can stress cause erectile dysfunction and libido problems

Can Stress Cause Erectile Dysfunction And Libido Problems?

By Johnathan P Cumberwell

Yes, stress can be enemy number one to your sex life. It can cause erectile dysfunction and libido problems in two main ways:

Firstly, when you stress, your brain essentially shuts down your reproductive system. Your brain has figured that this system is not necessary during stress.

Secondly, during stress, your body produces big amounts of ‘stress hormones’ such as adrenalinenorepinephrine and cortisol

These hormones can turn off your testosterone production, and divert bloodflow that otherwise would have gone to your penis.

stress can cause erectile dysfunction and libido problems

So when your reproductive system is on hold and stress hormones are raging in your body, you will normally find it close to impossible to get erections.

But although stress can cause sexual problems, stress in itself is actually good. 😊

Stress Is Actually Not A Bad ‘Thing’!

Stress is not a bad ‘thing’. It’s in fact very useful, and as most other sensations you experience, it serves a very important purpose. 

Stress helps you survive. And avoid danger. 

Stress kicks in when you are exposed to potential harm, or when your life is in danger.

It then gives you an instant injection of energy that helps you avoid the danger.

stress can save your life

Let’s look at an example:

For a moment, let’s assume you are skiing down a mountain. It’s a wonderful, sunny day and you are enjoying the snow and the scenery.

But all of a sudden, you hear a massive rumble behind you! An avalanche is coming and it’s right behind you!

Now what happens?

You get an immediate burst of energy and clarity, and you hastly scan the slope for an exit route. 

There is one to the right, and you ski as fast as you can to catch it. You got it. The avalanche passes and you’re safe.

skiing to avoid avalanche

Stress just saved your life. This stress is good. 😊  

Then why is stress also such a bad thing? 

I’ll explain in a minute, but let’s first understand the three key stress hormones.

The Stress Hormones

There are three principal stress hormones that are largely responsible for what happens in your body and brain during stress:

  • Adrenaline (also called epinephrine)
  • Norepinephrine
  • Cortisol
man on the phone stressing

Adrenaline and norepinephrine are together largely responsible for the instant boost in alertness, focus and energy you experience when stress kicks in. 

For instance, if someone close by you screams loudly, your brain (the hypothalamus) immediately starts to produce adrenaline and norepinephrine. This is then flushed into your bloodstream.

Instantaneously, you are put on high alert, ready to run, fight, or otherwise act.

These two chemicals, which are both hormones and neurotransmitters, work together to fully focus your body on the current potential threat. 

The release of these hormones instructs your heart to pump faster to increase bloodflow, opens airways in your lungs, expands arteries to essential muscles, releases glucose from storage, dilates your pupils, expands ear canals, increases sweating, etc.

lungs expanded stress response

At the same time, these hormones constrict bloodflow to non-essential muscles, reduce digestive activity, ignore the immune system and shut off the reproductive system.

Why are these systems shut off? Well, they are simply of no use at the very moment. Your number one priority is to survive or avoid harm. Digesting food and reproducing can wait.

During stress, it is not uncommon to have 50 times more adrenaline and norepinephrine in your blood, than during rest.

After adrenaline and norepinephrine have given you the immediate boost, cortisol kicks in. 

Cortisol is slower to have an impact than adrenaline and norepinephrine, but it is also longer lasting. 

The effect of adrenaline and norepinephrine typically lasts for seconds. The effect of cortisol can last for hours.

the effect of cortisol can last for hours 2048x1274 1

Cortisol enables you to sustain a high level of alertness and energy for a long period, in the event the situation requires it.

While cortisol plays many strings in the stress response, one key function is to mobilize energy. Primarily in the form of glucose

Cortisol stimulates production of glucose (gluconeogenesis), from substances such as amino acids, lactate, and triglycerides. This glucose keeps you sharp and alert. 

As cortisol works hard to produce energy, it also continues to divert resources from non-essential areas, to essential areas. 

This means that your heart rate and blood pressure will normally continue to be elevated, your immune system will typically be neglected, as will normally also anything related to sexual functions.

elevated blood pressure

That is how your stress response works. An amazing invention. 👍

However, this invention was designed millions of years ago. When our lives were very different to what they are today. 

And this causes headaches. Let’s explore.

Our Ancestors Probably Stressed A Lot Less Than We Do

Today’s society is very different from what it was a million years ago. Or 100,000 years ago.

