Depression and sexual difficulties in men: The role of mindfulness in targeting ruminative thoughts
Sexual health is recognized by the World Health Organization as a fundamental aspect of general health and well-being. Yet, perhaps because of the sensitivity of the topic, there is little awareness of the fact that sexual difficulties are extremely common in men.
Sexual Difficulties Are Common in Men
Sexual health is recognized by the World Health Organization as a fundamental aspect of general health and well-being. Yet, perhaps because of the sensitivity of the topic, there is little awareness of the fact that sexual difficulties are extremely common:
- Up to 41% of men report ongoing sexual difficulties. 
- Low sexual desire affects approximately 15% of men (across all ages).
- Ejaculating earlier than one wishes is the next most common sexual challenge that men report.
- Difficulties obtaining or keeping an erection sufficient for sexual activity is another common issue.
- Erectile dysfunction is strongly associated with increasing age, but by no means is isolated to only those in older age groups.
These Difficulties Can be Exacerbated by Depression
These sexual difficulties can cause men a lot of distress, but it’s important we view them as challenges rather than flaws. For example, if 40% of men went grey or bald, would we say this was a dysfunction? These are difficulties and challenges many men face, but dealing with them doesn’t make someone broken, weak, or any less of a man.
Depression is a major risk factor for sexual difficulties in men. Moreover, ongoing sexual challenges can give rise to and even perpetuate existing depressive symptoms. One of the ways that depression might impact sexual function in men is through cognitions, or negative thought patterns.
Negative thoughts might include “If I cum too quickly, my partner will be disappointed in me and our sex life”, “I’m worried about losing my partner if I can’t stay hard”, and “If I’m not interested in sex, then I’m not a ‘real man’ and no one will want to be my partner.”
Negative thoughts like these can trigger strong feelings (including fear, anger, sadness, and shame) which can then further interfere with sexual arousal and pleasure. Even nonjudgmental, distracting thoughts (e.g., thinking about work) can draw attention away from intimate moments, and can negatively affect a man’s sexual esteem, satisfaction, and responses. Because depression is often characterized by apathy, or loss of pleasure in activities, depressive symptoms can also negatively affect men’s feelings of desire for sex, their pleasure during it, and reduce their energy levels with sex.
Recognizing the Issue
Men who find themselves bombarded with negative thoughts and feelings might understandably avoid sexual activity, or even situations that might have the potential to lead to a sexual encounter, such as undressing in front of a partner or going to bed at the same time, and can prevent some men from attempting to form healthy romantic relationships. Avoidance of such situations is a natural consequence, which further exacerbates anxiety about sexual performance.
Men with low sexual desire tend to hold strong negative beliefs about the influence of age and body image on sexuality, and this makes them more vulnerable to activation of negative self-schemas (self-talk), specifically those of not being good enough, when confronted with a potential sexual situation. These self-critical schemas then trigger negative automatic thoughts, which prevent the man from further focusing on his sexual arousal and elicit negative emotions (e.g., anxiety), which continues to block sexual responses.
For some men, negative thoughts about sex can take on a ruminative quality (i.e., thinking about it over and over), which is a strong predictor of sex-related distress. For men with depression, rumination may be a familiar experience, as ruminative thoughts about oneself and the world around them are very common in depression, so it’s easy to see how depression and sexual difficulties can form negative feedback loops.
Some antidepressants can also cause sexual difficulties. Up to 37% of men on certain antidepressants may experience erectile dysfunction, while others experience less of an impact. Men who are on antidepressants should discuss potential side effects with their doctor to mitigate risks, and create a plan to monitor and make changes if needed. Of course, untreated depression can provoke even greater harms to sexual function.
There are several approved medications to treat sexual difficulties in men in a safe and effective way. Unfortunately, however, none of these directly target ruminative thought patterns, distractions, or behavioural avoidance.
