Erectile Dysfunction Survey | Counseling | Therapy

Erectile Dysfunction Survey

Shannon , LCSW — Therapist, director of intern program, director of rhode island office

15-20% of American men will experience erectile dysfunction at some point in their life. Despite its ubiquity, Erectile Dysfunction still causes distress for many men experiencing it. It’s common for men experiencing erectile dysfunction to feel intense anxiety, shame or guilt. Many men find themselves avoiding sex, or even relationships all together. If you have trouble obtaining or maintaining an erection, know that you aren’t alone, and that there is hope. Erectile dysfunction is treatable, and treatment can look as varied as the wide range of causes. Erectile dysfunction can be caused by issues in your physical health, emotional health, or lifestyle.

Complete the survey below to gain understanding about your erectile dysfunction, and help healthcare providers treat you effectively.


1. Have you ever been able to obtain an erection? Y N

2. Have you ever been able to maintain an erection through to ejaculation? Y N

If you answered “yes” to either of these questions, your Erectile Dysfunction is Acquired, not Life-long. This means that erectile dysfunction happened due to some change in your body or environment, and not due to a congenital condition (something you were born with.) To further help your healthcare provider pin-point the cause:
  • See if you can identify when, exactly obtaining or maintaing erections became difficult
  • List any other changes in your health or life happened around that time.

3. In the past month, have you ever woken up with an erection? Y N

4. Are you able to get an erection when you masturbate? Y N

5. Are you able to maintain an erection through ejaculation when you masturbate? Y N

6. Are you able to get an erection with some partners, but not others? Y N

7. Are you able to maintain an erection for some sexual activities, but not others? Y N

If you answered yes to any of the above questions, your Erectile Dysfunction is Specific and not General. This means you are able to obtain or maintain an erection in some situations. To help your health care provider better pin-point the cause of ED:
  • Make a list of situations in which you are able to obtain an erection.
  • Make a list of situations (if any) in which you can maintain an erection through ejaculation.

8. Have you experienced any of the following since your ED began?

Surgery Y N

Taking medications Y N

Smoking cigarettes Y N

Feeling anxious Y N

Feeling depressed Y N

Experiencing an increase in stress Y N

Starting or ending a relationship Y N

Experiencing a loss or other traumatic event Y N

Turning 60 Y N

If you answered yes to any of these questions, they may be related to your erection difficulties. Erectile Dysfunction can have many causes both somatic (relating to the body), and psychological. To further help your health care provider pin-point the cause:
  • List when those experiences began or occurred.

After you’ve assembled this information, make an appointment with your urologist or primary care physician. They will look for physical causes for your Erectile Dysfunction. They may also refer you to a sex therapist. Sex therapists like those at the Center for Growth / Sex Therapy in Philadelphia are trained to pinpoint the connection between emotional health and ED using talk therapy. A trained therapist not only explores how your family history, sexual history and your current relationship are impacting your sexual functioning, but they can also provide exercises to do alone or with a partner to build the strength and stamina of your erections.

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