There is a good chance we stressed significantly less back then.


hunters and gatherers a million years ago

Today, we modern humans are often woken up by an alarm clock in the morning. The day begins with stress.

We then often commute to work on a packed train, or we are stuck in traffic. More stress.

We then arrive at work where there is often pressure, competition, a demanding boss, politics, etc. Even more stress.

On the way home, we often commute again at the same time as thousands of other people. The stress continues.

Then there are bills, mortgages, pension, family, health, social media.. More sources of stress.

The unfortunate truth is that the life of the modern human being, is often filled with stress. 😠

london liverpool street stress

How was it back then..? A million years ago..?

There was certainly also stress in our lives back then. But it was probably less persistent and less constant.

For instance, a male had to fight for the privilege to mate. Stress.

Also, from time to time, there were probably conflicts between members of the tribe. And also between tribes. There were also probably predators. Stress was certainly part of life.

But life was probably also more relaxed. 

We didn’t have several meetings every day back then. Neither did we have performance targets. Nor metro cards. Nor did we work in open office landscapes.

open office landscape stressful

In other words, we lived in a very different world when our ‘fight or flight’ (stress) system was developed, compared to the world we live in today.

Which has created one very big headache: 

In today’s world, you and I encounter an endless number of ‘things’ that trigger this ‘fight or flight’ system. On a daily basis.

A crammed metro train. Traffic. A line of people waiting to buy lunch. Performance reviews. Bills. Not enough likes on your last social media post. Another weird dinner date.

These factors make us stress. 

Your heart rate jumps. You sweat a little. You feel a burst of anger. Your breathing changes.

elderly man stressing


A burst of stress every now and then doesn’t cause much harm. 

It’s the constant, elevated, day-to-day stress that does. 😩

Because constant stress means a constant production of adrenalinenorepinephrine and cortisol

These amazing hormones were designed for infrequent stressful situations. Not day-to-day stress.

In fact, studies have shown that elevated and persistent stress can cause all kinds of damage, such as depression, cardiovascular disease, cancers, cognitive disorders.

And it can cause erectile dysfunction and libido problems.

AdobeStock 126217748 min 1 2048x1365 1

Let’s explore how stress can lead to ED and a weak libido.

How Exactly Does Stress Cause Erectile Dysfunction And Libido Problems?

Stress can cause erectile dysfunction and libido problems in two key ways: 

    • Firstly, by shutting down those systems that are not important for the stressful situation, such as the reproductive system.
    • Secondly, by flushing your body with a large amount of stress hormones (adrenaline, norepinephrine and cortisol), which can in turn cause several kinds of damage. 

      In fact, these two factors are related as the second is partially responsible for the first. But your stress hormones also do a lot more damage than just shutting off unnecessary systems.

      stress is ‘fight or flight mode

      Channeling Of Resources Away From Your Reproductive System

      When you stress, your body and mind are put on immediate high alert – fully focused on the situation requiring special attention. 

      You enter ‘fight or flight’ mode. 


      Being told by your boss that the report is not good enough, and that you need to re-do it and have it on his desk in perfect condition by tomorrow morning.

      Being chased by a big and hungry animal. 

      man stressing chased by animal

      Both of these situations can be highly stressful. 

      But what actually happens inside your body? Let’s take a look:

      Immediately, adrenaline and norepinephrine are released into your bloodstream.

      This release sets off a cascade of events through your nervous, cardiovascular, respiratory, muscular, and endocrine system.

      You get an instant burst of energy. Your heart pumps faster. You breathe faster. 

      Your key muscles get backup energy, your vision and hearing shoots up, your senses are sharpened.  

      stress gives you an instant burst of energy

      Shortly thereafter, cortisol is released to continue what adrenaline and norepinephrine started.


      At the same time as certain key functions receive an injection of power, your stress hormones also shut down other processes. Such as digestion, reproduction, growth and immunity.


      Because you don’t need these functions to save your life.

      In other words, those operations that are not needed for dealing with the current danger, are shut off. 

      You got that?

      reproductive system shut off

      During stress, your body practically ignores your reproductive system.

      That means that anything related to sexual activity, gets little or no attention when you stress,

      Therefore, if you stress every day, your reproductive system is also shut off every day.

      Which means that your libido is likely to be depressed, and erectile dysfunction is likely to kick in.

      Research also shows that elevated stress over time can cause irregularities in women’s menstrual cycles. Stress has profound effects. 😬

      But not only do these stress hormones channel resources away from sexual functions: They are themselves also causing all kinds of trouble.

      puzzle all kinds of trouble

      Stress Hormones Run Riots In Your Body

      When you stress on a more or less constant basis, your body also produces these stress hormones on a more or less constant basis.

