As Schiavi pointed out in the previous edition of this book, “emphasis on specific determinants of erectile disorders has been influenced by prevailing theoretical perspectives as they have shifted over the time”. We have certainly seen a shift from the emphasis on psychological causes or determinants of erectile dysfunction to an emphasis on biological or organic causes of erectile dysfunction. The previous claims that 90%-100% of erectile dysfunctions have psychological origins changed to claims that 90%-100% of erectile dysfunctions have biological or organic causes. However, every experienced clinician in this area knows that the etiology of erectile dysfunction is usually multidetermined, involving a mixture of organic and psychological factors. Even an unequivocally biologically determined erectile dysfunction, such as erectile dysfunction associated with diabetes mellitus, has a psychological component.

Biological or Organic Factors

The list of biological or organic conditions most frequently associated with erectile dysfunction includes diabetes mellitus and other endocrine disorders, coronary artery or peripheral vascular disease, hypertension, hepatic failure, chronic renal failure, pelvic (i.e., prostatic) surgery, penile anomalies or diseases (including Peyronie’s disease), spinal cord injuries, multiple sclerosis, Parkinson’s disease, chronic obstructive pulmonary disease, hyperlipidemias, sickle cell anemia, decreased androgen production, smoking, substance abuse, and various pharmacological agents (psychotropics, antihypertensives, antiulcer drugs, b-blockers, hypolipidemics, antiarrhythmics, disulfiram). It is important to realize that any illness that is associated with weakness, discomfort, or psychological distress may contribute to erectile dysfunction.

Psychological Factors

Psychological factors contributing to erectile dysfunction have traditionally been divided into immediate and remote ones.

Various psychological conditions, such as performance and anticipatory anxiety, negative expectation, anger, relationship problems (arguments, divorce), mental disorders (depression, schizophrenia, substance abuse, panic disorder, generalized anxiety disorder, personality disorders or traits), poor self-esteem, job loss, death of one’s partner, power struggles, lack of intimacy, and gender identity or sexual-orientation conflicts, may lead to impaired erection. Individual expectations and poor sexual techniques could also contribute to erectile dysfunction.