Psychosexual therapy with men: why talking about sex is the hardest part

I see a lot of men who arrive in my consulting room not because they wanted to come, but because something in their sexual life has stopped working and they have run out of other options. They have tried solving it on their own. They have tried solving it practically. They have looked online. They have spoken to a doctor, often several times. Some have never spoke to anyone. By the time they reach a sex therapist they are often at the edge of what they can manage alone, and they are sitting down to do the thing they have spent their whole lives avoiding.

They are sitting down to do the thing they have spent their whole lives avoiding.

It is worth saying at the outset that this is not every man. Some men come to therapy easily. They sit down, they speak, they engage. The idea of exploring themselves with another person in a room, week after week, feels natural to them, sometimes even welcome, and they get a lot from it. Some men, around sex specifically, feel similarly. They have language for it, they have done thinking about it, and they can engage with a clinician in ways that feel productive from the first session. This piece is not about them.

This piece is about the men for whom that experience is the opposite of natural. Men who have been raised, in different ways, to view talking about feelings as unproductive, or as weakness, or as something other people do. And then who arrive in a room to talk about the part of their life they have probably been most quiet about. That combination is the one I want to look at.

For these men, the work has two parts. One is talking about feelings. The other is talking about sex.

Either of these, on its own, is difficult. The men I am describing have often been raised in environments where talking about feelings was discouraged, where emotion was viewed as a sign of weakness or as something unproductive, and where the expected response to difficulty was either to fix it practically or to push it to one side. They have rarely been modelled how to sit with a feeling, let alone name one.

And then we are asking them to do this about sex. The one part of their lives in which they have probably been most exposed, most quietly judged, and most fundamentally without language. Sex sits at the intersection of intimacy, identity, performance, and shame. To talk about it from the start is to feel vulnerable from the start. There is no preliminary conversation, no easing in. The label is on the tin.

Sex sits at the intersection of intimacy, identity, performance, and shame.

That intersection, the men for whom this is hard combined with the subject of sex itself, is the focus of this piece. It is the place where standard ideas about how therapy works tend to fail, and where I have had to learn to do things a bit differently to keep these men in the room long enough for anything useful to happen.

In over ten years of this work, across NHS and private practice, and across the outcomes we have now published in peer-reviewed work, I have come to think this is one of the most underestimated barriers in the field. We talk a lot about men not coming to therapy. We rarely talk about why the form of therapy itself is, for some men, around some material, part of the problem.

Two men I have been thinking about

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

T.S. A man in his early twenties, gay, who came out fairly recently. He has begun to engage with the gay scene, and he came to therapy because he is still finding his way with his sexuality and how to communicate it. He wants to come out to more people in his life, and he wants to understand what he actually wants from his sexual relationships. He arrived willing. He could talk. He was open to thinking about what he was feeling. What he did not have was language. The vocabulary for talking about sex, intimacy, and emotion had simply never been built for him. Growing up he was told, in different ways, that talking about feelings was unproductive, that being too emotional was a flaw, particularly in a boy, and that sex and sexuality were subjects to be avoided at home. He came in willing to engage, but standing in front of a door he did not know how to open.

H.B. A man in his early sixties, heterosexual, recently divorced after a long marriage. He has found himself dating again, in a world that has changed completely since he was last in it. The apps, the etiquette, the speed, the openness about sex, none of it is familiar. He feels alienated, particularly online, and he is unsure how to make connections that lead anywhere he actually wants to go. He came to therapy reluctantly. He had spent a long time avoiding the idea. He had tried other solutions first, reading, websites, pushing through the discomfort. It was a female friend who eventually suggested he might want to speak to someone, given the level of distress he was carrying. He arrived in the room closed and confused. He did not know what to expect, and he did not know why talking would help. He was someone who had always solved problems by working out a solution and moving through it, and the idea of sitting opposite a stranger to discuss his sexual life was not an obvious next step.

These two men are very different. Different ages, different orientations, different presenting questions. But they both arrived in my room facing the same essential challenge. The work I was about to ask them to do bumped up against everything they had been quietly taught about how a man manages himself.

Why this combination is harder than therapy alone

For most kinds of therapy, you can ease into the difficult material. A man coming in with anxiety, or with a work problem, or with something to do with his family, can warm up by talking around the issue before reaching the heart of it. The room can build trust by working on the less exposing material first. He can practise the basic skill of being in a therapy session, sitting with another person, finding words for things, allowing pauses, on subjects that feel manageable.