      And elevated and persistent levels of these hormones can be harmful in several ways.

      First of all, there is normally an inverse relationship between your level of cortisol and your level of testosterone. That is because cortisol is practically an ‘enemy’ to testosterone

      The two hormones ‘compete’ for the same space in your body, which means that more of one is normally highly correlated with less of the other. 

      So if you stress frequently, you will also produce a lot of cortisol.

      if you stress you will produce a lot of cortisol

      Which means that your testosterone is likely to be depressed.

      That’s not good, because you need a healthy level of testosterone in order to have a strong sex-drive and to ‘get it up’. 

      If you stress, you may also find it difficult to sleep enough. Or your sleep may be of poor quality.

      This causes another problem: Little testosterone production. Because essentially all your testosterone is manufactured at night when you sleep. 

      In other words, if you also sleep poorly, your testosterone is likely to be even lower.

      Chronically elevated levels of cortisol may also mess with your insulin.

      cells need insulin to use glucose as energy 1

      Research has demonstrated that excess cortisol causes both insulin resistance as well as diminished insulin production.

      Why and how is insulin important?

      The cells in your body need insulin in order to utilize glucose as energy. Insulin acts as the key that enables glucose to enter your cells.

      However, when there is little insulin, or when insulin is less effective at doing its job, you will end up having excess glucose in your blood. This is not good.

      This makes your blood thicker. Which makes it flow less smoothly.

      This is particularly problematic for your penis, because the blood vessels in your penis are super narrow. Hence this thick blood has a harder time flowing through these vessels.

      the blood vessels in your penis are super narrow

      Excess glucose can also get stuck on the inside of your arteries, causing plaque buildup. Eventually, this can cause atherosclerosis. This can further reduce bloodflow.

      This glucose overload normally also leads to high formation of a free radical called superoxide. This free radical hunts down and kills your nitric oxide. Therefore, your nitric oxide gets eliminated.

      And lets not forget that with thicker blood and narrower blood vessels, your heart also has to work overtime to pump blood around.

      This can over time lead to cardiovascular diseases. Such as heart disease and high blood pressure.

      By the way, high blood pressure will over time normally cause damage to your blood vessels, and particularly the endothelium, which produces nitric oxide

      In other words, a number of negative events can happen just from your insulin being impaired. 

      heart disease

      But these stress hormones cause more problems:

      Free calcium, but also norepinephrine, are the chemicals that keep your penis flaccid.

      The problem is that if you have larger amounts of norepinephrine than you should, your penis is likely to remain flaccid. And it will therefore take a bigger effort to get an erection.

      So as you understand, elevated levels of these stress hormones are likely to cause erectile dysfunction and reduced libido, via several pathways. 

      Let me tell you about my experience with stress.

      My Experience With Persistent Stress

      There have been periods of my life where I have gone through a lot of stress..


      This has for the most part been related to career or relationships. 

      For instance:

      I once worked for a small and entrepreneurial company. We were about 10 employees and shared a tiny office. 

      We almost sat on top of each other and therefore had no privacy. And everyone overheard everyone else’s conversations. 

      I found it difficult to enjoy and thrive in this setting.

      Also, particularly one of the persons in the office was (in my opinion), very difficult to work with. Working with this person added great amounts of negativity to my day.

      busy office with no privacy

      And I worked from about 08:30 in the morning until about 20:00 in the evening, so I pretty much spent all my awake time in the office.

      After a few months, I started to really dislike the situation. I started to stress. I woke up in the morning grumpy, because I didn’t want to go to work. 

      My days were filled with negative emotions. My stress levels grew. I didn’t smile. 

      I felt I was wasting my time working with the wrong people, and in the wrong environment. 

      And at the same time I also felt guilty for not doing as good of a job as I could have. Which meant I also sensed fear over potentially getting fired for the same reason.

      The stress I was experiencing was constant and persistent. It was there all the time.

      waking up in the morning stressing

      It put me in a constant depressed mood. I had by and large stopped enjoying life at this point. 

      Also, I carried this stress with me almost wherever I went, even outside of work.

      During this time, my desire for sex was almost non-existent. 

      It wasn’t on my mind, I didn’t think about it, it was simply not there. 

      Even if tried to watch pornography, there would hardly be any reaction at all. 

      My penis was barely alive. When I was with a woman, even if it was a new partner, I was unable to get and stay hard.

