Shame in men's sexual problems: what compassion focused therapy adds

Most men do not arrive in my clinic naming shame. They arrive much further down a road than that. They arrive naming behaviours that have got out of hand. Patterns they cannot seem to break. Choices they do not recognise themselves in. Starting to experience their bodies in ways that feel uncomfortable or confusing. They have usually spent months, sometimes years, trying to work it out on their own. They have tried to think their way out of it. They have tried to behave their way out of it. They have tried to control it. By the time they reach me, what they are describing is usually the consequence. Shame is what is underneath, and almost always, it is what is doing the driving.

Shame comes up in our work all the time, and in popular language too. We talk about it a lot. But it is actually really hard to define, and that matters, because in the therapy room what often presents is not shame itself. It is the consequence of shame. The behaviours, the patterns, the ways of being in the world that someone has built to live with something they cannot name.

What often presents in the room is not shame itself. It is the consequence of shame.

In over ten years working within sexual health services, across NHS and private practice, and across the clinical outcomes we have now published in peer-reviewed work, I have seen shame come up in loads of different ways. Sometimes it is obvious. It is a reaction to something specific. An event that makes someone feel they are not good enough, or that they have done something they are ashamed of. Much of the time, though, shame is not obvious at all. It is set into other behaviours. It guides actions. It shapes ways of thinking. It leads people to believe certain things about themselves and the world around them. The longer I work with shame, the more I think it is not a single emotion. It is a combination of complex emotions that leave people feeling they are less than, or that they are not achieving something in the way that they think they should.

Shame is taught, not innate

It matters where shame comes from. No child is ever born with shame. Babies are not born with shame. Young children often do not feel shame. Shame has to be taught.

Babies aren't born with shame. Shame has to be learnt and is taught.

Shame comes from the messages we receive that tell us we are not achieving something, or that we are not behaving in line with values, expectations, or standards that have been set outside of us. Our past experiences, the family we grew up in, the community around us, the wider culture, all of these directly affect how likely we are to feel shame, and what we feel shame about. So shame can only really be understood when we think about our relationship with other people, and with the world around us. At its heart, shame is the perception that we have let others down in some way, or that we are less than others in our social world.

What is good enough, what is expected of us, what we are supposed to be like, none of that comes from us. It comes from the dominant social views of whichever group we have grown up in. When we deviate, we are taught we have done something wrong. Through that lens, shame can be understood as a way of editing behaviour. Of keeping people in line. It is often a tool that is used socially to get people to behave in particular ways.

Within ourselves, shame is often a fear of being rejected. A fear of disconnection from the groups we belong to. When we feel shame, it is an internal signal telling us that we need to do something different. The trouble with shame is that over time, the experience of feeling shame can turn into something much more profound. A sense that there is something about us that is simply not good enough. That we have failed in some way.

Shame is not guilt, and the difference matters

It is important here to separate two emotions that often get confused. Guilt and shame.

Guilt is what we feel when we have done something wrong. It is uncomfortable. It feels horrible. But it points to a behaviour, and a behaviour can be put right. Guilt allows us to recognise that an action has been harmful, and it allows us to commit to doing something differently. There is a way forward. Guilt is momentary, or circumstantial. It speaks to that action, in that moment. It does not speak to who we are.

Shame is different. Shame is much more pervasive. Shame is not about what we have done. It is about who we are, and often it is about something we have been told is wrong about us that we cannot change. There is no behaviour to put right. There is no obvious next action. That is part of what makes shame so heavy. Repeated over time, with no clear way out, the message lodges into how we feel about ourselves. Shame can lead to feelings of low self-worth, low confidence, an inability to express ourselves or set boundaries. When we feel shame, we can inherently feel that we are not good enough, that there is something about us that is broken or different, that cannot be rectified.

This matters because feeling shame, the kind of shame that has lodged into a sense of self, often pushes us into other behaviours. We need to do something to avoid, escape, or fix these deeply painful feelings about ourselves. And that is where most of the patterns I see in clinic begin.

