Abstract
Erectile dysfunction (ED) is a common presentation in primary care; while psychogenic ED is well-described globally, cases in sexually inexperienced young men where moral incongruence, pornography-related guilt, and childhood trauma are predominant contributors are rarely documented. ED in young males is increasingly recognized as multifactorial, with biopsychosocial complexity, and it can be assessed even in the absence of partnered sexual activity using masturbation-based evaluation. We present the case of a 24-year-old single male with perceived sexual dysfunction: difficulty in sustaining penile erection during masturbation. He engaged in frequent masturbation with pornography, experiencing guilt and moral conflict, and was concerned about “sexual addiction” and anticipated future partnered sexual performance. He reported a background of childhood trauma, a strained paternal relationship with physical abuse, and symptoms of anxiety and low mood. General and systemic physical examinations were unremarkable. Mental state examination further revealed performance anxiety and psychosocial distress, without evidence of an organic pathology. Management aligns with the biopsychosocial framework prioritizing patient-centered psychosocial support, psychoeducation, and cognitive-behavioral strategies within the primary care setting, supplemented by initiation of pharmacotherapy and psychiatric collaboration, leading to notable improvement in psychological and sexual functioning. Clinicians should recognize that psychogenic ED in sexually inexperienced young males may stem from moral incongruence and pornography-related guilt. This case underscores the importance of comprehensive sexual history taking, identification of contributors to psychological distress, trauma history, and sexual behaviors. Early holistic intervention at the primary care level, supported by multidisciplinary collaboration, can facilitate timely recognition and effective management.
Introduction
Erectile dysfunction (ED) is defined by one of the symptoms of decreased erectile rigidity, obtaining or maintaining an erection during most partnered sexual activity over a period of 6 months and causing significant distress to an individual (Quinta-Gomes & Nobre, n.d.). While psychogenic ED is widely recognized, cases in sexually inexperienced young males where internalized moral beliefs and pornography-related guilt are predominant contributors are rarely documented. Presently, Malaysia-specific literature that exclusively quantifies psychogenic ED among young males is lacking; however, internationally, it was reported that 85.2% of males under 40 years old have become increasingly recognized, with psychological and psychosocial factors often playing a dominant role in the absence of organic pathology (Nguyen et al., n.d.; Safa & Waked, 2025; Topak et al., 2023). In a real-world Malaysian context, the gap in psychogenic ED local data underscores the need for case-based examples highlighting unique psychosocial contributors, such as moral incongruence and pornography-related guilt, and how they can be addressed in primary care.
Looking in a holistic biopsychosocial framework, both psychological and psychosocial factors, such as a history of childhood trauma, anxiety, and mood disorders, can significantly contribute to psychogenic ED (Cassioli et al., 2024; Dewitte et al., 2021; Manalo et al., 2022; Safa & Waked, 2025; Topak et al., 2023). Previous research published in the American Journal of Men’s Health has demonstrated that psychological distress, particularly anxiety and depressive symptoms, is frequently observed among men with ED, and that more severe ED is associated with higher levels of these symptoms (Quang et al., 2024).
Apart from relational and biological context, a detailed sexual history is important, including masturbation patterns, pornography use, unrealistic sexual expectations, and internalized moral beliefs, particularly in sexually inexperienced males (Rowland et al., n.d.; Safa & Waked, 2025; Topak et al., 2023; Whelan & Brown, 2021). In a young man presenting with ED, focusing solely on organic causes risks overlooking these contributors and may inadvertently mislabel the diagnosis and then the management.
Primary care plays a paramount role in the early recognition and management of psychogenic ED (Stanley et al., 2025). Primary care physicians are uniquely positioned to explore psychosocial background, initiate first-line biopsychosocial management, address comorbidities, and provide continuity of care, multidisciplinary coordination, and referral. Recognizing unusual psychosocial drivers, such as moral incongruence or pornography-related guilt, is particularly important for guiding early, patient-centered interventions. Shared decision-making is particularly important in this context, especially when weighing the benefits and risks of pharmacological treatments, ensuring that management aligns with patient values, expectations, and long-term well-being.
This case provides a novel teaching point for primary care, illustrating how perceived sexual dysfunction in a young, sexually inexperienced male may arise predominantly from psychological distress, amplified by guilt and internalized beliefs rather than an organic pathology. We aim to highlight the clinical relevance of moral incongruence and pornography-related guilt in psychogenic ED and reinforce the importance of patient-centered, holistic biopsychosocial management at the primary care level.