      This was a period of severe erectile dysfunction.

      crisis severe erectile dysfunction

      But this hasn’t been the only time I have struggled like this.

      I have also gone through other periods of my life when my stress levels have been constant and elevated, and where I have had the same sexual problems.

      Another time I stressed significantly, was after a breakup with a long-term partner. 

      After the breakup, I was so sad and lethargic, I think I was in clinical depression for a few months.

      It got so bad that I even had severe physical reactions that accompanied my emotional pain.

      During these months, my brain was extremely scattered. I could not focus, I jumped from one task to the next without being able to get anything done. I stressed almost non-stop every day.

      stress causing physical pain

      The stress also impacted my sleep. Many nights only left me with 4-5 hours of sleep.

      During this period, I was sexually life-less. Again I suffered from severe erectile dysfunction. And I had no libido. I was simply not interested in sex.

      For me, stress has been a big enemy to my sex life.

      How Do I Stress Today?

      I have learned how bad stress can be. Now I know. Therefore, I try to avoid stress at all costs. And I am putting to use a few techniques to help me avoid stress.

      As a result, my life is today pretty much stress free. 😊

      Here are the techniques I find particularly helpful:

      stop and feel the stress

      Firstly, when stress arrives, I stop. I stop and feel the stress. Because it typically manifests physically somewhere in the body. For me I normally feel it in my chest, upper stomach or in the kidney region. 

      I stop and I acknowledge it. And then I ask myself, why do I feel this stress. What is causing it? 

      When I understand the reason, I ask myself whether it’s necessary. The answer is almost always ‘no’.

      This way I confront my stress and stop it from growing. Instead of letting it take control of me, it normally goes away pretty quickly.

      Also, I try to avoid situations that can cause stress. For instance, I don’t work in a stressful job anymore, I don’t invest my savings in the stock market, and I try to choose my friends wisely.

      Exercise, yoga and mediation are also activities that bring peace and help me avoid stress. 

      exercise to avoid stress

      As well as having healthy connections with friends and people in my life.

      And also living healthy, as this both makes me happy and reduces health complications.

      How can I help you stress less?

      How Can You Stress Less?

      A problem with stress, is that it’s often so ingrained in our lives, that it has become part of who we are.

      Therefore, to change your stress habits can be difficult. But it’s not impossible.

      My number one suggestion to help you avoid stress, is to follow what I described above: Learn to sense stress when it arrives. This is key, because you have to identify it before you can deal with it.

      identify stress before you can deal with it

      Then I would acknowledge it. Just feel it. Where in the body is it? What physical sensation does it cause? How intense is it.

      Then I would question it. I would question why I sense it. What is bringing it about? Why did it arrive? Does the same stress experience arrive often?

      And I would question whether it is really necessary. If it’s not, you can let it go.

      So if you can stop the stress in its tracks, and prevent it from growing into a monster, much of the job is already done.

      This way you can become the master of your stress, instead of stress taking control of you.

      As a second step, I would also, if possible, reduce my exposure to stressful situations. Stop the stress at the source. Such as changing jobs, friends, environment, etc.

      couple on hike on the mountains

      And thirdly, I would find activities that I really enjoy. Whether it’s reading books, drawing, playing badminton or hiking. These activities can be amazing stress relief.

      And lastly, I would build and rebuild, more, better and stronger connections with good people. And of course, maintain these relations. 

      Having friends and good people in your life is normally a crucial factor in order to reduce stress.

      By the way, you may wonder: Is a little bit of stress OK?

      How Much Stress Is Too Much?

      As we know by now, stress can save your life. This stress is good.

      every day or very frequent stress is bad e1590326216339

      Let’s say you check your mobile as you walk. And let’s say a cyclist is about to crash into you. But let’s also say you hear him shout and just before the collision, you throw yourself to the side.

      This stress is good. You avoided harm and the stress lasted for a moment.

      But the stress you experience on a frequent basis, particularly the repetition of the same stress, the persistent stress – this stress is not good.

      This every-day (or very frequent) stress is bad. 

      If you can, I would recommend that you try to remove all, or as much as possible, of this stress from your life.

      Because the consequences of this stress can be dire: Heart disease, cancers, cognitive disorders, weight gain, erectile dysfunction and a lost libido. 

      daily stress is bad

      Hence, almost any kind of this stress is too much stress.  

      Let’s finish up with some final words on stress.

