from approximately 3% to more than 75% depending on age and assessment methods (Kessler et al., 2019). Global estimates continue to confirm a rising prevalence, particularly in low- and middle-income countries, where demographic aging, increasing cardiometabolic disease, and limited access to preventive care converge to elevate risk. For example, Kitaw et al. (2024, p. 1) reports that “The pooled global prevalence of erectile dysfunction in diabetic patients was 65.8% (95CI: 58.3-73.3%), while in Africa it was 62.9% (95CI: 46.1-79.7).” With such rapid increase, the developing countries including African states are the most affected.

Historically, ED has been conceptualized primarily in biomedical terms, with emphasis on vascular, hormonal, neurological, or anatomical causes (Yafi et al., 2016). However, in recent decades, scholarly attention has shifted toward the psychological and psychosocial dimensions of ED, recognizing that erectile difficulties trigger emotional distress, cognitive-behavioral disruptions, relationship problems, and sociocultural pressures (Allen et al., 2023; Allen & Walter, 2019). Beyond the individual, ED exerts significant adverse effects on intimate partners and couple relationships. Partners of men with ED report reduced sexual satisfaction, emotional distance, frustration, self-blame, and relationship strain (Elterman et al., 2021; Fisher et al., 2005). Dyadic distress further exacerbates performance anxiety and avoidance behaviors, reinforcing a relational cycle that sustains erectile difficulties if left unaddressed. Within this paradigm, the integration of mental health frameworks, especially the biopsychosocial model and cognitive-behavioral theory (CBT), provides deep understanding of how depression, anxiety, stress, and performance-related cognitions contribute to erectile problems (Allen & Walter, 2023; Greco & Siracusa, 2004).

In turn, such psychological factors predispose men to ED and perpetuate a vicious cycle where sexual difficulties exacerbate mental distress, and the resultant distress further undermines sexual functioning (McCabe & Althof, 2014; Yang et al., 2023). A cross-sectional study in China reports that nearly 65% of men presenting with ED met criteria for clinically significant depressive symptoms, and approximately 38% for anxiety (Xiao et al., 2023). The authors also report that the severity of ED was significantly associated with both increased depressive and anxiety symptomatology. The bidirectional nature of the ED–mental-health relationship is further supported by meta-analytic evidence demonstrating that depression increases the risk of ED, elevating the risk of developing depressive illness (Liu et al., 2018).

Yet, despite burgeoning interest in the psychological dimension of ED globally, there remains a relative paucity of research exploring these issues in sub-Saharan African settings. While sociocultural norms relating to masculinity, sexual performance, emotional expression, and help-seeking shape the experience and consequences of ED across many societies (Allen & Walter, 2019; Fisher et al., 2005), existing studies in sub-Saharan Africa have predominantly focused on prevalence and biomedical risk factors like diabetes, age, and hypertension, with limited attention to psychological, relational, and cultural processes that influence men’s sexual health experiences (Mkandawire et al., 2019; Shiferaw et al., 2020; Zeleke et al., 2021). As observed in Asian societies, where sexual matters are socially taboo and masculine norms discourage acknowledgment of sexual difficulties (Irfan et al., 2020; Quang et al., 2024), men in sub-Saharan Africa face comparable constraints that limit open discussion of sexual health issues. These gaps undermine an understanding of ED in contexts where masculine norms and stigma around sexual dysfunction and mental illness uniquely intensify distress and impede help-seeking (Anselimus, 2025). As a result, delayed engagement with medical care, frequently shaped by social and psychological barriers, contributes to the worsening of both physical and mental health outcomes (Zhu et al., 2025). In Tanzania, male sexual performance is linked to identity, self-worth, and relational status, while stigma surrounding both sexual dysfunction and mental illness inhibits men from presenting for psychological support. This cultural perspective increases the importance of exploring ED not simply as a physical condition but as a complex interplay of emotional, cognitive, interpersonal, and sociocultural factors.

From a theoretical perspective, the biopsychosocial model serves as a foundational framework, as it stresses that sexual functioning is determined by interactions among biological processes (vascular integrity, hormonal milieu, neurological pathways), psychological variables (mood, anxiety, sexual self-schema, performance cognitions), and social influences (relational factors, cultural norms, stigma) (Borrelli et al., 2017). CBT further articulates how maladaptive beliefs (catastrophizing about performance, fear of failure, low sexual self-efficacy) and behavioral responses (avoidance of sexual activity, safety behaviors, over-monitoring of arousal) maintain erectile difficulties (Greco & Siracusa, 2004; Mattson, 2011). This allows us to conceptualize ED in lieu of solely vascular or endocrine pathology but as potentially rooted in or amplified by psychological processes and the sociocultural milieu in which men live.

