Counseling and sex therapy for ED: what the studies show

In short: counseling for erectile dysfunction is a conversation-based treatment, sometimes with a partner in the room, that works on the thoughts, worries and relationship patterns that can keep ED going. Sex therapy is a specialized form of psychotherapy that goes deeper. The research behind it is real but modest: the trials are mostly small and some are decades old. Taken together, they suggest that therapy helps some men on its own and that adding it to an ED medicine tends to do better than the medicine alone. This page covers what a course of counseling involves, what the trials actually measured, and how to check a therapist’s training.

What is sex therapy for erectile dysfunction?

Sex therapy is a type of psychotherapy that focuses on sexual experiences, and for ED it targets the psychological and relationship side of the problem. The European Society for Sexual Medicine (ESSM) draws a line between counseling, which gives support, guidance and limited advice to help a man manage ED, and psychotherapy, which looks at long-running, recurring emotional and thinking patterns; it places sex therapy within psychotherapy (Dewitte et al., ESSM position statements, 2021). The same statements note there is no clear evidence on which type of psychological treatment suits which type of ED, so most research is reported as “psychological treatment” in general.

Counseling is part of the standard menu, not a fringe option. The NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) lists it alongside lifestyle changes and medicines, and says a health care professional may suggest it when mental health or emotional issues are affecting ED (NIDDK, Treatment for ED). For the full list of options, see our overview of ED treatment options.

What happens in counseling for ED?

Counseling usually moves in steps, starting with talk and information and going deeper only if needed. ESSM recommends the PLISSIT model: the therapist first gives permission to talk openly, then limited information about what is going on, then specific suggestions such as homework assignments, and finally intensive therapy when deeper underlying issues are involved (Dewitte et al., 2021).

The building blocks ESSM lists for a typical program include:

• Education about how erections and ED work, so both partners understand the problem and can talk about it more comfortably.
• Anxiety reduction, often through sensate focus: a graded series of touching exercises in which intercourse is set aside for a while and brought back step by step.
• Cognitive work that tests unhelpful beliefs and unrealistic expectations, such as the idea that sex always has to be perfect.
• Couple work on communication: what ED means to each partner and how any medical aids fit into the couple’s sex life.

ESSM also advises checking early whether the push for treatment is coming from you, your partner or the relationship, and tackling unrealistic expectations, to help prevent dropping out and dissatisfaction (Dewitte et al., 2021). If anxiety about performance is the main issue, our guide to working through performance anxiety goes deeper on CBT and sensate focus.

What did CBT and couples-therapy trials find?

The trials lean in favor of therapy, but they are small and of mixed quality. A Cochrane review pooled 11 trials with 398 men. In five of them, group psychotherapy cut the number of men whose ED persisted compared with a waiting list, and the benefit held at six months in the trials that followed men that long; therapy compared with injections or vacuum devices showed no difference (Melnik et al., Cochrane, 2007).

A systematic review of 20 controlled trials in men with sexual dysfunctions (ED and others, such as premature ejaculation) found that psychosocial treatments improved sexual function overall, that 12 of the 20 used either a Masters and Johnson style program or CBT, and that most approaches worked about equally well. It also flagged the rather low methodological quality of the studies, and noted that one trial found therapy did better than sildenafil while another found sildenafil did better (Berner and Günzler, J Sex Med, 2012). A wider meta-analysis across all sexual dysfunctions found psychological treatment beat a waiting list, but said the strongest evidence was for two conditions in women and more research was needed for the rest, ED included (Frühauf et al., Arch Sex Behav, 2013).

Couples trials point the same way. In a randomized pilot of 53 couples where the man had psychogenic ED, after four weeks 48% of men given sildenafil plus CBT-based sex therapy met the study’s success mark for erectile function, against 29% on sildenafil alone (Banner and Anderson, J Sex Med, 2007). A pilot from Seattle randomized couples to sildenafil alone or sildenafil plus brief couple sex therapy and reported support for the combined approach in men whose ED had mixed causes (Aubin et al., J Sex Marital Ther, 2009).

Can therapy be combined with ED medicine?

Yes, and the combination has the best support of anything on this page. A 2014 meta-analysis of 8 studies with 562 men found combined treatment worked better for ED symptoms than either an ED medicine or psychological treatment alone, and better than the medicine alone for sexual satisfaction. The medicine and therapy on their own did about equally well. The authors called the combination promising but said stronger trials are needed (Schmidt et al., J Sex Med, 2014).

The added value often shows up beyond the erection itself. In a small Italian trial of 30 couples, vardenafil alone and vardenafil plus CBT-based sex therapy both improved erectile function, but only the combined group saw gains in both partners’ sexual satisfaction (Boddi et al., Andrology, 2015). A follow-up of 20 men in Pakistan 15 to 18 months after treatment found those who had CBT alongside their medicine kept improving, while those on medicine alone did not; the authors note dropouts limit how far this can be generalized (Khan et al., J Sex Med, 2019).

Sticking with treatment is part of the reason. ESSM cites research that more than half of couples are no longer sticking with medical aids for erections after the first year of treatment, and it rates combined medical and psychological treatment as more effective than either alone (Dewitte et al., 2021). The American Urological Association (AUA) guideline says that for men being treated for ED, referral to a mental health professional should be considered to promote treatment adherence, reduce performance anxiety and integrate treatments into a sexual relationship. That is a moderate recommendation resting on grade C evidence, meaning the guideline panel has low certainty in the underlying studies (AUA Erectile Dysfunction Guideline, Statement 6). Whether a medicine fits you is a prescriber’s decision.