In my book, Better Sex Through Mindfulness (2018), I review dozens of studies that have found mindfulness to improve many aspects of sexual desire, arousal, satisfaction, and to reduce sex-related distress. Mindfulness is a practice of refocusing your attention on the present moment, in a non-judgemental way. While the bulk of studies focused on women, the available research suggests that mindfulness can also be very effective for delaying premature ejaculation, improving sexual desire and satisfaction, and even addressing the psychological factors that lead to erectile dysfunction.
The research I lead indicates that directly targeting the tendency to ruminate is one of the main mechanisms by which mindfulness improves sexual functioning. Importantly, targeting rumination is also one of the key ways that mindfulness improves depressive symptoms.
Here are some practical steps you can take to try managing sexual difficulties:
Check in with your healthcare provider (doctor)
- If you are experiencing changes to your sexual function or desire and it’s creating a lot of distress for you, talk to a health care provider about these concerns in order to address physical, hormonal, or medical issues that might be the underlying cause.
Pay extra attention to your thoughts
- Take a week to pay attention to the kinds of negative thoughts you have about yourself and your sexuality. In particular, note if any of these thoughts surface during anticipated or actual sexual activity.
Try this simple mindfulness exercise
A simple mindfulness exercise is to find a quiet space and practice deep breathing.
- Try to put any thoughts about the day or sexual difficulties aside and instead focus on the moment.
- Feel the air moving in and out of your body as you focus on your breathing.
- When you notice your thoughts wandering (and they will, especially when you’re just beginning), re-focus again on your breathing (without getting mad or upset at yourself).
- You can try to do this for 3 minutes once a day for a week or two.
- After a while, you can start using this technique to re-focus your attention when you get upset in other situations during your day.
Consider starting a routine mindfulness practice
There are a large number of apps that deliver mindfulness exercises in bite-sized daily audio recordings. Even as little as 10 minutes per day can be beneficial for helping to increase your mindfulness. Some apps that I recommend are Headspace, JKZ Meditations (App Store), and Calm.
Apply the skills you learn
- Once you’re more familiar with mindfulness practice, you can apply the skills you learn in present-moment, letting go of negative or judgmental thoughts, and allowing yourself to focus on sexual desire and pleasure. Try this in the lead-up to a sexual encounter, and then while you are engaged in sexual activity (either alone or with a partner).
Seek professional support
- Sometimes enlisting the help of a sex therapist or sexual medicine physician can be critical to addressing these issues and getting evidence-based help. Though men may not talk about it much, you may be surprised just how many men make use of these resources.
Taking active steps to address and improve any area of your health (including sexual difficulties) are worth taking, and instead of reflecting weakness, it represents agency, control, and desire to be the best version of yourself.
Dr. Lori Brotto, Vancouver, BC, Canada
- PhD in Clinical Psychology, Professor, Department of Obstetrics and Gynaecology, University of British Columbia (UBC)
- Executive Director, Women’s Health Research Institute
I am a Professor at UBC and hold a Canada Research Chair in Women’s Sexual Health where my research focuses on developing and testing mindfulness-based interventions for a variety of populations with sexual dysfunction. I’m also a Registered Psychologist providing care to promote sexual health and well-being. In my clinical practice, I see men and their partners, across a range of ages, who struggle with sexual issues.
- Mitchell, K. R., Mercer, C. H., Ploubidis, G. B., Jones, K. G., Datta, J., Field, N., … Wellings, K. (2013). Sexual function in Britain: Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet, 382, 1817–1829. http://dx.doi.org/10.1016/S0140-6736(13)62366-1
- Francois, D., Levin, A., Kutscher, E., & Asemota, B. (2017). Antidepressant-induced sexual side effects: Incidence, assessment, clinical implications, and management. Psychiatric Annals, 47(3), 154-160. https://doi.org/10.3928/00485713-20170201-01
- Brotto, L. A. (2018). Better sex through mindfulness: How women can cultivate desire. Vancouver/Berkeley: Greystone Books.