Literature on the psychology of ED has foregrounded several key mechanisms. First, depression has been implicated in the onset and maintenance of ED through pathways like diminished libido, anhedonia, negative self-evaluation, and behavioral withdrawal, all of which hinder sexual arousal and performance (Liu et al., 2018; Yang et al., 2023). Second, anxiety, especially performance anxiety, has been identified as a salient contributor to ED. Men with diagnosed anxiety disorders have a significantly elevated risk of ED, likely through increased sympathetic arousal, distractive cognitions, hypervigilance to sexual cues, and avoidance of sexual encounters (Allen & Walter, 2023). Third, chronic stress and psychosocial burdens (relationship conflict, work pressures, sleep disturbance) dysregulate neuroendocrine responses (e.g., heightened cortisol, impaired nitric oxide–mediated vasodilation) and decrease sexual pleasure and the rigor of erections (Vasan et al., 2025; Yang et al., 2023). In sum, psychological distress does not merely co-occur with ED but functions as a direct or indirect causal agent.

Alongside pharmacological and psychotherapeutic approaches, growing evidence highlights the complementary role of lifestyle and mind–body interventions in the management of ED. Exercise-based rehabilitation, aerobic training, dietary modification, relaxation techniques (e.g., Benson’s relaxation), and stress reduction have demonstrated beneficial effects on erectile function, psychological burden, cardiometabolic health, and hormonal regulation across diverse clinical populations (Ismail, 2022; Ismail et al., 2023; Ismail & Hamed, 2024). These findings emphasize the value of integrative and complementary therapies as adjuncts to conventional ED treatment.

On the clinical front, psychological assessment of men with ED has gained traction, yet evidence suggests that mental health evaluation is underutilized in ED clinics. A recent review found that although ED is inherently intertwined with mental health concerns, interdisciplinary collaboration between urology/andrology and mental health specialists remains limited and mental health screening is inconsistently implemented (Morcos et al., 2025). This emphasizes an important clinical imperative that sexual health services must broaden their purview to incorporate mental health screening, psychoeducation, and psychological therapies including CBT or sex therapy to address the full spectrum of ED determinants.

In sub-Saharan Africa, the literature on ED has grown, although much of it remains focused on prevalence and biomedical risk factors rather than psychological dimensions. In Tanzania, for example, a community-based study in Kinondoni District, Dar es Salaam, found a 24% prevalence of some form of ED (n = 441) and identified age ≥55 years and diabetes as the strongest predictors (Pallangyo et al., 2016). Another study in Moshi municipality reported a 29.7% prevalence, with age and hypertension as independent predictors (Nyalile et al., 2020). Among diabetic men in Tanzania, one hospital-based study found a 55.1% prevalence of ED (n = 312); old age, peripheral neuropathy, and peripheral vascular disease were significant predictors (Mutagaywa et al., 2014). A systematic review and meta-analysis of African studies on ED in diabetic men (n = 13 studies; 3,501 participants) estimated pooled prevalence at 71.45% (95% CI = 60.22–82.69) (Shiferaw et al., 2020). In another cross-sectional study on the prevalence of ED and associated factors among newly diagnosed antiretroviral therapy (ART)-naïve men living with HIV (n = 373), ED was found in 56.3% (95% CI = 51.2%–61.3%), whereas the majority presented with mild (45.2%) to mild-moderate (40.0%) ED (Iddi et al., 2025). While these studies show high prevalence and biomedical risk factors (age, diabetes, hypertension, obesity), they rarely examine psychological variables (depression, anxiety, stress) or practitioners’ perspectives.

This means men experiencing ED face additional psychosocial barriers. Cultural expectations around male virility, normative silence on sexual performance difficulties, limited access to mental health care, and stigma regarding emotional vulnerability converge to shape a distinctive lived experience of ED (Mkandawire et al., 2019). Such factors can discourage men from seeking psychological support, amplify shame and secrecy, and thereby prolong the ED-anxiety/depression cycle. More so, when ED is medically treated without addressing underlying psychological and relational factors, the risk of relapse or incomplete recovery remains elevated (Melman & Gingell, 1999).

Rationale of the Study

Despite the high prevalence of ED in Tanzania and the growing recognition of its psychological correlates globally, there remains a critical gap in contextually grounded knowledge regarding how mental health professionals conceptualize and manage ED within sociocultural realities. Understanding the vantage point of mental health professionals is important because their conceptualizations of ED directly shape assessment practices, diagnostic framing, therapeutic choices, interdisciplinary referral patterns, and the extent to which psychological and sociocultural determinants of ED are addressed or overlooked in clinical care (Greenhalgh et al., 2004; World Health Organization [WHO] & World Organization of Family Doctors, 2008). In low-resource settings, where formal sexual health pathways are limited, clinicians’ beliefs and training usually determine whether ED is treated solely as a biomedical condition or approached through an integrated biopsychosocial lens, with significant implications for patient outcomes (Patel et al., 2018; WHO & World Organization of Family, 2008). Existing studies in the region largely prioritize biomedical risk factors, leaving psychological mechanisms, cultural meanings, relational dynamics, and clinical decision-making by psychologists underexplored. Addressing this gap is essential for informing culturally responsive assessment practices, integrating mental health into sexual health services, and guiding training, policy, and interdisciplinary collaboration.

