When it won't go up: erection problems before 40

In one clinic, one in four men with new erection problems was under 40. Usually it is nerves, condoms, chems or a big night, sometimes it is the heart, and the pills come with one rule you must never break

It happens to everyone, and it always happens at the worst moment: the guy is perfect, the evening is going well, and your cock has decided to sit this one out. Erection problems are filed in most heads under "older men". The numbers say otherwise, and the reasons at 30 are usually different from the reasons at 60.

Here is how common it is, what usually causes it, what the porn debate shows, and the one drug combination every gay man should know about.

You are not the only one

An Italian clinic looked at 439 men who came in for the first time with erection problems. 114 of them, 26%, were 40 or younger, with an average age of 32. Nearly half of those young men had problems severe enough to score as severe ED on the standard questionnaire, about the same share as the older patients. They also smoked and used drugs more often.

Outside clinics, a review of large international surveys put the share of young men with some degree of erection trouble as high as 30%. Gay men are no exception. In an online survey of 7,001 men who have sex with men, 45% reported a period in the previous year when getting or keeping an erection was a problem, and 44% reported performance anxiety, the two going hand in hand. A bad patch, in other words, is closer to normal than to rare.

The anxiety loop

An erection is a relaxation job. The smooth muscle inside the erectile tissue has to let go so blood can rush in, and the nerves that keep it tense, the ones that run on noradrenaline, are the same system that switches on under stress. Worry, in short, works against the plumbing.

In the classic model of the trap, men without erection problems get, if anything, more aroused when the pressure is on, because their attention stays on the sex. Men who have had problems turn their attention to the stakes instead (will it work, what will he think) and the arousal drains away. One soft moment becomes the thing you watch for next time, which makes the next soft moment more likely.

The condom drop

Hard, then the wrapper, then not so hard: the condom moment has a name in the research, condom-associated erection problems. In 278 men at a sexual health clinic, 37% had lost an erection with a condom at least once in their last three uses. Among young gay and bi men the figure quoted is 56%, and in a Chicago study those problems predicted ditching condoms when topping six months later.

Part of it is the pause and the fiddling, part of it is fit. In a lab study, men who reported condom problems simply had smaller erections in the first minute of an erotic film, with or without distraction or pressure, which suggests that some men need more time or more touch to get going. The practical fixes follow: try several sizes and brands, put it on when you are fully hard, and keep touching while you do it.

Booze, chems and smoke

Alcohol does what Shakespeare's porter said it does. In a lab study of 16 men, a low or moderate amount of alcohol slightly reduced erections in response to porn, and a high amount reduced them a lot. Oddly, across population surveys regular drinkers report less erectile dysfunction than non-drinkers, probably because of who drinks, not what alcohol does. The short version: tonight's sixth drink is the problem, not the glass of wine.

Chems are a classic case of the mind willing and the body not. In a London study of 30 gay and bi men who used crystal meth, mephedrone or GHB/GBL during sex, the drugs boosted desire, but losing the erection on crystal and mephedrone was "very widely reported", along with taking ages to come. Many men took erection pills to make up for it. Cocaine has the same reputation, though the evidence is old and thin: in 1988, 62% of 50 men admitted for cocaine and alcohol dependence reported sexual problems.

Smoking is the slow version. A meta-analysis of prospective studies found current smokers had about 1.5 times the odds of erectile dysfunction of non-smokers, and former smokers still had somewhat raised odds. Even sleep plays a part: ten young men kept to five hours a night for a week saw their daytime testosterone fall by 10 to 15%. That is hormones, not erections, but it is not helping.

Is it the porn?

The most heated question in the field is unsettled. On one side, a 2016 review with case reports argued that internet porn, with its endless novelty and escalation, can condition arousal to the screen so that real partners do not register, and that some men recovered after quitting. It is a hypothesis with case stories, not a trial.

On the other side, the large surveys do not find much. Across four samples of nearly 4,000 European men under 40, porn use showed little or no link to erection problems. A set of American studies, one of them following men for a year, found no link between how much porn men watched and their erections. What did go with erection problems was feeling that their own porn use was out of control, and even that did not predict erections getting worse over time.

When the body is talking

A few clues help separate head from hardware. Problems caused by nerves or circumstances tend to start suddenly and leave night-time and solo erections intact, while physical causes tend to creep in gradually and affect every situation. If you still wake up hard and everything works on your own, the plumbing is probably fine; the Erection chapter explains why night erections are such a useful test.

The other reason to take a persistent problem seriously is the heart. The authors of one long study suggest that erection problems and heart disease may be two faces of the same trouble in the blood vessels. In a Minnesota cohort of 1,402 men followed for up to ten years, men in their forties with erection problems developed coronary heart disease at 48.5 cases per 1,000 person-years, against 0.94 in men the same age without them, about 50 times the rate. Few men that young had ED, so the figure is rough, but the message is clear: in younger men, ED is a reason to check the heart. If it is persistent, gradual and present even when you are alone, see a doctor.

Pills, and the one rule

Sildenafil (Viagra) and tadalafil (Cialis) boost the chemical signal that opens the tap, as explained in What's inside. They do not create an erection on their own: in the trials, it was sexual stimulation that produced better erections after the pill. Sildenafil is usually taken about an hour before sex and works from 30 minutes to four hours. Tadalafil improved erections for up to 36 hours after a dose, hence the weekend pill.

In an Australian survey of 2,250 gay and bi men, about one in five had used one in the previous six months, most often to stay hard for longer or to get hard more easily, and use went with illicit drugs and riskier sex.

Now the rule. Never combine these pills with poppers. Poppers are alkyl nitrites, and nitrites and nitrates release nitric oxide, the same signal the pills amplify. Together they can make blood pressure drop dangerously. The labels of both Viagra and Cialis say it plainly: do not take them if you use "poppers" such as amyl or butyl nitrite. A clinical review of poppers flags the same drug interaction. The same goes for nitrate heart medicines such as nitroglycerin sprays and isosorbide tablets. Tadalafil lasts long enough that doctors are told to wait at least 48 hours after the last dose before giving a nitrate, even in an emergency, so a Friday pill can still be a problem on Sunday.