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Module 19 — Erections and Performance Anxiety
Step out of the worry loop around sex, together.
It happened once, on a tired night, and now one of you watches for it every time. The other has started to wonder whether they are still wanted. This module walks through a session about erections and performance anxiety, so you know what we ask and what we might suggest.
When an erection becomes a worry
Summary: what usually happens in the session
1 You each say what has been happening. In turn, in your own words, out loud or written down first.
2 Your therapist asks about your body, health and medications. And will usually suggest seeing a doctor as well, alongside therapy.
3 You map the loop, one step at a time. What sets it off, how it feels in your body, and what your head says.
4 You work out which pattern fits. Worry, shutdown, the room, bracing for rejection, or attention elsewhere.
5 You each say what a softening means to you. For one of you it may feel like failure, for the other like rejection.
6 You choose one thing that interrupts the loop. A small experiment for next time, not a fix for everything.
7 Your therapist may suggest a slow practice at home. Only if you both agree, with no goal and nothing to prove.
One way this session can go, not a script. Your therapist will shape it to the two of you and to their own way of working.
Step 1. You each say what has been happening
Sessions with us are online, with the two of you together at home and your therapist on the screen. Everything is talk, and nothing sexual happens in a session. Your therapist usually starts by asking each of you what has been happening and when it began. If it is easier to write your answer down and read it out, that works too.
Both of you are part of this. The partner whose erections have changed often feels embarrassed, watched or afraid of letting the other down. The other partner may feel unwanted, or unsure whether to reach out or hold back. Both experiences are real, and neither of you is the problem.
Performance anxiety is not only about erections. It can affect anyone, whatever their body, and most of this session works the same way for any of you.
The opening question. Tell me what has been happening, in your own words. Start wherever feels easiest.
Step 2. Your therapist asks about your body, health and medications
Erection changes are not always about worry. Problems with the heart and blood vessels, diabetes, medications, hormones, sleep, and alcohol or other substances can all play a part,1 and none of these can be talked away in therapy. So your therapist asks about each of them.
A medical check, alongside therapy. If erection changes are new, lasting or getting worse, your therapist will usually suggest seeing a doctor as well. That runs alongside your sessions, not instead of them. If a medication may be part of it, that is a conversation with the doctor who prescribed it, rather than a change to make on your own.
Some problems need a specialist, for example a urologist, and your therapist will help you decide. Whatever the body is doing, the worry around it is something you can work on together in sessions.
The health question. Around the time this began, did anything shift in your health, sleep or medications? Small things count too.
Step 3. You map the loop, one step at a time
For many people it starts with one rough night. Next time, they worry it will happen again. Then, instead of feeling what is happening, they watch and grade themselves. Therapists call this spectatoring. Worry pulls attention away from the body, and the body's response stalls.2
Avoiding sex brings relief in the moment, which is why it feeds the worry instead of easing it.
Your therapist may invite the partner whose erections have changed to walk through their own version: what sets the loop off, the first sign of it in the body, and the words their head repeats. Stress at work, guilt about a partner's pleasure and low mood can all feed it. The other partner listens, and does not need to answer yet.
Mapping it. Where does it usually start for you? What is the very first thing you notice in your body?
Step 4. You work out which pattern fits
For neurodivergent people, a softening that looks like worry is sometimes something else. Naming which pattern is in play helps interrupt it, because each one needs a different kind of help.
Worry and a mind that is elsewhere can feel alike in the moment. Asking “was I afraid, or was I somewhere else?” often tells them apart.
Shutdown is about capacity, not worry. Autistic adults describe shutdown as feeling frozen or stuck, sometimes unable to move or speak.3 After a long day of noise or masking, the body may simply have nothing left for sex.
A mind that is somewhere else. One account of autism describes attention that runs deep in one channel at a time.4 If that channel is a work problem, the body may never get the signal that sex is happening. Many people with ADHD describe attention drifting during sex, to a sound or a task left undone.5
Some people also brace so hard for a partner's disappointment that the body shuts down before anything starts. This is often called rejection sensitivity. It is not a diagnosis, and the research on it is still early.6
Step 5. You each say what a softening means to you
To the partner whose erection fades, it can feel like failure. To the other, it can feel like proof they are no longer wanted. Often neither has said this out loud. Each may also have been pulling back to protect the other, and both have felt alone.