Against this backdrop, the present qualitative study responds to several knowledge gaps. First, although the psychological dimension of ED is well documented in high-income contexts, less is known about how psychologists dealing with ED perceive, interpret, and intervene with ED in lower-income, culturally distinct settings. Second, while quantitative associations between mental health variables and ED abound, qualitative research exploring the how and why of this interplay, especially from practitioners’ vantage points, is relatively scarce. Third, the integration of mental health care into sexual health frameworks in Tanzanian public and private sectors has been underinvestigated; understanding practitioners’ experiences can inform policy, training, and service design. This study therefore contributes a practice-informed understanding of ED as a biopsychosocial and culturally embedded phenomenon, providing insights relevant to clinical psychology, sexual health services, and mental health integration in low-resource settings.

Purpose

The purpose of this study was to explore how mental health professionals in Tanzania conceptualize and respond to ED in adult male clients. Particular focus was casted on psychological factors including depression, anxiety, and stress; their interrelationships with erectile functioning; and the cultural, social, and relational contexts in which these phenomena occur. To achieve this purpose, the study is guided by the following research questions:

• Research Question 1 (RQ1): How do psychologists understand the relationships between ED and psychological conditions such as depression, anxiety, and stress?

• Research Question 2 (RQ2): What cultural, social, and relational factors do psychologists perceive as influencing the presentation and management of ED among adult men in Tanzania?

• Research Question 3 (RQ3): What assessment and intervention strategies do psychologists use when working with clients experiencing ED alongside co-occurring mental health concerns?

Materials and Methods

This study employed a qualitative phenomenological design to explore psychologists’ experiences and meaning-making when working with adult male clients who present with ED alongside mental health concerns. Qualitative methods are appropriate for examining complex, contextually situated phenomena where the goal is to generate in-depth understanding of participants’ perspectives, processes, and meanings (Creswell & Poth, 2018). A phenomenological orientation focuses specifically on how professionals experience and interpret a lived phenomenon—in this study, clinical encounters and conceptualizations of male sexual dysfunction within psychological practice—and is therefore well suited to capture rich, firsthand descriptions from practitioners (Moustakas, 1994). A phenomenological design was chosen because the research aims to foreground psychologists’ subjective experience, interpretive processes, and the meanings they ascribe to cases of ED rather than to measure prevalence or test hypotheses. Phenomenology produces descriptive and interpretive accounts that illuminate how phenomena are experienced in naturalistic settings (Moustakas, 1994), complementing thematic analysis, which systematically identifies patterns across participants’ narratives (Braun & Clarke, 2006).

Participants and Sampling

Twelve psychologists working in public and private health and education facilities in Tanzania participated. Participants were purposively sampled to ensure they had direct, recent experience with adult male clients presenting sexual dysfunction and concurrent mental health concerns (Palinkas et al., 2015). Purposive sampling allows researchers to select information-rich cases that are particularly knowledgeable about the phenomenon under study (Palinkas et al., 2015). Where appropriate, snowball referrals from initial participants were used to identify additional eligible psychologists, especially to secure a balance across settings (public/private, urban/rural) and levels of clinical experience. A sample of 12 was judged sufficient to reach meaningful thematic depth while maintaining feasibility given the specialist population; similar interview studies with expert participants often achieve thematic saturation or adequate “information power” with modest sample sizes (Guest et al., 2006; Malterud et al., 2016). The study emphasized depth of interview and analytic richness over a large sample.

Participants were eligible if they: (a) held professional recognition as a psychologist in Tanzania, (b) had at least 2 years’ experience in clinical work, mental health support provision, or counseling, (c) had managed adult male clients who presented with sexual difficulties (including ED) and co-occurrent mental health concerns within the preceding 3 years, and (d) consented to audio-recording and participation. Exclusion criteria included current involvement in the study team and inability to participate in a single 45- to 90-min interview.

Data Collection

Data were collected through semi-structured interviews. The method offered a balance between consistent coverage of core topics and flexibility for participants to elaborate on salient experiences and meanings (Kvale & Brinkmann, 2015). An interview guide was developed from the literature on sexual dysfunction, psychosexual assessment and intervention, and culturally specific factors in Tanzanian mental health practice. The domains included clinical assessment routines, diagnostic and explanatory models, therapeutic strategies, perceived barriers and facilitators, cultural and gendered influences, training needs, and ethical and legal considerations.

