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There is often a contributing and complicating and sometimes a primary psychological or relational problem. Psychological impotence is where erection or penetration fails due to thoughts or feelings psychological reasons rather than physical impossibility; this can often be helped. Notably in psychological impotence, there is a strong response to placebo treatment. Erectile dysfunction, tied closely as it is to cultural notions of potency, success and masculinity, can have severe psychological consequences. There is a strong culture of silence and inability to discuss the matter.