# Working through performance anxiety: what counseling and studies support

> Performance anxiety usually eases with approaches that take pressure off rather than fight it. Counseling, especially cognitive behavioral and sex therapy, has the best support, and small trials suggest it works better alongside an ED medicine than a pill alone. Propranolol is not labeled for anxiety, and a clinician can also check for physical causes.

_Last updated: 2026-10-17_

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**In short:** performance anxiety is the worry about whether your body will
cooperate, and that worry can be enough to interrupt an erection. It is common,
it is well described in the research, and the approaches with the most support
all work the same way: they take the pressure off instead of trying to force a
result. Counseling, in particular cognitive behavioral therapy (CBT) and sex
therapy, sits at the center. An ED medicine can help some men while they work on
the anxiety, and the small trials that combined the two found better results
than a pill alone. This page walks through what each approach involves, what the
studies found and how strong that evidence is.

| Approach                              | What it involves                                                                   | What the evidence shows                                                                           |
| ------------------------------------- | ---------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------- |
| Cognitive behavioral therapy          | Spotting and testing the thoughts that feed the worry; gradually ending avoidance  | Recommended for sexual performance anxiety, though controlled trials specific to it are lacking   |
| Sex therapy (including sensate focus) | Structured touch exercises with intercourse set aside for a while, plus counseling | Group sex therapy beat a waiting list in pooled small trials                                      |
| Mindfulness training                  | Practicing attention to the present moment instead of self-monitoring              | Promising in a 10-man pilot with no control group                                                 |
| Counseling plus an ED medicine        | Therapy while a PDE5 inhibitor such as sildenafil is prescribed                    | Better results and fewer dropouts than the medicine alone in two small trials                     |
| Propranolol                           | A prescription beta-blocker                                                        | Not labeled for anxiety; reviews find the evidence for anxiety disorders too weak for routine use |

## What is sexual performance anxiety?

Sexual performance anxiety is a fear of failing during sex that becomes the
problem it fears. One review estimates it affects 9 to 25 percent of men and
contributes to psychogenic ED (ED driven mainly by psychological factors) and to
premature ejaculation
([Pyke, Sexual Medicine Reviews, 2020](https://pubmed.ncbi.nlm.nih.gov/31447414/)).
The European Society for Sexual Medicine (ESSM) describes the loop: a man starts
"spectatoring," watching and judging his own response, and the resulting rise in
[stress-system](/stress-ptsd-and-ed/) activity inhibits arousal. Over time some men avoid sex
altogether, which keeps the negative feelings going
([ESSM position statements, Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).

That loop is why a single difficult night can turn into a pattern. If you are
not yet sure whether anxiety or a physical cause is behind what you are
noticing, start with our guide to
[telling ED and performance anxiety apart](/ed-vs-performance-anxiety), which
covers the clues in onset, situation and morning erections. The ESSM notes that
ED, even in younger men, usually has a mix of psychological and physical causes
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)), and
the help on this page can be useful either way.

## What helps with performance anxiety?

The approaches with the most support lower the pressure rather than trying to
override it. The ESSM statements say the core of psychological treatment for ED
is cognitive and behavioral work aimed at reducing anxiety, challenging unhelpful
beliefs, ending sexual avoidance and improving intimacy and communication
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).
NIDDK, part of the National Institutes of Health, says a health care
professional may suggest counseling when mental health or emotional issues are
affecting ED, and that counselors can help lower anxiety and stress about sex
([NIDDK, Treatment for ED](https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment)).

The American Urological Association (AUA) guideline goes a step further for men
already being treated for ED: it says referral to a mental health professional
should be considered to help with sticking to treatment, to reduce performance
anxiety and to fit treatment into the sexual relationship. That is a moderate
recommendation built on grade C evidence, meaning the supporting studies are
limited
([AUA Erectile Dysfunction Guideline]()).
NIDDK also suggests relaxation techniques such as deep breathing when you feel
stressed, as part of looking after your mental and emotional health
([NIDDK, Treatment for ED](https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment)).

## How does CBT approach performance anxiety?

CBT treats the anxious thoughts as something to examine, not obey. The ESSM
statements give examples of the automatic thoughts that feed the loop, such as
"I am a failure" or "my erection is not firm enough," along with unrealistic
beliefs about male performance, and they note that men with ED tend to blame
themselves and feel less in control
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).
A therapist helps you notice those thoughts, test them against what actually
happens and replace them with more accurate ones, while homework gradually
reduces avoidance.