Each interview lasted approximately 45–90 min and was conducted in a private room at the participant’s workplace. Interviews were conducted in both English and Kiswahili languages according to the participant’s preference to maximize comfort and expression; language choice was documented. With written informed consent, interviews were audio-recorded and supplemented by field notes capturing contextual observations and non-verbal cues (Kvale & Brinkmann, 2015).

Data Analysis

In the first place, audio files were transcribed verbatim. Kiswahili interviews were transcribed in Kiswahili and then translated into English. Similarly, translation was checked using back-translation procedures on a purposive subset of transcripts to ensure conceptual fidelity (Squires, 2008). All transcripts were anonymized (pseudonyms and removed identifiers) before analysis.

Subsequently, thematic analysis (Braun & Clarke, 2006) took the course to identify, analyze, and report patterns across the dataset. Thematic analysis is flexible and well suited to applied health research because it allows both inductive (data-driven) and deductive (theory-driven) coding and produces themes that are accessible for policy and practice audiences (Braun & Clarke, 2006). In the process, researchers read transcripts repeatedly, listened to audio recordings, and produced reflective analytic memos to capture early impressions and contextual notes. A combination of inductive coding (identifying issues emerging directly from participant language) and deductive coding (codes derived from clinical theory and the research aims) was applied. Two researchers independently coded an initial subset of transcripts to develop a provisional codebook. Codes were collated into candidate themes that reflected patterned responses across participants (e.g., explanatory models of ED, clinical assessment practices, barriers to psychosexual intervention). The themes were iteratively reviewed against the full dataset to ensure internal coherence and external relevance. On the contrary, discrepant cases were retained and discussed rather than discarded. Final themes were defined clearly with illustrative subthemes and exemplar quotations selected to capture variation. Themes were finally related back to the study aims, theoretical framework, and extant literature during reporting.

Results

The first research question sought to explore psychologists’ understanding of the relationships between ED and psychological conditions including depression, anxiety, and stress. From this question, the following themes emerged.

ED as a Psychosomatic Response to Depression and Emotional Withdrawal

Participants consistently described ED as deeply intertwined with depressive symptoms, noting that many male clients present with both conditions in a way that makes the psychological and physical symptoms inseparable. Psychologists explained that depression often manifests through reduced motivation, diminished self-esteem, emotional numbness, and an overall withdrawal from pleasurable activities, all of which directly undermine sexual desire and performance. Several participants emphasized that ED frequently emerges not as a standalone condition but as an embodied expression of unresolved emotional pain, hopelessness, or chronic life stress. In this view, the erectile difficulties are not only biological events but also symbolic indicators of a man’s internal emotional collapse and loss of vitality.

One psychologist noted,

Many of the men with erectile dysfunction I came across also showed classic signs of depression-fatigue, disinterest in things they once enjoyed, and a heavy sense of hopelessness. Their sexual functioning dropped because the emotional engine behind desire was no longer there. It is not simply the body failing; it is the whole person shutting down. (Participant 4, Clinical Psychologist)

Another added,

For some clients, the erection problem was the first thing they noticed. but when I explored further, I noticed deep sadness, unresolved grief, and sometimes financial stress that has consumed them emotionally. Their bodies were just expressing what the mind has been carrying for too long. (Participant 12, Counselling Psychologist)

These perspectives show how depression and ED are mutually reinforcing, creating a cycle where depressive symptoms reduce sexual functioning, which in turn worsens self-blame, shame, and depressive thoughts. The findings align with biopsychosocial understandings of male sexual dysfunction, suggesting that ED cannot be treated effectively without addressing the emotional underpinnings. In Tanzania, cultural expectations position men as emotionally strong providers, which means that depressive symptoms are masked or denied, making ED a more visible surface through which deeper distress becomes clinically recognizable.

ED as Shaped by Anxiety, Performance Pressure, and Cognitive Hyperarousal

Participants also emphasized that anxiety, especially performance anxiety, is a central psychological driver of ED among men. Psychologists explained that anxiety activates cognitive hyperarousal, where men overthink their sexual performance, fear disappointing their partners, or catastrophize potential failure. This anticipatory fear disrupts the physiological processes needed for arousal, creating a cognitive-physiological loop that maintains the dysfunction. Several participants noted that anxiety about masculinity, sexual adequacy, and partner expectations increases pressure during sexual encounters, making relaxation difficult and erections more unpredictable.