You can always say it. If any of this starts to feel like too much, you can say I am uncomfortable. That is a complete sentence. Nobody has to explain it or defend it. We stop, we look together at what is happening, and we decide as a group whether to stay with it or to understand first what is getting in the way.
Hearing what a softening has meant to your partner, or saying what it has meant to you, is often the hardest moment in this session. Saying it is how the two of you stop guessing.
Your therapist may invite you to agree on something simple: that a softening is fine, and is not the end of closeness. Many couples find it helps to say it out loud before they ever need it.
Words some couples agree on. Soft is fine. If it happens, we stay close, and nothing has gone wrong.
Step 6. You choose one thing that interrupts the loop
Your therapist usually asks what has ever pulled you back into the moment, even briefly. It might be one sensation to focus on, such as warmth or your breath. It might be slowing down, saying “I am in my head” out loud, or stopping for the night without calling it a failure.
The first three rows are written alone. The last two are often settled together, in a session, while nothing is being asked for.
The aim is to interrupt the loop once, the next time it starts.
Step 7. Your therapist may suggest a slow practice at home
Many couples start by bringing back closeness that is not sexual: a hug that leads nowhere, lying close while you talk. Your therapist may also suggest a practice built on sensate focus, a way of touching with nothing to achieve. Sensate Focus, One Step at a Time explains it.
Small steps, over weeks. The practice usually moves from touch over clothes toward more, one small step at a time, and only as far as you both want. Many couples take longer than planned, and that is fine. Either of you can stop and simply be close at any point.
The pattern you named shapes how you do it. For worry, counting breaths. For shutdown, choosing a day with energy left. For a wandering mind, naming out loud what you touch. The point is to show your nervous system that softening is not failure.
If you do not feel safe. These tools are for relationships where both of you can say yes, no, wait or stop without being punished for it. If sex has happened under pressure, or if either of you is afraid of the other, tell your therapist on your own. The work on sex pauses while that is looked at.
After the session
If you agreed to see a doctor, try to book the appointment this week. Two worksheets on our site go with this work. The Performance Anxiety Loop worksheet maps your own version of the loop, and is best filled in alone first. The Erection Confidence worksheet sets out the four-week practice, with notes for each pattern and a page to record what helped.
The workbook below is for after the session, on your own first. It takes about five minutes. Bring what you noticed to your next session.
If this is hard to do. If this is too much right now, there is no need to push through. Spend some time with your partner talking about what makes it hard, and share what comes up: embarrassment, fear of letting the other down, or worry that you are no longer wanted. That conversation is part of the work.
Should I see a doctor about erection problems before sex therapy?
If erection changes are new, lasting or getting worse, your therapist will usually ask you to see a doctor as well, alongside your sessions rather than instead of them. Heart and blood vessel problems, diabetes, medications, hormones, sleep, and alcohol or other substances can all play a part. If a medication may be involved, that is a conversation with the doctor who prescribed it.
What is the performance anxiety loop?
For many people it starts with one rough night. Next time they worry it will happen again, and instead of feeling what is happening they watch and grade themselves, which therapists call spectatoring. The body's response stalls, shame follows, and avoiding sex makes the next time feel riskier.
Can autism or ADHD look like erectile dysfunction?
Sometimes. For neurodivergent people, a softening can come from shutdown when there is nothing left after a long day, from a room that is too much for the senses, from bracing for a partner's disappointment, or from attention that is somewhere else. Naming which pattern is in play helps, because each needs a different kind of help.
What can the other partner do?
Say what a softening has meant to you, and listen to what it has meant to your partner. Many couples agree, out loud and ahead of time, that softening is fine and is not the end of closeness. A short phrase from you, such as soft is fine, stay here with me, can help interrupt the loop.
Your workbook
Your answers save to this device only - we cannot see a word of what you write. Fill this in after a session about erections and performance anxiety, on your own first.