The honest caveat: a review of sexual performance anxiety says CBT and
mindfulness are proven for non-sexual performance anxiety and social anxiety and
are recommended for the sexual kind, but that controlled studies in sexual
performance anxiety itself are lacking
([Pyke, 2020](https://pubmed.ncbi.nlm.nih.gov/31447414/)). Internet-delivered CBT
programs for ED have shown early benefit in some studies, though dropout was high
in at least one
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).

## What happens in sex therapy for performance anxiety?

Sex therapy is talk-based counseling with structured exercises done at home,
usually [with a partner](/talking-to-your-partner-about-ed/). A technique often used is sensate focus: a series of
touching exercises that starts with non-genital touch, with the couple asked not
to aim for arousal and to set intercourse aside for a while
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).
The point is to take the goal off the table, so attention can move back to
sensation and away from checking. Intercourse is brought back step by step once
confidence has rebuilt, and the exercises are usually paired with the kind of
thought work CBT uses.

## Does mindfulness help with performance anxiety?

Mindfulness looks promising, but the evidence is early. In a pilot study, 10 men
with situational ED took part in a four-week mindfulness group that combined
education, sex therapy elements and mindfulness skills. Compared with before
treatment, their erectile function and sexual satisfaction scores were higher six
months later, and only one man dropped out
([Bossio et al., J Sex Med, 2018](https://pubmed.ncbi.nlm.nih.gov/30297094/)).
The authors are clear that with no control group and a small sample, they could
not draw conclusions about how well it works. The ESSM rates mindfulness and
other newer approaches as promising, on low-level evidence (level 4, grade C)
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).

## What do trials of counseling for ED show?

The trials point the same way, but they are small and mostly old. A Cochrane
review included 11 trials with 398 men. Pooling five of them, it found that group
psychotherapy reduced the number of men whose ED persisted compared with a
waiting list, with focused sex group therapy doing best
([Melnik et al., Cochrane, 2007](https://pmc.ncbi.nlm.nih.gov/articles/PMC8852803/)).
The ESSM cautions that studies of psychological treatment for ED are limited by
small samples, short follow-up and a lack of controlled designs
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).

A more recent randomized trial in Pakistan assigned 137 young men with
non-organic ED to sildenafil, CBT-based sex therapy, the two combined, or placebo.
The authors concluded that therapy alone and the combined approach were their
treatments of choice, and the therapy-only group's depression scores fell more
than those of the sildenafil or combined groups
([Bilal and Abbasi, Sexual Medicine, 2022](https://pmc.ncbi.nlm.nih.gov/articles/PMC8847802/)).
It is one study in one population, so it adds support rather than settling the
question.

## Can an ED pill help break the anxiety cycle?

For some men, yes, and it may work best alongside counseling. In the sildenafil
label's clinical studies, men whose ED was psychogenic were analyzed separately:
84% of those on sildenafil reported improved erections, compared with 26% on
placebo
([sildenafil prescribing information, DailyMed](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6d8dbaa6-d61a-46ae-a641-f664104f4714)).
The same label notes that sildenafil has no effect without sexual stimulation,
so it supports the body's response rather than creating one. Our explainer on
[how ED medications work](/how-ed-medications-work) covers the mechanism.

The case for combining comes from the Cochrane review: in two trials, men given
group therapy plus sildenafil were less likely to still have ED and less likely to
drop out than men given sildenafil alone
([Melnik et al., 2007](https://pmc.ncbi.nlm.nih.gov/articles/PMC8852803/)). The
ESSM states that combined medical and psychological treatment has proven more
effective than a single treatment on its own, and that therapy can help prevent the problem coming
back
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).
If a pill has seemed to fail, anxiety and how it was taken are both worth
reviewing; see [when sildenafil does not seem to work](/sildenafil-not-working).
ED medicines are prescription drugs with real interactions, and they must never
be combined with [nitrates](/nitrates-and-ed-medications).

## Is there a medication for performance anxiety? What is propranolol approved for?

No medicine is labeled for sexual performance anxiety, and propranolol is not
labeled for anxiety of any kind.

Status: prescription beta-blocker; anxiety is not a labeled use. Source: propranolol hydrochloride tablets label (DailyMed), checked 2026-10-17.

The propranolol label lists high blood pressure, angina, atrial fibrillation,
survival after a heart attack, migraine prevention, essential tremor,
hypertrophic subaortic stenosis and a type of adrenal tumor
([propranolol hydrochloride tablets label, DailyMed](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d71ac16a-e2df-4630-9653-28749ece80a2)).
Prescribing it for anxiety is off-label. A systematic review found the evidence
too weak to support routine use of propranolol in any anxiety disorder
([Steenen et al., J Psychopharmacol, 2016](https://pubmed.ncbi.nlm.nih.gov/26487439/)),
and a 2025 review of beta-blockers for anxiety reached a similar view and called
for a large trial
([Archer et al., J Affect Disord, 2025](https://pubmed.ncbi.nlm.nih.gov/39271062/)).