A therapist had this to say,

When a man enters a sexual situation already worried about whether he will “perform,” his mind blocks the natural physiological response. They start monitoring themselves—“Is the erection coming? Will it last?” and this mental noise shuts the whole process down. (Participant 8, Sex Therapist)

Another participant added,

Many clients tell me they feel watched or judged in the bedroom, even when their partners are supportive. The anxiety becomes so strong that the body responds as if in danger, not in pleasure. The more they try to control the erection, the more the anxiety wins. (Participant 11, Counselling Psychologist)

These findings indicate that anxiety creates a feedback loop where fear of failure produces failure, reinforcing future fear. The insights resonate with cognitive-behavioral theories of sexual dysfunction, which argue that hypervigilance, self-monitoring, and negative automatic thoughts disrupt arousal pathways. Since masculinity is usually tied to sexual virility, performance anxiety is heightened, making men particularly vulnerable to anxiety-induced ED. They emphasize the need for psychosocial interventions that target thought patterns, partner communication, and emotional regulation.

Stress, Life Pressures, and Chronic Strain as Hidden Disruptors of Male Sexual Functioning

Most psychologists identified chronic stress linked to financial struggles, job instability, family responsibilities, and societal expectations as a major contributor to ED. They explained that prolonged stress dysregulates hormonal and physiological systems, reduces libido, and drains emotional resources needed for intimacy. Many participants described clients who, despite having functional relationships, experience ED simply because their minds are overwhelmed by the burdens of everyday survival. Stress from unemployment, debts, caregiving duties, and marital conflicts was repeatedly cited as creating a psychological environment incompatible with sexual arousal.

One psychologist shared,

Many men experiencing erectile challenges are under tremendous stress-work pressure, debts, and trying to support extended families. Their bodies and minds are constantly in “fight mode,” and sex becomes another task rather than a moment of connection. (Participant 3, Clinical Psychologist)

Another explained,

You cannot expect a man who is stressed about meeting basic needs to relax enough for sexual intimacy. Stress tightens the body, overwhelms the mind, and shuts down desire. Many men think something is wrong with them physically, but the real issue is the weight they are carrying every day. (Participant 15, Counselling Psychologist)

These findings reveal stress as a silent yet powerful disruptor of sexual functioning, an insight deeply connected to the socioeconomic realities of many men. The results reinforce stress-related arousal inhibition models, which suggest that chronic stress biologically suppresses sexual systems. Importantly, stress-related ED cannot be resolved solely through medical interventions; it requires addressing the broader psychosocial environments in which men live. The interplay between economic hardship, relational strain, and sexual performance demonstrates how ED is not merely an individual health problem but a reflection of larger structural pressures.

The second research question explored cultural, social, and relational factors that psychologists perceive as influencing the presentation and management of ED among adult men in Tanzania. The findings were as presented hereunder.

Masculinity Norms, Sexual Expectations, and the Pressure to Perform

Participants emphasized that cultural constructions of masculinity in Tanzania shape how ED is experienced, interpreted, and disclosed by men. Psychologists explained that many men internalize societal expectations to be consistently sexually potent, emotionally strong, and capable providers, all of which make sexual difficulties feel like a threat to their identity. Because masculinity is closely tied to virility and the ability to satisfy a partner, ED creates profound embarrassment, leading many men to hide their symptoms or delay seeking psychological support. According to participants, this pressure intensifies performance anxiety and shame, causing men to view ED not simply as a health issue but as evidence of personal failure and diminished manhood.

One psychologist explained,

In our context, a man’s sexual performance is almost treated as a measure of his masculinity. When he experiences erectile difficulties, he feels he has failed not only himself but also societal expectations. This makes it very hard for men to talk openly or seek help early. (Participant 6, Clinical Psychologist)

Another participant had this to say,

I see clients who believe that having an erection problem makes them “less of a man.” This belief affects their confidence, relationships, and even how they behave socially. The cultural script of masculinity becomes a barrier to healing. (Participant 10, Counselling Psychologist)

These findings show how sexual performance is symbolically linked to masculine identity in many communities in Tanzania, making ED a culturally loaded condition. This aligns with African masculinities literature, which argues that men often experience sexual challenges as threats to their social legitimacy. This suggests that treatment approaches must account for these gendered expectations and incorporate culturally sensitive psychoeducation that redefines masculinity beyond sexual performance.

Stigma, Silence, and Help-Seeking Barriers Rooted in Cultural Beliefs

Stigma and silence surrounding discussions of sexual health among adult men was among dominant themes. Participants noted that many cultural norms in Tanzania discourage open conversation about sexual difficulties, framing them as private or shameful matters. This silence is reinforced by beliefs that ED is a sign of spiritual punishment, witchcraft, loss of male power, or marital disunity. Psychologists reported that men usually explore traditional healers, herbal remedies, and spiritual explanations before turning to psychological services, which delays effective assessment and treatment. The stigma creates fear of judgment from partners, peers, family members, and even health care providers.