What I noticed
Answer these on your own first. There are no wrong answers. Your answers stay on this device, so if you share it, your partner may be able to see them. Pick the closest option even if none is exact.
Whose experience am I mostly answering about? — Mine, it is my body, My partner's, Both of ours
A medical check: — Booked, Not yet, Already done, Not sure yet
Which pattern seems strongest right now, as far as I can tell? — Worry about how it will go, Shutdown, nothing left, The room is too much, Bracing for rejection, Attention somewhere else, Not sure yet
When a softening happens, it lands for me as: — A failure, A rejection, A worry, Something we can talk about, Not a big deal
To bring next time
Write a line or two. If something is about your safety, tell your therapist privately instead.
One thing that has pulled me back into the moment, even briefly
What I would like my partner to understand about this
Where this comes from
Every source below was checked against the published record. They are grouped by the kind of evidence they are, so the numbers may not run straight down the page — a number points back to where the source is used in the lesson.
Research discussion
The steps in this session come from our clinical work with neurodiverse couples and from our guide to sex and desire. They have not been tested in a trial. The advice to see a doctor is standard clinical guidance rather than a finding of ours.
The review of erection problems1 brings together population studies linking them with medical conditions and lifestyle. Those studies were of men, mostly at one point in time, so they show links rather than causes, and say nothing about couples. The review of performance anxiety2 found it reported by both men and women, and tied to erection problems. It also found few trials of treatment, and concluded that no treatment is yet well proven.
The study of shutdown3 analyzed how autistic adults describe it in their own words. It shows what shutdown is like, not how often it happens. The account of attention running in one deep channel4 is a theory paper, with no new data.
The book on ADHD and sex5 rests on a survey of people who chose to answer, so it shows that distraction during sex is a familiar experience, not how common it is. The review of rejection sensitivity6 found only twelve small, varied studies, and none that tested a way to help.
Who this research was done with. The studies behind this module, none of them of neurodiverse couples, drew heavily on white, comparatively well-off, English-speaking participants. If your household carries pressures those samples did not — money, immigration, racism, disability, unsafe housing — the practice still applies, but the room you are practicing in is harder. That is the room, not you.
Clinically reviewed by Harry Motro, PsyD, LMFT · California LMFT #53452 · Founder and Clinical Director, Neurodiverse Couples Counseling Center · Clinical supervisor · Updated October 5, 2026
Peer-reviewed research
1. Rosen RC, Wing R, Schneider S, Gendrano N (2005) Epidemiology of erectile dysfunction: The role of medical comorbidities and lifestyle factors. Urologic Clinics of North America, 32(4), 403-417. https://doi.org/10.1016/j.ucl.2005.08.004 A review of epidemiological studies of erectile dysfunction and its associations with medical comorbidities and lifestyle factors. Cited for the point that erection changes often have physical contributors that need a medical evaluation. Limitation: a narrative review of largely cross-sectional studies of men; it shows associations, not causes, and does not study couples or neurodivergent people.
2. Pyke RE (2020) Sexual performance anxiety. Sexual Medicine Reviews, 8(2), 183-190. https://doi.org/10.1016/j.sxmr.2019.07.001 A review of the literature from 2000 to 2018 on the prevalence and treatment of sexual performance anxiety. It reports performance anxiety in both men and women, contributing to erectile dysfunction and premature ejaculation; cognitive behavior therapy and mindfulness training are recommended by extension from other anxiety, but controlled studies of performance anxiety itself are few, and the author concludes that no treatments are well proven. Limitation: a narrative review of a thin treatment literature; no couples or neurodivergent samples.
3. Paris K, Lodestone AZ, Houser M, Lewis LF (2026) "Shutdowns are like you're stuck on the blue screen of death": A metaphor analysis of autistic shutdowns. Autism in Adulthood, 8(4), 687-697. https://doi.org/10.1089/aut.2024.0193 Participatory secondary analysis of qualitative data from two prior studies of shutdowns in autistic adults (N = 86; asynchronous interviews and a survey), using a metaphor identification procedure on 87 typed pages. Six metaphors: being frozen, a computer crash, going inside myself, when I can't keep up, survival mode, and playing a role; shutdowns described as being stuck, often with physical or vocal immobilization, and frequently as a response to perceived threat. Limitation: qualitative; cannot say how common or how long; online first 2025.