The label also carries cautions that matter here. It lists male impotence among
possible side effects, it should not be used by people with bronchial asthma or
certain slow heart rhythms, and it warns against stopping suddenly without
medical advice
([propranolol label, DailyMed](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d71ac16a-e2df-4630-9653-28749ece80a2)).
More on medicines and erections, and why not to stop one on your own, is in our
guide to [medicines that can affect erections](/medications-that-affect-erections).
Whether any medicine fits your situation is a question for a prescriber who knows
your heart and lung history.

## Should a partner be involved?

Often, yes, when there is a partner and they are willing. NIDDK notes a counselor
may ask you to bring your partner for more support
([NIDDK, Treatment for ED](https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment)).
The ESSM recommends including the partner where possible, says positive partner
involvement helps resolve the problem and keep treatment on track, and notes that
relationship conflict is an important reason men stop following treatment or drop
out
([Dewitte et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/)).
Men without a partner have been studied too. In one small controlled trial, 21
men without partners were assigned to men's therapy groups or a waiting list; the
groups improved more on sexual attitudes and behaviors, though how often erection
difficulties happened did not differ between the two
([Price et al., Arch Sex Behav, 1981](https://pubmed.ncbi.nlm.nih.gov/7023415/)).

## When to talk to a clinician

Talk to a clinician if erection worries keep coming back, if you
have started avoiding sex because of them, or if anxiety or low mood is spilling
into the rest of your life. A clinician can also check for the physical causes
that can sit alongside anxiety; our guides to
[when to see a doctor about ED](/when-to-see-a-doctor-about-ed) and
[how ED is diagnosed](/how-ed-is-diagnosed) explain what that visit covers.
Do not stop a prescribed medicine on your own; ask the prescriber first
([NIDDK, Treatment for ED](https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment)).

## Sources

- [American Urological Association, Erectile Dysfunction Guideline](): Statement 6, referral to a mental health professional (moderate recommendation, evidence grade C).
- [NIDDK, Treatment for Erectile Dysfunction](https://www.niddk.nih.gov/health-information/urologic-diseases/erectile-dysfunction/treatment), last reviewed October 2024: counseling, partner involvement, relaxation and deep breathing, 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](https://pmc.ncbi.nlm.nih.gov/articles/PMC8766276/): the anxiety loop, mixed causes, CBT components, sensate focus, mindfulness, internet CBT, limits of the evidence, combined treatment, partner involvement.
- [Melnik T, Soares BG, Nasello AG. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst Rev. 2007;CD004825](https://pmc.ncbi.nlm.nih.gov/articles/PMC8852803/): 11 trials, 398 men.
- [Pyke RE. Sexual Performance Anxiety. Sex Med Rev. 2020;8:183-190](https://pubmed.ncbi.nlm.nih.gov/31447414/): prevalence and the state of treatment evidence.
- [Bilal A, Abbasi NUH. Randomized placebo controlled trial of sildenafil citrate, cognitive behavior sex therapy and integrated treatment in men diagnosed with non organic erectile dysfunction. Sex Med. 2022;10:100464](https://pmc.ncbi.nlm.nih.gov/articles/PMC8847802/).
- [Bossio JA et al. Mindfulness-based group therapy for men with situational erectile dysfunction: a mixed-methods feasibility analysis and pilot study. J Sex Med. 2018;15:1478-1490](https://pubmed.ncbi.nlm.nih.gov/30297094/).
- [Sildenafil citrate tablets prescribing information, DailyMed](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6d8dbaa6-d61a-46ae-a641-f664104f4714): clinical studies (psychogenic subgroup) and the need for sexual stimulation.
- [Propranolol hydrochloride tablets label, DailyMed](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d71ac16a-e2df-4630-9653-28749ece80a2): indications, contraindications, abrupt-cessation warning, genitourinary adverse reactions.
- [Steenen SA et al. Propranolol for the treatment of anxiety disorders: systematic review and meta-analysis. J Psychopharmacol. 2016;30(2)](https://pubmed.ncbi.nlm.nih.gov/26487439/).
- [Price SC et al. Group treatment of erectile dysfunction for men without partners: a controlled evaluation. Arch Sex Behav. 1981;10(3):253-268](https://pubmed.ncbi.nlm.nih.gov/7023415/).
- [Archer C et al. Beta-blockers for the treatment of anxiety disorders: a systematic review and meta-analysis. J Affect Disord. 2025;368](https://pubmed.ncbi.nlm.nih.gov/39271062/).

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