Sex therapy does not work like that. The label is on the tin. From the first session, both of us know what we are here to talk about, and what we are here to talk about is precisely the territory where most men feel the least confident and the most exposed. There is no warming up. There is no peripheral material to ease through. We start, immediately, with the thing he has spent his life carrying without words.

Sex therapy does not work like that. The label is on the tin.

This sits on top of everything else that makes therapy difficult for many men. The unfamiliarity of sitting with feelings. The cultural messages that suggest doing so is unproductive or self-indulgent. The instinct to find a practical fix and to feel slightly diminished if a problem cannot be solved that way. The expectation, often absorbed without ever being named, that real men do not need this kind of conversation.

Layer the two together, limited fluency with emotional language and the requirement to use that limited fluency immediately on the most exposing material in a man's life, and you understand why so many of the men I see either do not come, or come once and disappear. It is not because they do not want to do the work. Many of them do. It is because the form of the work itself is asking them to do something that runs against everything they have been quietly told about how to manage themselves in the world.

This needs to be paid attention to. And in my view, it requires us to adjust our approach.

Why I work this way

Traditional therapy training is broadly cautious about directive work. The therapist is taught to follow the room. To allow material to emerge in its own time. To trust the process and the relationship. There is real value in this, and for many people it is exactly what they need.

For the men I am describing, in this particular territory, it can be the wrong tool.

Asking a man who has never had the chance to develop emotional vocabulary, who has been told most of his life that talking is not the answer, to come in and freely explore the most exposing material he has, in his own time, at his own pace, is like asking him to swim without armbands when he has never been in water before. You can hold the space. You can model patience. You can wait. But while you are waiting, he is drowning. He may not look like he is drowning. He may look composed. But internally the experience is overwhelming, and one of two things happens. Either he stops coming, or he comes but never gets near the thing he is actually carrying.

Like asking him to swim without armbands when he has never been in water before.

So with these men, I scaffold. Not always, and not all the way through. But in the early sessions I am noticeably more directive than orthodox training would generally suggest. I name things explicitly. I model language. I offer choices. I use psychoeducation, telling a man what I know about how these patterns develop, what the research shows, what other men in similar situations have experienced. I make the implicit explicit. "Where would you like to start?" "Here is what I think this is about." "Here are the things we could work on, and here is what working on them might actually look like, week to week".

This is uncomfortable for many therapists, and it was uncomfortable for me when I started doing it. It can feel as though I am taking too expert a position too early, or as though I am closing down a man's exploration before it has had a chance to begin. I have learned that the opposite is usually the case. Without that scaffold, the man's exploration never starts. With it, he has a frame within which he can begin to take the lead himself. He can opt in to what feels right, push back on what does not, take ownership of the process. The scaffold is what makes his agency possible, not what removes it.

The men I work with tend to respond strongly to this. Being shown the parameters of the work, what it is for, where it might go, what we might do together, gives them the security to engage. Without it, the openness of the room is just one more thing they have to navigate without a map.

What I did with each man

With the first man, what I noticed early on was that he could talk, but he could not yet make use of his own talking. He arrived in one session ready to discuss a recent sexual encounter that had left him feeling a particular way. He started to describe it and I made a decision that I would not interrupt. I let him do, essentially, a stream of consciousness for around five minutes, without curating it for him, without trying to shape what he was saying. I held an active listening position, but I held back from intervening.

When he paused, I asked him whether he wanted me to reflect back what I had heard. He said yes. I then spent some time not repeating his words, but reflecting back the sense I had made of them. What I had heard, both in what he had said explicitly and in what he had said without quite saying. The emotional register underneath the content.

That was a powerful moment in our work. He had not previously experienced someone listening to him that way. The reflection mirrored him back, not in a judgemental form, not in a clinical form, but in a form that took seriously the things that mattered to him. After that session, the whole dynamic of our work shifted. He began to bring different parts of himself more freely. He found that he could trust the talking to take him somewhere. The capacity to think about what he wanted for his sexual life, and for his life more broadly, opened up.

