Group therapy for men's sexual problems: what one-to-one cannot reach

The first time I tried to think seriously about group approaches for sexual problems was about twelve years ago. I was a trainee in an NHS sexual health clinic, and a colleague was keen to explore whether groups might be a useful way of helping people talk about sex differently. I remember the visceral reaction from the team when we raised it. It will not work. People will not want to come. They will not engage. It will be too uncomfortable. The clinicians, the other professionals, the wider service. The reaction was strong, almost defensive, and it was specifically about sex. Group therapy itself has existed for decades in many other clinical territories, often without much comment. But sex therapy in a group, talking about our bodies and our sexual lives with other people in a room together, seemed to provoke something else.

That reaction has not gone away. Group therapy as a modality still struggles to get equal billing with individual one-to-one work, particularly in the area of sex and relationships. In some ways I understand why. The idea of sitting in a room of strangers to talk about feelings, let alone sex or our bodies, can feel completely overwhelming. There is a safety in the one-to-one model, in knowing the conversation stays inside a small, contained relationship. Worries about being exposed in front of others, about not having enough space to be heard, about being judged by people in the room. All of these concerns are real and they make sense. For many people, one-to-one therapy is exactly the right option and what they need.

But I think not enough attention is paid to what group therapy can offer in this particular territory. Across twelve years of doing this work, much of it now within the NHS at 56 Dean Street, including the development of evidence-based group interventions whose outcomes have been published in peer-reviewed research, I have come to believe that for a particular kind of man, around the particular subject of sex and relationships, group is sometimes the better tool. Not the lesser one. The better one.

Group is sometimes the better tool. Not the lesser one. The better one.

This piece is about why.

Concerns are real and rational

For most men I see in clinic around sex and relationships, three pressures stack on top of each other when group therapy is suggested.

The first is the unfamiliarity of being in a therapy room at all. Many men have rarely if ever sat with another person and talked openly about how they feel. The cultural messages that suggested doing so is unproductive, or weakness, or self-indulgent, are still loud in the world they grew up in. Therapy itself is a stretch.

The second is the subject. Sex, intimacy, bodies, performance, identity. The territory in which men have probably been least permitted to develop emotional vocabulary, and in which the cultural conversations available to them have most often been performative, jokey, competitive, or silent.

The third is group. Adding other people to the room. Strangers. Other men. The risk that they will be judged, exposed, compared. The risk that someone else will have it together in ways they don't. The risk of being known by people who weren't supposed to know.

Stacked together, these three pressures explain why many of the men I see refuse group when it is first offered. No way. Not for me. I will not feel comfortable. I cannot do this with other men in the room. The refusal is rational. It is also, I have come to learn, often a refusal of the very thing that would help most.

What group can do that one-to-one cannot

There are three things group therapy offers in this territory that one-to-one sessions simply cannot reproduce, no matter how skilled the therapist.

The benchmark you have been missing

One of the biggest problems with sex is that most of us have no benchmark for it. We do not know, really, what other people are experiencing. Unless you have a particularly open group of friends who talk freely about their sex lives and their bodies, you do not get reliable information about what other people are doing, what they find difficult, what they enjoy, what they worry about. This is true for almost everyone, but it lands particularly hard on men who have grown up in cultures where the only available conversation about sex was performative or comparative.

That absence of a benchmark creates a particular kind of loneliness. It tells a man that whatever he is going through must be his alone. That nobody else thinks like this. That nobody else is worried about this. That nobody else has this kind of sexual life. The shame this generates is enormous, and it persists because there is no obvious way to test the assumption.

In a group, that assumption is tested. Someone speaks. Then another. And the man listening realises, often within the first session, that what he has been carrying alone is not actually unique to him. Other people sit with the same worry, the same pattern, the same shame. That recognition cannot happen in one-to-one therapy in the same way, because one-to-one is, by definition, one voice carrying the shame opposite one voice trying to hold it.

The compassion you can only see when it is not coming from a therapist

I can sit with a man in my therapy room and say, in all sincerity, that what he is describing is understandable, that his shame is not warranted, that other men have walked through this and come out the other side. He may take it in. Or he may not. There is a felt sense in the room, often unspoken, that, well, I am going to say that, am I not. I am there to support him. I am being paid to be there. He cannot quite trust my response in the way he might trust the response of someone with no such position.

Group changes this. When another participant, with no agenda, no professional role, no responsibility for the man's wellbeing, says something that resonates with the experience he has just described, the impact is different. The compassion is being given by an equal. By someone who has been through their own version of the same territory. That kind of recognition lands in a way that a therapist's reassurance, however genuine, cannot.