One participant described this dynamic that,

Many men come to therapy as a last resort. They have already tried herbal treatments such as “Congo herbal powder—commonly known as ‘mkongo’” or gone to spiritual healers because they believe the problem is either witchcraft or a curse. Talking about sexual issues openly is still considered a taboo in many communities. So, stigma delays help-seeking. (Participant 2, Counselling Psychologist)

Another added,

Some clients reported fear of being laughed at if they shared their problem. They think people will mock them or say they are not “strong” anymore. This fear keeps them silent for months or even years before they come for psychological support. (Participant 13, Clinical Psychologist)

The findings demonstrate an important role of cultural stigma in shaping help-seeking patterns, consistent with studies on sexual health stigma. The silence surrounding ED reinforces delayed diagnosis and increases psychological distress. This suggests that interventions should include community education, campaigns to fight against stigma, and culturally attuned counseling strategies that acknowledge the symbolic meanings embedded in ED within local belief systems.

Marital Dynamics, Communication Patterns, and Relational Tensions

Participants also emphasized that ED is heavily influenced by relational and marital dynamics, especially communication quality, emotional closeness, and partner reactions. Psychologists explained that many men experience intensified ED symptoms when there are unresolved conflicts, lack of emotional intimacy, and unmet relational needs in their partnerships. Several participants noted that when couples avoid discussing sexual expectations or frustrations, misunderstandings accumulate, causing tension and emotional distance. Partners misinterpret ED as infidelity, loss of interest, or betrayal, which further increases psychological pressure on men. In this way, relationship strain becomes both a cause and consequence of the dysfunction.

A psychologist shared,

Erectile dysfunction rarely exists in isolation. Many times, the couple is already struggling with communication or trust issues. When the man cannot perform, the tension increases, and both partners start blaming themselves or each other. (Participant 5, Marriage and Family Therapist)

Another expert noted,

I have come across cases where the woman interprets the dysfunction as a sign that the man has another partner. This misunderstanding creates emotional distance, and the man becomes even more anxious. The sexual problem becomes a relational problem. (Participant 9, Counselling Psychologist)

The findings emphasize the relational nature of ED and resonate with systemic and relational theories, which view sexual difficulties as both interpersonal and intrapsychic phenomena. In Tanzania, marital roles, gender expectations, and economic pressures shape couple dynamics, which further amplifies the impact of relational tensions on ED. Effective management therefore requires couples-focused interventions, communication skills training, and relational counseling that address underlying emotional patterns rather than treating ED as an individual physical dysfunction alone.

The third research question sought to establish assessment and intervention strategies psychologists use when working with clients experiencing ED alongside co-occurring mental health concerns. In pursuit of this, the following were the findings.

Comprehensive Biopsychosocial Assessment and Collaborative Case Formulation

The majority of the participants reported that their assessment approach to ED involves a comprehensive biopsychosocial framework that explores medical, psychological, relational, and sociocultural dimensions of the client’s life. Psychologists emphasized that ED cannot be understood without examining mood symptoms, anxiety patterns, stressors, relationship dynamics, and cultural beliefs about masculinity and sexuality. They described conducting detailed clinical interviews, exploring the onset and progression of symptoms, assessing sexual history, and collaboratively developing case formulations that integrate both psychological and contextual factors. Many practitioners noted the importance of ruling out underlying medical conditions by encouraging clients to undergo medical evaluations, demonstrating an integrated approach to sexual health.

A psychologist stated,

I always begin with a full biopsychosocial assessment because ED is rarely one-dimensional. I ask about mood changes, stress, relationship issues, and even cultural beliefs. This helps us build a comprehensive picture of what is happening in the client’s life. (Participant 1, Clinical Psychologist)

Another practitioner added,

We work collaboratively. Clients tell their story, and together we identify psychological patterns and contextual pressures. Sometimes we even involve medical doctors to ensure the assessment is complete and the client receives holistic care. (Participant 14, Counselling Psychologist)

These results demonstrate that psychologists adopt multidimensional assessment strategies that reflect global best practices in sexual dysfunction evaluation. Such approaches align with integrative models that view ED as a product of biological vulnerability, psychological processes, and relational influences, rather than a purely physiological issue. The emphasis on collaborative formulation allows clients to reframe ED not as a personal failure but as a complex, treatable condition shaped by multiple interacting factors.

Cognitive-Behavioral and Anxiety-Reduction Interventions Targeting Maladaptive Thought Patterns

Among the major interventions were CBT techniques designed to challenge maladaptive beliefs, reduce performance anxiety, and modify cognitive distortions associated with ED. Participants explained that many men internalize catastrophic thinking (“I will fail again,” “My partner will leave,” “I am no longer a man”) that heightens anxiety and further impairs sexual functioning. Psychologists therefore focus on identifying negative automatic thoughts, restructuring dysfunctional beliefs about masculinity and performance, and teaching anxiety-management skills including breathing techniques, grounding exercises, and progressive relaxation. These strategies aim to reduce hyperarousal and create a mental environment conducive to sexual response.