With the second man, what I did differently was earlier and more structural. In the first or second session, we mapped out, in fairly concrete terms, what he thought the problem was and what he felt he needed from these sessions in order to feel that progress was being made. I did not necessarily agree with all of his framings. There were things I thought were probably going to surface that he was not yet naming. But I let his framing lead, and we built a rough trajectory of how we might work over a series of sessions. We thought together about the balance between talking and practical skills, between open conversation and more concrete work. We sketched out what we might cover and in roughly what order.

He took the information on board in that first session without a big visible reaction. The shift came the following week. When he came back, he spoke about the mapping exercise. He said that, in working through it, he had been able to see his own problem more clearly. He did not thank me for that, but the way he spoke made it clear that he had felt understood. He was more engaged. He was more responsive to my questions. The session opened up in a way the first one had not. And from there, the actual work could begin.

In reality we never stuck to the plan. The work moved into territory neither of us had predicted in those early sessions. But the plan itself was what built the trust. He could see that I had heard what he was bringing. He could see that the work would have a shape. He could see that he had a hand in deciding what that shape would be. Without that early piece of mapping, I believe he would have disengaged within the first few sessions.

What these men have said afterwards

I have heard versions of the same sentences from many of the men I have worked with. I am going to write three of them here because I think they say something that I could not say in their place.

> "I did not think this would help me at all. I thought the talking would be pointless. Now that I have done it, I can see different perspectives and ideas."

> "I didn't think I would feel able to talk about anything. Talking would feel dangerous or unsafe. But having been here, it has made me feel connected, and more in touch with my own needs and the needs of other people."

> "I thought therapy was for others. Therapy was for women. Therapy was for someone else. But being in this space I realised, actually, this could benefit me. This helped me make sense of my problem in a different way."

The third one is the one I think about most. The assumption that therapy is for other people, that it belongs to someone else, that a man would either not need it or not be able to use it, is, in my experience, one of the biggest reasons capable men in this position do not come. And it tends to dissolve, when it dissolves, very quickly. Often within a few sessions. Often before they had expected anything to feel different at all.

The assumption that therapy is for other people, that it belongs to someone else, is one of the biggest reasons capable men in this position do not come.

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

I want to end this piece in a practical place, because the question of how to actually move from "I think I should do something about this" to "I am doing something useful about this" is, for many men, the hardest distance to travel.

If you are reading this and recognising yourself in either of the two men I have described, or if you are a partner, friend, or family member trying to support a man toward therapy, the most important thing I can say is this. Do not begin with "you should go to therapy."

That instruction, on its own, is almost never enough. It assumes that talking, for its own sake, will help. For many of the men I see, that assumption was the first reason they avoided coming in the first place. Open-ended emotional exploration with no clear purpose is precisely the experience they have been taught to dismiss, or to feel slightly suspicious of.

What works better is to start with a different question. What is it you want? What would you actually want to get out of a conversation? What is the thing you are hoping to change?

That question can be asked of yourself, if you are the man in question. It can be asked of him, if you are the partner or friend. Either way, it shifts the frame from "I should be able to talk about my feelings" to "I have a problem I want to work on, and I am considering whether this is a useful way to work on it." For most men, the second framing is far more workable.

And then, when looking for a therapist, do not be afraid to be specific in what you ask. I have this problem. I want to change it. What would therapy bring me? What would you actually do? What would that look like, week to week? How would you know if it was working?

Many therapists will not be comfortable with that conversation. They have been trained to keep the work open-ended, to let it emerge. That is a legitimate position, but for the men I am describing it is often the wrong starting point. Find a therapist who will engage with those questions directly. Who will tell you what they would do. Who will give you a sense of what the work might look like before you commit to it. That is not a sign of an inflexible therapist. It is, in my view, a sign of one willing to meet you where you actually are.

Asking those questions does not mean the therapy will only ever go where you initially wanted it to. It almost certainly will not. But starting with a sense of agency, with some shape to the work, with a frame you helped build, is what makes it possible to follow the conversation into the more difficult territory later.

Where this work has to start

The work I do with men around sex and relationships is possible. It is, in fact, often surprisingly successful, and surprising in particular to the men themselves. But it has to start where the man actually is. Not where the textbook says he should be. Not where his training might have taught a therapist he should be.

That is the piece of work I think most needs to be more widely understood. Not that men should be better at therapy. But that therapy, for some men, around some topics, needs to be different.

Therapy, for some men, around some topics, needs to be different.

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.