And it works in both directions. The men in these groups also learn to give that compassion to others. To listen. To witness. To respond from a place of warmth toward someone they have never met. For many of the men I see, this is the first time they have ever been asked to receive empathy from another man on this subject, or to give it. The skills they develop in the group around how to speak and how to listen extend far beyond the group. They reshape how the man relates to himself, to his partner, and to others.

The non-performative space

For most men, by the time they reach my clinic, almost every conversation they have ever had about sex has been performative. Bravado. Jokes. Comparison. How many people have you slept with. What was she like. What did you do. Inside long-term relationships with female partners, conversations about sex are sometimes more honest, but they often become problem-focused. They get raised only when something is going wrong, and they get pushed to one side when other priorities arrive.

Having a dedicated space, where talking about sex is the explicit purpose, where bravado is set aside, where each person is allowed to be honest about what they actually feel about their sexual life, what works for them, what does not, what they want more of, what they have been avoiding, is rare. It is almost unheard of for most of the men I work with. Group provides that space in a way that one-to-one cannot, because one-to-one cannot give you the felt experience of a room of men, none of them performing, none of them comparing, all of them trying.

Two men I have been thinking about

To make this concrete, here are two men whose work in groups has stayed with me.

C.M.

The cases described in this essay are anonymised. Initials and identifying details have been changed throughout. Some are composites.

A man in his early thirties, who identifies as gay. He came to me because his sexual life had started to feel out of control. He was having sex more often than he wanted. He was thinking about it constantly. He was using apps; he sometimes used drugs alongside sex. The behaviour was taking up an increasing amount of his time, his attention, and his life, and he had begun to recognise that he was being pulled toward things he did not actually want.

When I first suggested a group, his answer was immediate. No way. There is no way I am sitting in a room with other gay men talking about this. I am already self-conscious about my body. I am already self-conscious about my sexual experiences. I do not feel comfortable around other gay men in that kind of space.

These narratives are common. For many of the men I see who identify as gay or bi, sex and sexuality occupy a strange and contradictory position. Their sexual identity has been simultaneously visible and hidden across their lives, sometimes celebrated and sometimes shamed. The wider scene can feel both overtly sexual and yet emotionally disconnected. Talking honestly about sex with other men, outside of the performative scripts, can feel completely alien. What is often missing is a middle ground. A space where men can be honest about what they have actually experienced and what they actually want, without being measured against socially dictated stories about gay sex.

He agreed, eventually and reluctantly, to come to the first session. Just to listen. He could leave if he wanted. He said he probably would.

He arrived nervous. The group, like most of them, was mixed. Some men were more confident; some were quieter. He sat at the edge of the conversation. As people began to share, tentatively at first, I noticed him soften. He was listening. He was nodding. He was attentive in a way I had not expected.

In the last five minutes of that first session, unprompted, he spoke. He talked about how something another participant had described had resonated with his own experience. The other man heard him. He smiled. Something happened in the room that I cannot fully describe in clinical language: a moment of recognition between two strangers who had each, separately, been carrying the same thing.

At the end of the group, I checked in with him. Without me having to ask, he said: I will be back next time. I do have more I need to say.

Over the course of the weeks that followed, he engaged more and more. He spoke about his own experience. He gave feedback to others. He received it back. At the end of the programme, he talked about feeling that the work had helped him move toward the sexual life he actually wanted. But more than that, he spoke about the experience of being heard and seen by other gay men in a way he had not believed possible. He began talking about joining sports clubs and social spaces for gay men that were not sexual. He was, for the first time in his adult life, looking for community.

The second

A man in his early forties, heterosexual, who came to a group running for men with erection problems. There had been the same pushback when we set up the group as there had been twelve years before. People will not want to talk about this. Not with other men. Not in a room. But the group attracted men who could see that talking about it might be useful in a way that medication alone had not been.

This man arrived confident. He was happy to talk. He was happy to describe his own situation, his recent break-up after a long relationship, his new partner, the realisation that his body was not responding the way it used to. What he found difficult, particularly in the early sessions, was listening.

The other men in the group were heterosexual, but their experiences were genuinely diverse. Their assumptions about sex, about what men were supposed to do in sex, about what their partners wanted, varied widely. He found this disorienting. I do not know if this is for me, he said early on. I am happy to talk about my own experience, but I do not understand what I am supposed to learn from other people's.