      Final Words On Stress

      There is good stress: The kind that saves your life.  And there is bad stress: The kind that gives you problems such as erectile dysfunction.

      The bad stress, can provoke erectile dysfunction in two ways:

      • By shutting off your reproductive system, and 
      • By the long-term effects from excess stress hormones
      man stressing at work

      The bad stress has almost become a disease of the modern society. It affects almost everyone. 

      However, there are techniques you can apply to: 1) stop this stress, and 2) remove the stress that still lingers in your body.

      In other words, you can train yourself to stress down and become stress-free.

      By the way, throughout evolution, individuals that didn’t experience stress probably had a lower survival rate.

      Because they would be less likely to escape dangerous situations. Therefore, it’s fair to say that there has been a selection for people who stress.

      Survival of the ‘stressiest’. 😊

      stressful day at work

      Research Studies

      Andersson K, Stief C. Penile erection and cardiac risk: pathophysiologic and pharmacologic mechanisms. Am J Cardiol. 2000 Jul 20; 86(2A):23F-26F.

      Bae J, Park S, Kwon JW. Factors associated with menstrual cycle irregularity and menopause. BMC Womens Health. 2018; 18: 36. Published online 2018 Feb 6. doi: 10.1186/s12905-018-0528-x.

      Bancroft J, Janssen E, Strong D, Carnes L, Vukadinovic Z, Long JS. The relation between mood and sexuality in heterosexual men. Arch Sex Behav. 2003 Jun; 32(3):217-30.

      Barlow DH. Causes of sexual dysfunction: The role of anxiety and cognitive interference. J Consult Clin Psychol. 1986; 54:140-8.

      Cellek S, Cameron NE, Cotter MA, Muneer A. Pathophysiology of diabetic erectile dysfunction: potential contribution of vasa nervorum and advanced glycation endproducts. Int J Impot Res. 2013 Jan; 25(1):1-6. DOI: 10.1038/ijir.2012.30.

      brain scan on impact of stress

      Chatterton RT, Vogelsong KM, Lu Y, Hudgens GA. Hormonal responses to psychological stress in men preparing for skydiving. J Clin Endocrinol Metab. 1997; 82:2503-9.

      Chu B, Marwaha K, Ayers D. Physiology, Stress Reaction. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

      Cummings DC, Quigley ME, Yen SS. Acute suppression of circulating testosterone levels by cortisol in men. J Clin Endocrinol Metab. 1983; 57:671-3.

      Daly W, Seegers C, Rubin DA, Dobridge JD, Hackney AC. Relationship between stress hormones and testosterone with prolonged endurance exercise. European Journal of Applied Physiology. 2005; 93, 375-380.

      Daniel J, Mikulaj L, Vrazda L. Mental and endocrine factors in repeated stress in man. Studia Psychologica, Vol 15(3), 1973, 273-281.

      Dickerson SS, Kemeny ME. Acute stressors and cortisol responses: a theoretical integration and synthesis of laboratory research. Psychol Bull. 2004 May; 130(3):355-91.

      research study on stress hormones

      Exton NG, Truong TC, Exton MS, Wingenfeld SA, Leygraf N, Saller B, Hartmann U, Schedlowski M. Neuroendocrine response to film-induced sexual arousal in men and women. Psychoneuroendocrinology. 2000; 25:187-99.

      Gruenewald TL, Kemeny ME, Aziz N. Subjective social status moderates cortisol responses to social threat. Brain Behav Immun. 2006 Jul; 20(4):410-9.

      Hale VE, Strassberg DS. The role of anxiety on sexual arousal. Arch Sex Behav. 1990 Dec; 19(6):569-81.

      Hannibal KE, Bishop MD. Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. Phys Ther. 2014 Dec;94(12):1816-25. doi: 10.2522/ptj.20130597. Epub 2014 Jul 17.

      Hedon, F. Anxiety and erectile dysfunction: a global approach to ED enhances results and quality of life. International Journal of Impotence Research (2003) 15, Suppl 2, S16–S19. DOI:10.1038/sj.ijir.3900994.

      scientific research on adrenaline

      Kalaitzidou I, Venetikou MS, Konstadinidis K, Artemiadis AK, Chrousos G, Darviri C. Stress management and erectile dysfunction: a pilot comparative study. Andrologia. 2014 Aug; 46(6):698-702. DOI: 10.1111/and.12129.

