Sexual Performance Anxiety: The Cycle, Causes and What Helps

"The first time it didn't work, I put it down to being tired. But ever since, every time we start, all I can think is: is it going to fail again?" I hear words like these in my consulting room very often. Most of the time they come from men who are physically healthy. They still wake up with erections and have no trouble when they masturbate, yet with a partner things don't go the way they hope. What is happening is not that they are "less of a man". It is a brain-and-nervous-system mechanism that can be explained, and it can be fixed. This article walks you through sexual performance anxiety, from the cycle that keeps it going to the approaches that have real evidence behind them.

What is sexual performance anxiety?

Sexual performance anxiety is fear or worry that you won't "perform well" sexually: fear of not getting an erection, of losing it halfway, of finishing too quickly, of disappointing your partner, or that your body isn't attractive enough. The worry shows up before or during sex, and it genuinely reduces how the body responds.

It is not a separate diagnosis in DSM-5-TR, but it is an important factor behind several sexual problems, especially situational erectile dysfunction (ED) and premature ejaculation (PE). A review by Pyke (2020) concluded that it is common in both men and women, and is often overlooked because most people never talk about it.

One thing I want you to know from the start: occasionally not getting hard or finishing quickly is a normal part of being human. Tiredness, alcohol, work stress or a new partner can all make the body stumble. The real problem begins when we read that one occasion as "I'm broken" and start monitoring ourselves every time afterwards.

The cycle: worry, self-monitoring, and a body that won't respond

Masters and Johnson described a behaviour they called spectatoring: stepping outside yourself to watch and grade your own performance during sex, instead of being present with what you feel. Later, Barlow (1986) added that people with sexual difficulties tend to focus on "threat", such as signs that the erection is fading, rather than on erotic cues. The more you monitor, the more arousal drops.

The cycle usually runs like this:

1. One bad experience, for example not getting hard on a night when you were exhausted or had been drinking.
2. Anticipation: "Will it happen again next time?"
3. Spectatoring: during sex you keep checking whether you are hard enough and what your partner is thinking.
4. The sympathetic nervous system switches on. The body goes into fight-or-flight and the blood vessels in the penis constrict. This is explained in detail in Stress, relaxation and erections.
5. The body really doesn't respond: the erection isn't firm enough or fades, or some men rush to finish because they are afraid of losing it.
6. The belief is "confirmed", and you return to step 2 with the loop tighter than before. Some people start avoiding intimacy altogether.

1. 1
   One slipDidn't get hard or finished fast once
2. 2
   AnticipationFear it will happen again next time
3. 3
   SpectatoringChecking firmness and what partner thinks
4. 4
   Fight or flightSympathetic system on, vessels constrict
5. 5
   Body stallsNot firm enough, fades, or rushes to finish

Based on Masters and Johnson's spectatoring and Barlow's model (1986). Treatment can break the cycle at several points, e.g. CBT, mindfulness and sensate focus.

Common causes and triggers

• Expectations that don't match reality, such as needing to get hard instantly, last a long time or make your partner climax every time. Images from porn and films set a standard far above what real bodies do. Read a story from my consulting room in Sex isn't perfect like in the movies.
• A new partner or a new relationship, and the wish to impress.
• Periods of specific pressure, such as trying to conceive around ovulation, or after an argument.
• Having been criticised or teased about size, firmness or speed.
• General anxiety, depression and chronic stress from work or money.
• Body image: worry about weight, penis size or shape.
• A real physical problem in its early stages, such as early vascular ED, with anxiety piled on top so the symptoms look worse than the body actually is.

It happens to women too

Performance anxiety is not only a men's issue. Many women worry about not getting aroused, not being lubricated enough, not reaching orgasm, or about how their body looks during sex. The same self-monitoring lowers arousal, and some feel they have to "fake it" so their partner feels reassured, which widens the gap between body and mind even more.

If this sounds like you, read Orgasm difficulties in women. Most of the principles in this article, including mindfulness, sensate focus and communicating with your partner, apply to every gender.

Telling them apart: anxiety alone, or a physical cause as well?

Anxiety and physical causes are not completely separate. Many people have both. But there are clues that help a doctor assess what is going on.

This table is only a guide, not a diagnosis. Men with ED should have their cardiovascular risk factors checked at least once, because ED can be an early warning sign of vascular disease. Read Causes of erectile dysfunction.