As one participant explained,

I use cognitive restructuring to help clients challenge harmful beliefs around masculinity and performance. Many come with catastrophic thoughts that fuel the anxiety cycle. Once we address these thoughts, their confidence improves. (Participant 7, Counselling Psychologist)

Commenting on methods to reduce anxiety, another psychologist said,

We incorporate anxiety-management techniques, especially for clients who experience panic-like symptoms during intimacy. Techniques like deep breathing or grounding help reduce the pressure they place on themselves. (Participant 16, Clinical Psychologist)

The results highlight CBT as a central modality for addressing the psychological mechanisms that sustain ED, consistent with cognitive-behavioral models of sexual dysfunction. Through targeting both cognitive distortions and anxiety responses, psychologists help clients break the cycle of fear and failure. The emphasis on psychoeducation and cognitive reframing also shows cultural sensitivity, as practitioners design interventions to capture and address local beliefs about masculinity, responsibility, and sexual expectations.

Couple-Based Interventions to Strengthen Communication, Intimacy, and Relational Support

Participants also emphasized the importance of involving partners in therapy, especially when relational dynamics contribute to the onset or maintenance of ED. Psychologists described using couple-based interventions to enhance communication, rebuild trust, and improve emotional intimacy. They noted that in many cases, partners misinterpret ED as a sign of infidelity or loss of attraction, which increases relational conflict and worsens client anxiety. Through guided discussions, emotional expression exercises, and joint problem-solving, psychologists help couples develop shared understanding and supportive sexual expectations. Some practitioners also incorporate behavioral exercises to reduce performance pressure and re-establish intimacy without the immediate expectation of intercourse.

One psychologist shared,

Couples therapy is very important because sexual issues often affect both partners. When couples learn to talk openly about fears, misunderstandings reduce, and intimacy begins to return. (Participant 11, Marriage and Family Therapist)

Another expert noted that,

We teach couples to shift from performance-based sex to connection-based intimacy. Exercises like sensate focus help reduce pressure and rebuild trust, especially when conflict or fear of judgment is involved. (Participant 3, Clinical Psychologist)

These findings emphasize that ED is not simply an individual condition but a relational phenomenon shaped by communication patterns, emotional climate, and partner interpretations. Couple-based interventions align with the view of sexual difficulties as embedded within relationship dynamics. Marital expectations and gender roles strongly influence sexual interactions, and thus, partner-inclusive therapy becomes especially critical in promoting sustainable improvements in sexual functioning and relational wellbeing.

Discussion

Psychologists in this study conceptualized ED not as a purely biomedical condition but as closely intertwined with psychological distress, particularly depression, anxiety, and chronic stress. This framing is consistent with evidence demonstrating a bidirectional association between ED and depression. For instance, Liu et al. (2018) reported that depression is associated with an increased risk of ED (odds ratio [OR] ≈ 1.39), while ED itself predicts subsequent depression (OR ≈ 2.92). Apart from affective symptoms, participants emphasized cognitive processes such as catastrophic performance appraisals, fear of sexual failure, and excessive self-monitoring during sexual activity. These align with cognitive-behavioral models of psychogenic ED, which posit that negative automatic thoughts, attentional hypervigilance, and performance-related anxiety activate sympathetic arousal and divert attention away from erotic cues, thereby inhibiting sexual response. Research has consistently identified performance anxiety as a central mechanism in psychogenic ED (Pyke, 2020; Velurajah et al., 2022), and cognitive-behavioral interventions explicitly target these maladaptive cognitions and safety behaviors.

Cultural norms, social stigma, and relationship dynamics shape men’s experiences of ED and their willingness to seek help. Psychologists were very clear that masculine ideals including virility, sexual potency, and toughness are deeply rooted, and ED thus poses not only a personal health problem but also a threat to social identity and male honor. This finding resonates with literature on African masculinities, which emphasize how sexual performance is integral to social status, self-worth, and gender legitimacy (Lindsay & Miescher, 2003; Ouzgane & Morrell, 2005; Ratele, 2016). Stigma and help-seeking patterns further complicate matters. Psychologists described how men often resort first to traditional healers, spiritual remedies, or self-medication, largely because discussing sexual dysfunction in psychological terms is taboo. This aligns with studies showing that in many low- and middle-income settings, formal mental health services are not the first port of call for men with sexual health concerns. Findings show that social and spiritual explanations often dominate (Nyalela & Dlungwane, 2023, 2024), which results in delayed psychological intervention and potentially harmful trajectories, especially when traditional remedies replace evidence-informed approaches.