Case Presentation
A 24-year-old single male presented with a 6-month history of perceived sexual dysfunction: difficulty in sustaining penile erection during masturbation and short ejaculation latency. He has no past medical or surgical comorbidities. A detailed sexual history revealed frequent masturbation with pornography use since the age of 15, primarily accessed through internet-based video platforms using his personal smartphone and laptop, associated with guilt, moral conflict regarding sexual behaviors, and concern about “sexual addiction.” He had never engaged in partnered sexual activity. He reported spontaneous morning erections and had no symptoms suggestive of hypogonadism.
The perceived sexual dysfunction had caused significant psychological distress, including anticipatory anxiety about his future partnered sexual performance. Psychosocial history revealed childhood adversity, including being an offspring of his father’s third marriage, a strained paternal relationship characterized by episodes of physical punishment and emotional neglect during childhood, which contributed to long-standing feelings of insecurity, depression, and anxiety. There was no known family history of psychiatric illness, including anxiety or mood disorders. He denied illicit substance or alcohol use.
His general and focused physical examination, including cardiovascular, neurological, and urogenital systems, was unremarkable. Mental state examination revealed mild anxious affect and ruminative thoughts related to sexual performance, with intact insight and no psychotic symptoms or suicidal ideation. Assessment using masturbation-based evaluation and the Erection Hardness Score (EHS) showed inconsistent erection hardness (EHS 2–3), with preserved spontaneous erections, supporting a predominantly psychogenic etiology.
Laboratory investigations were limited to renal profile (RP), liver function tests (LFTs), and thyroid function tests (TFTs), all within normal limits (Table 1). Serum testosterone, fasting blood sugar, and lipid profile were not obtained, as the patient was a healthy young 24-year-old male with no clinical features suggestive of hypogonadism, metabolic, or other endocrine dysfunction.
Laboratory Results.
A working diagnosis of psychogenic sexual dysfunction driven by anxiety, moral incongruence, and adverse childhood trauma was established. Management in the primary care setting prioritized a biopsychosocial approach, including psychoeducation, reassurance regarding sexual physiology, behavioral modification, and early identification of psychosocial contributors. He was co-managed with psychiatry, which included cognitive-behavioral strategies and anxiety management techniques. He was commenced on sertraline, titrated to 100 mg once daily, with notable improvement in mood, anxiety symptoms, and sexual function. The patient reported cessation of masturbation for 2 months through engagement in spirituality, hobbies, and avoidance of pornography, illustrating practical strategies that can be applied in primary care for similar cases.
Discussion
ED in young males is increasingly recognized as multifactorial, with biopsychosocial complexity where psychogenic factors, such as anxiety, depression, performance concerns, moral incongruence, and trauma, often outweigh organic causes (Cassioli et al., 2024; Jiang et al., n.d.; Manalo et al., 2022; Topak et al., 2023). Evidence from studies published in the American Journal of Men’s Health further supports this perspective, demonstrating that ED is closely associated with psychological distress, particularly anxiety and depressive symptoms, and highlighting the importance of mental health assessment when evaluating men with ED (Diao et al., 2024; Quang et al., 2024). Meanwhile, although primary guidelines for ED emphasized the context of at least 6 months in 75%-100% of partnered sexual activity, the diagnosis can still be established in those without a partner (Mao et al., 2025; Quinta-Gomes & Nobre, n.d.; Zhang et al., 2023). Masturbation-based assessment using EHS in sexually inexperienced patients provides a practical and clinically informative method to evaluate erectile performance, particularly in primary care settings (Mao et al., 2025; Zhang et al., 2023). Therefore, in this case, the patient’s core features of reduced erection quality during masturbation (EHS 2–3) for more than 6 months, preserved spontaneous erections, absence of medical comorbidities, normal physical examination, anxiety, and history of childhood trauma support a predominantly psychogenic ED origin, amplified by moral incongruence and pornography-related guilt.