He was resistant. It was not obvious to him how anyone else's story applied to his life.

Over the course of the programme, the group did what groups do. People shared. They listened. They offered each other support. They started developing their own language for what they were experiencing. He participated in his own way, mostly by telling his own story.

Then, in one of the later sessions, something happened that I have thought about many times since. He stopped in the middle of a conversation. He turned to one of the other participants and said: I just remembered what you said, in one of the earlier sessions. I completely understand where you are coming from now. I had this experience with my girlfriend last night.

He paused. He looked genuinely shocked. Something that had been described to him weeks earlier, that had felt completely alien at the time, had suddenly made sense through his own life. The penny had landed late. But it had landed.

The penny had landed late. But it had landed.

What he came to understand was that sex, for him, could be different from how he had been imagining it. That the way another participant had described his own partner's preferences had given him a new frame for what was happening with his own partner. That perhaps the role he had been trying to play in sex was not what was being asked of him. He did not arrive at this through his own thinking alone. He arrived at it because he had been sitting in a room, week after week, hearing other men describe their lives, and the material had been held inside him, even when he had not consciously been engaging with it, until it was ready to be of use.

That is something a one-to-one session almost never gives you. The material is not just responded to in the moment. It is held. Returned to. Layered. Made sense of slowly. In a group, ideas have time to settle in places you did not know you were holding them.

What men have said afterwards

Three voices have stayed with me, each from a different man at the end of a different group.

> "I suddenly felt part of something that I've never felt part of before."

That was a gay man reflecting on the experience of the room. He had never previously known closeness between men of the kind that the group had shown him.

> "It completely changed the way I thought about myself and my relationship."

That was a heterosexual man (P.L.) who had been certain group therapy would never help him. The perspectives he heard from other men in the room reshaped what he then brought back to his partner. His relationship, he later said, came back from the brink.

His relationship, he later said, came back from the brink.

> "Strangely, being in the group, I benefitted more from hearing others than talking myself."

That was a gay man who had spent a long time believing his own disclosure would be the hardest part of the work. It turned out the listening was where the work happened for him. The connections he made privately, as other men spoke, did more than any sentence of his own.

These three voices, in different versions, are among the things I hear most often at the end of a programme. They tell me that the change group brings for these men is rarely about insight in the dramatic sense. It is about no longer being alone in what they have been carrying. And it is sometimes about finding, to their own surprise, that the listening was the work.

Why I work this way

A traditional group therapy training is broadly cautious about being directive. The therapist's role is taught as that of a holding presence: let things emerge, follow the room, hold the space, trust the process. There is real value in this and for many groups in many contexts it is exactly the right approach.

For the men I am describing, around the territory of sex and relationships, in the early sessions, it is in my experience the wrong tool.

If I hold a purely open-ended, purely person-centred space at the start of a group of men who have walked in nervous, self-conscious, unsure why they have come, expecting to feel exposed, the room goes in one of two unhelpful directions. Either it stays in extended uneasy silence, with people too anxious to speak first. Or it fills with monologues. One participant fills the gap, then another, but there is no listening, no reflection, no genuine encounter. Either way, the group does not become the thing it could become.

So I scaffold. Not all the way through, and not for the whole life of the group. But in the early sessions I am more directive than orthodox training would generally suggest.

We agree the parameters of the group together. We talk explicitly about what safety looks like in the room. How we will give feedback to each other. How we will listen. How we will respond. This sounds basic but it matters, because it creates a shared language for how to communicate before the difficult material arrives.

And then, and this is the move that goes most clearly against the grain of how groups are usually run, I encourage everyone in the room to say something in the first session. Something about their experience. Something about what has brought them. Something about what they want from being there. They do not have to say very much. They do not have to disclose anything they are not ready to disclose. But I am direct about asking them to speak.

The orthodox view is that you let people speak when they are ready, that pushing them too early breaks trust. I have learned, repeatedly, that the opposite is more often true here. Knowing something about every other person in the room, something that ties them together, transforms what the group can become. It creates commonality early. It makes the silences less frightening later.

With the directive frame in place, the room becomes capable of much more.

When group is not the right call

Group therapy is not the right starting point for every man, and saying that honestly is part of what makes the case for group credible rather than promotional. There are several legitimate reasons why one-to-one therapy may make more sense first, or instead.