Relational factors were equally central. The clinicians noted that ED rarely occurs in relational isolation: conflict, communication breakdowns, and mutual misinterpretation (especially around blame and trust) deepen the distress and perpetuate dysfunction. For instance, partners may wrongly interpret ED as infidelity, disinterest, or rejection. These relational dynamics heighten anxiety, reduce emotional intimacy, and cement performance pressure. Internationally, sex therapy (especially systemic or couple therapy) recognizes these patterns. Interventions such as sensate focus, communication training, and joint problem-solving are evidence-based in restoring intimacy and reducing performance demands (Masters & Johnson model; sensate focus technique) (Binik & Hall, 2014). Psychologists in this study similarly advocate for couple-level work, confirming that effective ED treatment in this context must attend to relational as well as individual processes.

Another study’s concern was how psychologists assess and intervene when working with men experiencing ED in conjunction with mental health concerns. Participants described holistic biopsychosocial assessments, integrating sexual history, mood and anxiety measures, relational exploration, and life stress evaluation. They reported collaborating with medical professionals to rule out biological causes, which shows integrated care principles. Regarding intervention, cognitive-behavioral strategies were dominant. Psychologists reported restructuring negative beliefs (e.g., about masculinity, failure), reducing performance anxiety via relaxation and grounding, and addressing hypervigilance. These strategies are strongly aligned with CBT models of sexual dysfunction, which emphasize correcting maladaptive cognitions, reducing arousal-related anxiety, and shifting patterns of avoidance and safety behaviors.

Empirical literature supports the effectiveness of such approaches. A randomized controlled trial of guided internet-delivered CBT for ED showed significant improvements in erectile functioning at 6-month follow-up (Andersson et al., 2011). There is also emerging evidence for Cognitive Behavior Sex Therapy (CBST): a pilot trial in young men with non-organic ED found that CBST yielded comparable improvements in erectile functioning and reductions in anxiety relative to pharmacological treatment (Bilal & Abbasi, 2020). Furthermore, a more recent randomized controlled trial (RCT) in Pakistan demonstrated that integrated treatment (sildenafil plus CBST) produced larger improvements than either intervention alone (Bilal & Abbasi, 2022). These empirical findings confirm the clinical strategies described by our psychologist participants, supporting the use of integrated and multimodal psychological therapies. Beyond CBT, psychologists emphasized psychoeducation, explaining the mind–body connection, normalizing ED, and correcting myths about masculinity and sexual performance. This aligns with international recommendations: guidelines from the International Consultation on Sexual Medicine emphasize that psychoeducation is a foundational element, helping clients and partners understand the biopsychosocial dynamics of dysfunction and reducing shame (Brotto et al., 2024). More so, couple-based interventions were another key component: therapists described using exercises such as sensate focus and communication training to rebuild intimacy and reduce demand. Sensate focus, originally developed by Masters and Johnson, is well established in sex therapy: it encourages experiential, non-goal-focused sexual touch, reduces performance anxiety, and fosters emotional connection (Avery-Clark & Weiner, 2014).

Conclusion

The findings demonstrate that psychologists in this study conceptualize ED as a multidimensional condition arising from the interaction of biological vulnerabilities, emotional distress, relational dynamics, and sociocultural expectations. In their accounts, anxiety, depressive symptoms, performance pressure, and strained intimate relationships were described as common entry points through which men present with ED in clinical settings. Participants also highlighted how culturally embedded scripts of masculinity, especially expectations of sexual competence, emotional restraint, and self-reliance intensify distress, inhibit help-seeking, and shape how men interpret erectile difficulties. In response, psychologists described drawing on cognitive-behavioral and biopsychosocial frameworks to address maladaptive beliefs, performance-related anxiety, and interpersonal patterns, often extending intervention beyond the individual to include partners. Collectively, these findings emphasize ED as a psychosocially embedded experience and point to the need for holistic, culturally responsive psychological services that attend simultaneously to cognitive, emotional, relational, and sociocultural dimensions of men’s sexual health.

Recommendations

Several recommendations emerge for strengthening psychosexual health services. First, there is a need to scale and adapt CBT-based sex therapy models for use in both individual and couple formats, to ensure that interventions are culturally grounded, accessible, and feasible for low-resource clinical settings. Second, routine psychosexual screening and psychoeducation should be integrated into primary health care, chronic disease clinics, and mental health services to reduce stigma, promote early identification, and ensure timely referrals. Third, interdisciplinary collaboration, linking psychologists, urologists, psychiatrists, and community health workers, should be institutionalized to enhance the coordination and continuity of care. Finally, sustained community-level initiatives are required to challenge harmful gender norms, normalize conversations about men’s sexual and mental health, and promote help-seeking. These actions would not only improve clinical outcomes for men with ED but also contribute to broader sexual health literacy and psychological wellbeing across communities.