It could be indeed challenging at a busy primary care level, which requires clinical judgment and holistic assessment, emphasizing the importance of identifying unique psychosocial drivers in young patients presenting with sexual dysfunction (Cassioli et al., 2024; Jiang et al., n.d.; Manalo et al., 2022; Topak et al., 2023). In this case, his psychosocial factors revealed significant antecedents of adverse childhood trauma, anxiety, and low mood, which are predictors of psychogenic ED as emotional stressors mediate sexual functioning (Cassioli et al., 2024; Jiang et al., n.d.; Manalo et al., 2022; Topak et al., 2023). Notably, the patient’s internalized moral beliefs and guilt surrounding pornography and masturbation were central contributors to his sexual dysfunction, highlighting a clinical teaching point for primary care physicians. Moreover, problematic pornography use and frequent masturbation have been associated with ED, performance anxiety, reduced arousal, and maladaptive sexual expectations, especially in psychologically vulnerable groups, as observed in this case (Rowland et al., n.d.; Jacobs et al., n.d.). The patient’s perception of “sexual addiction,” combined with anticipatory anxiety about future partnered sexual activity, reflects the interplay of internal psychological distress and psychosocial context, a combination rarely documented in young, sexually inexperienced males (Whelan & Brown, 2021).
Looking at all his underlying issues through a multidimensional and biopsychosocial lens, the management requires a multidisciplinary approach that incorporates both non-pharmacological and pharmacological treatment, which facilitates targeted improvement in both psychological and sexual functioning (Safa & Waked, 2025). Primary care plays a unique role in early intervention by providing psychoeducation, reassurance regarding sexual physiology, and behavioral modification, which empowered the patient to engage in healthier lifestyle choices and alternative coping strategies (Dewitte et al., 2021; Safa & Waked, 2025). Recognizing that his psychological distress stemmed from internal value conflicts surrounding pornography and masturbation, guilt and anticipatory concerns about partnered sexual activity facilitated cognitive-behavioral interventions focused on maladaptive belief correction, thought reframing, anxiety reduction, and processing of underlying trauma, highlighting a structured approach that can be applied in primary care practice (Cassioli et al., 2024; Dewitte et al., 2021; Jiang et al., n.d.; Safa & Waked, 2025).
Cultural and religious contexts may also shape how individuals perceive sexual behaviors (Wong, 2012). In many Asian societies, including Malaysia, discussions surrounding sexuality, pornography use, and masturbation remain socially sensitive topics (Phuah et al., 2023; Wong, 2012). Young individuals may internalize moral or religious expectations regarding sexual behavior, which can lead to moral incongruence when personal behaviors conflict with perceived values (Phuah et al., 2023; Wong, 2012). Such internal conflict may manifest as guilt, shame, or anxiety, which in turn may negatively influence sexual confidence and ED. In this case, the patient’s spiritual beliefs contributed to his internal conflict regarding pornography use and masturbation, which amplified feelings of guilt and performance anxiety. However, spirituality also served as a coping framework during recovery, as the patient redirected his focus toward spiritual practices, hobbies, and lifestyle changes, helping him reduce pornography exposure and improve psychological well-being. This highlights the importance of culturally and spiritually sensitive biopsychosocial assessment in primary care when managing psychogenic sexual dysfunction.
In line with the fundamentals of family medicine, shared decision-making was essential in initiating pharmacotherapy, balancing improvement in anxiety and mood against potential sexual side effects of selective serotonin reuptake inhibitors (SSRIs; Tran et al., 2025). He was engaged in a shared decision, benefit and risk that SSRIs have shown to be effective in treating anxiety and depression, supporting recovery, but could contribute to sexual dysfunction, ED, decreased libido, and delayed ejaculation (Tran et al., 2025). Therefore, a longitudinal plan aimed at stable remission of psychiatric comorbidities while monitoring sexual function with a future partner, including dose adjustment or switching agents as needed, was implemented (Tran et al., 2025). This case exemplifies how primary care clinicians, through careful psychosocial assessment and collaboration with psychiatry, can address complex psychogenic ED effectively, providing a teaching point for early recognition and holistic management in young males (Safa & Waked, 2025; Topak et al., 2023).
Conclusion
This case illustrates how psychogenic ED in sexually inexperienced young males may be driven by moral incongruence, pornography-related guilt, and psychosocial stressors, rather than organic pathology. A comprehensive sexual history, along with careful clinical assessment and holistic management, is essential. Early recognition of these unique psychosocial contributors in primary care, combined with a biopsychosocial and multidisciplinary approach, can facilitate timely intervention and improve patient outcomes.
Footnotes
Ethical Considerations
Not applicable.
Consent to Participate
The patient provided written informed consent for the publication of this case report, including all relevant clinical information and anonymized details.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.