The first is the level of distress someone is currently carrying. Group settings work when participants are able to hold themselves in the room reasonably well across a session. This is not about not having strong feelings in a group, which is normal and welcome and often the point. It is about whether the level of distress someone is living with would make it difficult to contain what comes up in front of other people. Severe depression, levels of social anxiety where someone may not feel able to speak at all, or any mental health difficulty where someone is struggling with thoughts of harm to themselves or others, are all reasons where one-to-one work in a contained relationship is the right place to start. Group is something that may become useful later, when the ground beneath someone is steadier.

The second is neurodiversity. Group therapy can be excellent for many neurodivergent participants, and I have seen group spaces allow people to connect in ways they did not believe possible. But if a group is not specifically focused on neurodiversity, and the majority of participants are neurotypical, the experience can feel alienating, particularly around the unspoken social rules that groups inevitably run on. For some people, one-to-one therapy, or a group specifically designed around their experience, is the better first step.

The third is trauma. Trauma shows up differently for different people, but if someone is currently experiencing symptoms of post-traumatic stress, such as flashbacks, intrusive thoughts, or a persistent sense of being unsafe, a group setting can be destabilising. The work of processing significant traumatic events benefits from a contained, one-to-one, evidence-based relationship first. Group work, if it becomes useful later, comes later.

The fourth, particularly relevant for some of the men I see, is current substance use that is significantly affecting day-to-day functioning. If alcohol or other drug use is at a level where it is difficult to sustain attention through a session, hold a conversation, or get through the time between sessions without using, group is not the right starting point. Targeted substance use support is the right first step, in itself a vital piece of work, before any therapeutic space, group or one-to-one, is likely to be productive.

In each of these situations, group is not being ruled out. It is being deferred. Many of the men I have worked with in groups arrived only after doing other work first. That is sometimes exactly how it should be.

If you are thinking about this for yourself, or for someone in your life

If you are reading this and considering therapy, or you are thinking about whether a man in your life might benefit from it, group is worth taking seriously even if your first reaction is to dismiss it.

It can be easy to write off. I will not get anything out of being in a room with strangers. Nobody else will have my experience. I do not want to listen to other people's stories. If that is genuinely how you feel, group may not be the right starting point and a one-to-one option could be better. But many men who arrive in groups have started from exactly that position and found themselves surprised. The fact that you are thinking about it at all often means that, somewhere underneath the resistance, you sense the loneliness in your own experience and the possibility that other people might share it.

When looking for a group, there are specific things worth asking before you commit.

Ask how the group is structured. How does the first session begin? Does the facilitator set out what the work will look like, or is the room left entirely open? For most men, knowing the shape in advance reduces the anxiety of walking in. A facilitator who can describe what the early weeks will look like, what topics tend to come up, how feedback is handled, is signalling that the room will be held.

Ask what happens if you become uncomfortable. What if you want to leave a session. What if you want something to be different. What if you want to stop entirely. A good group will have answers to these questions and a clear path for raising them.

Ask, particularly if you are attending a group of men who share a community, what the facilitator does about anonymity. What happens if you recognise someone in the room. What happens if someone says something and you realise you know them. This comes up often in groups for men who have sex with men, where the wider community can feel small. A well-run group has worked through these scenarios and will tell you how they manage them.

You do not have to commit to everything at once. Attending one session, listening, watching how the room is held, deciding then whether to stay, is reasonable. Any group worth attending will allow this.

A well-run group's first session usually has a clear structure. The facilitator introduces what the work is for, sets out the principles by which the room will run, and creates space for each person to say something brief about why they have come. You will know quickly whether the room feels capable of holding what you might eventually want to bring.

What carrying it alone actually costs

For some men, around the subject of sex and relationships, group does something one-to-one therapy cannot. It breaks the loneliness of believing your experience is unique to you. It allows compassion to be given and received between equals rather than dispensed from a paid professional. And it creates one of the few non-performative spaces most men ever have to talk about sex.

Compassion given and received between equals, rather than dispensed from a paid professional.

It breaks the loneliness of believing your experience is unique to you.

I have watched too many men dismiss group too quickly. I have watched too many men, having reluctantly agreed to one session, find something there that they had not believed possible.

What this kind of group is for is not transformation in the dramatic sense. It is the slow, often quiet, undoing of an assumption that whatever you have been carrying, you have to carry alone.

The slow, often quiet, undoing of an assumption that whatever you have been carrying, you have to carry alone.

Dr Michael Yates is a Clinical Psychologist, EFS-ESSM Certified Psychosexologist and COSRT-registered Sex and Relationship Therapist. He is Lead Clinician and Psychology Service Lead at 56 Dean Street, part of Chelsea and Westminster Hospital NHS Foundation Trust.