      Kamba A, Daimon M, Murakami H, Otaka H, Matsuki K, Sato E, Tanabe J, Takayasu S, Matsuhashi Y, Yanagimachi M, Terui K, Kageyama K, Tokuda I, Takahashi I, Nakaji S. Association Between Higher Serum Cortisol Levels and Decreased Insulin Secretion in a General Population. PLoS One. 2016 Nov 18;11(11):e0166077. doi: 10.1371/journal.pone.0166077. eCollection 2016.

      Kessler RC, Andrews G, Colpe L, Hiripi E, Mroczek DK, Normand SL, Walters EE, Zaslavsky AM. Short screening scales to monitor population prevalence and trends in nonspecific psychological distress. Psychol Med. 2002; 32:959-76.

      Laurent SM, Simons AD. Sexual dysfunction in depression and anxiety: conceptualizing sexual dysfunction as part of an internalizing dimension. Clin Psychol Rev. 2009 Nov; 29(7):573-85. DOI: 10.1016/j.cpr.2009.06.007.

      Lykins AD, Janssen E, Graham CA. The relationship between negative mood and sexuality in heterosexual college woman and men. J Sex Res. 2006 May; 43(2):136-43.

      doctors research project on stress response

      Meisler AW, Carey MP. Depressed affect and male sexual arousal. Arch Sex Behav. 1991 Dec; 20(6):541-54.

      Morokoff PJ, Baum A, McKinnon WR, Gillilland R. Effects of chronic unemployment and acute psychological stress on sexual arousal in men. Health Psychol. 1987; 6(6):545-60.

      Morokoff PJ, Gillilland R. Stress, sexual functioning, and marital satisfaction. Journal of Sex Research, Vol 30(1), Feb 1993, 43-53.

      Mourikis I, Antoniou M, Matsouka E, Vousoura E, Tzavara C, Ekizoglou C, Papadimitriou GN, Vaidakis N, Zervas IM. Anxiety and depression among Greek men with primary erectile dysfunction and premature ejaculation. Ann Gen Psychiatry. 2015 Oct 29;14:34. DOI: 10.1186/s12991-015-0074-y. eCollection 2015.

      Nakamura K, Sheps S, Arck PA. Stress and reproductive failure: past notions, present insights and future directions. J Assist Reprod Genet. 2008 Mar; 25(2-3): 47–62. Published online 2008 Feb 15. doi: 10.1007/s10815-008-9206-5.

      Opstad PK. Androgenic hormones during prolonged physical stress, sleep, and energy deficiency. Journal of Clinical Endocrinology and Metabolism. 2013; 74, 1176-1183.

      scientific research process of penile erection

      Ranabir S, Reetu K. Stress and hormones. Indian J Endocrinol Metab. 2011 Jan-Mar; 15(1): 18-22.

      Reed-Maldonado AB, Lue TF. A syndrome of erectile dysfunction in young men? Transl Androl Urol. 2016 Apr;5(2):228-34. DOI: 10.21037/tau.2016.03.02.

      Rizza RA, Mandarino LJ, Gerich JE. Cortisol-induced insulin resistance in man: impaired suppression of glucose production and stimulation of glucose utilization due to a postreceptor detect of insulin action. J Clin Endocrinol Metab. 1982 Jan; 54(1):131-8.

      Rosner W. The function of corticosteroid-binding globulin and sex hormone -binding globulin: recent advances. Endocr Rev. 1990 Feb; 11(1):80-91.

      Smith AD. Psychologic factors in the multidisciplinary evaluation and treatment of erectile dysfunction. Urol Clin North Am. 1988 Feb; 15(1):41-51.

      Ter Kuile MM, Vigeveno D, Laan E. Preliminary evidence that acute and chronic daily psychological stress affect sexual arousal in sexually functional women. Behav Res Ther. 2007; 45:2078-89.

      Welsh TH, Bambino TH, Hsueh AJ. Mechanism of glucocorticoid-induced suppression of testicular androgen biosynthesis in vitro. Biol Reprod. 1982 Dec; 27(5):1138-46.

      Yafi FA, Jenkins L, Albersen M, Corona G, Isidori AM, Goldfarb S, Maggi M, Nelson CJ, Parish S, Salonia A, Tan R, Mulhall JP, Hellstrom WJ. Erectile dysfunction. Nat Rev Dis Primers. 2016 Feb 4;2:16003. DOI: 10.1038/nrdp.2016.3.

      Zitzmann M, Nieschlag E. Testosterone levels in healthy men in relation to behavioral and physical characteristics: facts and constructs. Eur J Endocrinol. 2001 Mar; 144(3):183-97.