4. Murray D, Lesser M, Lawson W (2005) Attention, monotropism and the diagnostic criteria for autism. Autism, 9(2), 139-156. https://doi.org/10.1177/1362361305051398 Conceptual paper concluding from the literature, the diagnostic criteria and first-person accounts including one author's own that atypical strategies for allocating attention are central to autism, with attention flowing in a narrow deep channel rather than spread across many inputs. Cited for the cost of being pulled out of one focus. Limitation: a synthesis and argument with no new data; cited as the source of the frame, not as a finding.
6. van Asselt A, Reekers D, Roke Y (2026) Rejection sensitivity dysphoria in autistic adults: A scoping review. Neurodiversity, 4. https://doi.org/10.1177/27546330261441753 PRISMA-ScR scoping review of responses to rejection and criticism in autistic adults and adults with high autistic traits, published through May 2025: 1,285 records screened, 12 studies included (four qualitative, six experimental, two cross-sectional). RSD is not an established research construct and is not in DSM-5 or ICD-11; conceptualizations and measures varied considerably, quantitative findings on intensity were inconsistent, qualitative studies consistently described rejection as highly impactful, and no study examined criticism or evaluated an intervention. Limitation: a scoping review of a small and heterogeneous literature; it cannot say how common intense rejection responses are.
Clinical sources and public data
5. Tuckman A (2019) ADHD After Dark: Better Sex Life, Better Relationship. Routledge, New York. https://www.routledge.com/ADHD-After-Dark-Better-Sex-Life-Better-Relationship-1st-Edition/Tuckman/p/book/9780367223939 A large self-selected survey of adults with ADHD and their partners, written up for clinicians and couples. Clinically valuable on distraction during sex, the timing of medication and the asymmetry of initiation, and the source of most of the frequency figures that circulate about ADHD and sex. Limitation: a self-selected survey, presented as such by its author; not an epidemiological estimate and not a controlled study.
Further reading
• Neurodiverse Couples Counseling Center (2026) Neurodiverse Sex Therapy: a guide for neurodiverse couples on sex, desire and intimacy. Practice materials, Neurodiverse Couples Counseling Center. https://www.neurodiversecouplescounseling.com/sex The practice's guide this course is built from: here, the medical-first caveat for erection changes, the loop from stress and worry through spectatoring and shame to avoidance, the neurodivergent additions to it (shutdown, sensory overload, a mind locked elsewhere), and the antidotes (sensate focus, body-scan mindfulness, restoring non-sexual closeness first). Limitation: clinical material developed in use, not a study.
• Neurodiverse Couples Counseling Center (2026) Performance Anxiety Loop. Practice materials, Neurodiverse Couples Counseling Center. https://www.neurodiversecouplescounseling.com/worksheets/performance-anxiety-loop Maps one person's version of the loop, filled in alone first: triggers, body cues, the repeating thoughts, what has interrupted the loop before, and the neurodivergent layer; ends with one small experiment. Limitation: a clinical tool developed in use, not a validated instrument.
• Neurodiverse Couples Counseling Center (2026) Erection Confidence. Practice materials, Neurodiverse Couples Counseling Center. https://www.neurodiversecouplescounseling.com/worksheets/erection-confidence Rule out medical causes first; tell apart the anxiety loop, autistic shutdown, rejection anticipation and monotropic distraction; a four-week graded practice with notes for each pattern; a reflection page. Limitation: a clinical tool developed in use, not a validated instrument.
Help with erections and performance worry, at your pace
The Neurodiverse Couples Counseling Center works with couples where one or both partners are autistic, ADHD or AuDHD, including when erections or worry about sex have become hard. We suggest a medical check where it fits, and work on the loop with both of you. Therapy for clients in California, coaching worldwide, all by telehealth. A first conversation costs nothing.
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