Does online sex therapy work for ED?

It may, though the evidence is early. In a randomized pilot, 98 men took part in an internet program based on sensate focus and cognitive restructuring, with no face-to-face contact, compared with a waiting list. The authors concluded it worked for ED, though the main comparison with the waiting list fell just short of the usual cutoff for statistical significance; for premature ejaculation it was no better than waiting (van Lankveld et al., J Sex Med, 2009). ESSM rates internet-based therapy as promising, notes that it can get around shame, cost and distance, and points out that dropout was high in one program (Dewitte et al., 2021). Premature ejaculation has its own evidence base; see our guide to premature ejaculation treatment.

Does a partner have to take part?

No, but it often helps when there is a willing partner. ESSM recommends including the partner where possible, because positive involvement helps solve the problem and keep treatment going, and because partners may need support of their own: ED can leave them feeling unattractive, guilty or rejected (Dewitte et al., 2021). NIDDK notes that a counselor may ask you to bring your partner to sessions (NIDDK, Treatment for ED). One of the group-therapy trials in the Cochrane review enrolled only men without a steady partner, so therapy is not only for couples (Melnik et al., 2007).

How do you find a qualified therapist?

Start with a referral from the clinician treating your ED, then check the therapist’s license and training. The American Association of Sexuality Educators, Counselors and Therapists (AASECT) describes its certified sex therapists as licensed mental health professionals who have specialized in sexual concerns (AASECT, Certified Sex Therapist).

To be certified, AASECT requires that a therapist:

• holds a state license to practice psychotherapy independently in psychology, medicine, social work, counseling, nursing or marriage and family therapy;
• has at least 90 hours of sexuality education and 60 hours of sex therapy skills training, plus couples counseling training if they have not had it already;
• has completed at least 50 hours of supervision with an AASECT-certified supervisor over at least 18 months, covering 300 hours of treating clients with sexual concerns;
• has read AASECT’s code of conduct for certified members, and renews certification every three years.

Those details come from AASECT’s published requirements (AASECT, Sex Therapist Certification Requirements). AASECT keeps a referral directory on its website, searchable by country or U.S. state (AASECT, Referral Directory). Certification is one useful signal, not the only one: a licensed psychologist or counselor with experience in sexual problems can also help. When you first contact someone, it is reasonable to ask whether they work with ED, whether they see couples, and whether they offer sessions online. Our guide to talking to a doctor about ED covers how to raise the subject and ask for a referral.

When to talk to a clinician

See a clinician before or alongside counseling, because a therapist cannot do the medical checks that ED calls for. The AUA says men with symptoms of ED should have a thorough medical, sexual and psychosocial history, a physical exam and selective lab testing (AUA Erectile Dysfunction Guideline). If low mood, loss of interest or hopelessness is part of the picture, mention it; our guide to depression and ED explains how the two affect each other. If you are unsure whether worry or a physical cause is behind the change, our explainer on telling ED and performance anxiety apart is a good next read. Do not stop a prescribed medicine on your own; ask the prescriber first (NIDDK, Treatment for ED).

Sources

• American Urological Association, Erectile Dysfunction Guideline: Statement 1 (medical, sexual and psychosocial history) and Statement 6 (referral to a mental health professional; moderate recommendation, evidence grade C).
• NIDDK, Treatment for Erectile Dysfunction, last reviewed October 2024: counseling, partner sessions, not stopping medicines on your own.
• Dewitte M et al. A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine. Sex Med. 2021;9:100434: counseling versus psychotherapy, PLISSIT, treatment components, adherence, combined treatment, partner involvement, internet-based therapy.
• Melnik T, Soares BG, Nasello AG. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst Rev. 2007;CD004825: 11 trials, 398 men.
• Schmidt HM et al. Combination of psychological intervention and phosphodiesterase-5 inhibitors for erectile dysfunction: a narrative review and meta-analysis. J Sex Med. 2014;11:1376-1391: 8 studies, 562 patients.
• Berner M, Günzler C. Efficacy of psychosocial interventions in men and women with sexual dysfunctions, part 1: male sexual dysfunction. J Sex Med. 2012;9:3089-3107.
• Frühauf S et al. Efficacy of psychological interventions for sexual dysfunction: a systematic review and meta-analysis. Arch Sex Behav. 2013;42:915-933.
• Banner LL, Anderson RU. Integrated sildenafil and cognitive-behavior sex therapy for psychogenic erectile dysfunction: a pilot study. J Sex Med. 2007;4:1117-1125.
• Aubin S et al. Comparing sildenafil alone vs. sildenafil plus brief couple sex therapy on erectile dysfunction and couples’ sexual and marital quality of life: a pilot study. J Sex Marital Ther. 2009;35:122-143.
• Boddi V et al. An integrated approach with vardenafil orodispersible tablet and cognitive behavioral sex therapy for treatment of erectile dysfunction: a randomized controlled pilot study. Andrology. 2015;3:909-918.
• Khan S, Amjad A, Rowland D. Potential for long-term benefit of cognitive behavioral therapy as an adjunct treatment for men with erectile dysfunction. J Sex Med. 2019;16:300-306.
• van Lankveld JJ et al. Internet-based brief sex therapy for heterosexual men with sexual dysfunctions: a randomized controlled pilot trial. J Sex Med. 2009;6:2224-2236.
• AASECT, Certified Sex Therapist, Sex Therapist Certification Requirements (requirements version 2026.T.1) and Referral Directory, checked 2026-10-17.