Leans towards anxiety

• Sudden onset after a clear event
• Only with a partner or in some situations
• Morning and solo erections still firm
• Sexual desire still normal

Leans towards a physical cause

• Gradually worsening over time
• In almost every situation
• Morning erections weaker too
• Diabetes, blood pressure, cholesterol or smoking

vs

A guide only. Many people have both. Have a doctor assess you.

Evidence-based treatment

Cognitive behavioural therapy (CBT) and sex therapy

CBT helps you notice automatic thoughts such as "If I don't get hard, they'll leave me", test how true they are, and replace them with more flexible ones, such as "Bodies have good days and bad days, and intimacy comes in many forms." Sex therapy combines education, adjusting expectations and exercises you do at home. A meta-analysis by Frühauf and colleagues (2013) found that psychological interventions help a range of sexual problems, including ED and orgasm difficulties.

Mindfulness

Mindfulness means gently bringing your attention back to the sensations in front of you without judging them, which is the direct opposite of spectatoring. A pilot study by Bossio and colleagues (2018) found that mindfulness-based group therapy was feasible and showed promise for men with situational ED. You can find starter exercises in Mindful sex.

Sensate focus

This is a structured series of touch exercises in which the couple agrees to put penetrative sex on hold for a while. With no "exam" to pass, the nervous system doesn't need to stay on guard. Many couples find that the body starts responding by itself during the "ban". Read the principles in Sensate focus: rebuilding intimacy and the step-by-step programme in Sensate focus exercises step by step.

PDE5 inhibitors as a temporary aid

Medicines in this group, such as sildenafil and tadalafil, help blood flow into the penis when there is sexual stimulation. When anxiety is the main driver, doctors sometimes use them as a short-term confidence aid, so that you can have several good experiences and the anxiety cycle loosens. The medicine is then gradually reduced, as assessed by your doctor.

Things to know:

• A Cochrane review (Melnik and colleagues, 2007) found that in some studies, combining medication with group therapy worked better than medication alone. Medication should not be the only answer.
• Never combine them with nitrates (such as under-the-tongue tablets for chest pain) or with poppers, because blood pressure can drop dangerously.
• Buying pills online to try on your own risks counterfeit products, the wrong dose, and missing hidden vascular disease. Use them only as assessed and prescribed by a doctor.
• If an erection lasts longer than 4 hours, go to an emergency department immediately.

How to talk with your partner

Silence often does more harm than the problem itself. Many partners interpret it as "they don't want me any more", when in fact the other person is scared. Try this:

• Choose a time outside the bedroom, not straight after an occasion that didn't go well.
• Speak from your own feelings, for example "I've been really anxious about this lately, and I'm afraid you'll be disappointed", rather than staying silent or making excuses.
• Tell your partner what helps, such as not rushing, not asking "what's wrong?" in the middle of things, and valuing other kinds of closeness just as much.
• Agree on a break from penetration together, to take the pressure off.
• For partners: your empathy and patience are among the best medicines there are. Teasing or comparisons, even as a joke, always tighten the cycle.

If every conversation turns into an argument, read Common couple problems and how to talk them through.

What you can start doing today

1. Change the goal from "I have to succeed" to "be present with the sensations and the closeness".
2. Breathe slowly, making the out-breath longer than the in-breath, for 5–10 minutes a day, and use it when the worry starts.
3. Catch the thought loop. When you notice you are grading yourself, bring your attention back to one sensation, such as skin, temperature or breath.
4. Look after the basics: enough sleep, less alcohol, regular exercise, and quitting smoking.
5. Stop comparing yourself with porn. If you feel that watching raises your expectations or feels out of control, read Porn addiction or CSBD?

When to see a doctor, and how the clinic can help

See a doctor if:

• The problem keeps recurring for several weeks and is causing distress, or you have started avoiding intimacy.
• You are over 40 or have diabetes, high blood pressure, high cholesterol or smoke. Physical causes should be checked as well.
• You don't get erections in any situation, including in the morning.
• You have depression or anxiety that is affecting your life. If you feel you can't cope, call 1323, Thailand's free 24-hour mental health hotline (Thai language; ask for English support).

At Dr. Kris Clinic I look after the body and the mind together. We start by talking through your particular cycle, check for physical causes where needed, offer sexology counselling for individuals or couples, practise techniques such as sensate focus, and consider short-term medication when it is appropriate, as assessed by the doctor. Consultations are available in person at the clinic in Surat Thani and online, in English or Thai.