Why shame feels so dangerous

Shame is experienced as a threat. When we feel threatened, in any real or perceived way, our central nervous system responds. Shame is dangerous because being shamed is dangerous. It tells us there is something about us that, if it became visible, could lead to rejection. To being ostracised from the social connections we depend on. That is why it is held so tightly, and why it drives so much of what we do.

To cope with it, we engage in a range of behaviours that try to fix, avoid, or distract ourselves from these deeply threatening feelings. We move towards things that give relief. Substances. Sex. Achievement. Pleasing others. Performing a version of ourselves that feels acceptable.

The way that shows up is really diverse. It can manifest as anxiety, depression, overthinking, self-consciousness, changing our behaviours to please others, hiding parts of ourselves, becoming defensive, using substances, sex, pretending to be something we are not. Using other behaviours to escape and avoid.

This is the key clinical point. Often what presents in the room is not shame itself. It is the consequence of shame. It is the behaviour someone has built to keep shameful feelings at bay. These behaviours often work, frequently in the short term. They allow someone to feel better about themselves. They allow someone to present a version of themselves to the world that feels acceptable. But over time, they lead to cutting off other parts of the self. They lead us to deny parts of ourselves that we feel are unacceptable, or that we have been told are intolerable to others.

What shame looks like in the room

When shame shows up in session, it can come out in a whole array of ways.

For some people, when shame emerges, or we get close to a topic that might trigger it, there is an attack or defensive response. They push back. They deny that it is happening, they tell you that you are wrong, they challenge the material. "This isn't important. We shouldn't be talking about this." There can be an immediate shutdown.

For others, possibly more commonly, I notice a change in how someone sits in the room. They become smaller. They submit, they please, they agree. They stop being curious. They withdraw. They give less information. They sometimes look clouded, as though they are no longer able to think clearly. Their words become less coherent. Their body closes up.

When I witness shame in the room, I often notice it in myself before I name it in them. I can suddenly feel on edge. I find myself less willing to ask the next question. Sometimes I feel a stronger pull to care for the person in front of me. Sometimes I feel defensive myself, and I am curious about that when it happens. If I am feeling defensive, why? What is going on?

People rarely name shame directly. They say they feel overwhelmed, anxious, angry. Interrogating those feelings gently often reveals shame underneath.

Earlier in my career I might have worried about this, got stuck in the work, avoided certain topics because they felt too difficult to go any further. With more experience, I have learned that we don't have to resolve all of it in one session. The reaction tells us something. Often what is underneath is shame.

Two clients I have been thinking about

The shape of shame is so different from one person to the next that I want to share two anonymised, composite portraits, because they show two very different ways it shows up.

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

G.O. A southern European guy in his late thirties who identifies as gay. He came to clinic struggling with chems. He had been using drugs in sex for around five years, and was now at a point where almost all the sex he was having was on drugs. The use of apps and multiple partners had become compulsive. He had recently lost his job. The pattern was clearly damaging his life.

He was able to speak with clarity about how sex was being used to manage stress, anxiety, and self-consciousness in his life. But he denied, throughout the work, that he felt any shame. He spoke about supportive parents, a relatively painless coming out, friends and family who had always been advocates for him. He felt he had always been able to express himself sexually. And yet he kept returning to one observation: that being himself in a sexual space, without drugs, felt overwhelming.

What slowly emerged over our work together was the function of silence in his life. He had grown up in a culturally conservative Catholic family where discussions of sex were rare. Of any kind. Let alone sex between men. What he had been calling support from his family was, on closer inspection, the absence of outward rejection. The absence of hostility. But the silence was total. It continued into his adulthood. Most of his friends were heterosexual. He had no models for talking about sex between men, no language for what it could feel like, what intimacy could be.

Through the work, he began to identify that the silence itself had been shaming. Shame is not always somebody telling us we are bad. It is just as often what is not said. The implicit message that certain things are not available to be discussed. That there are parts of ourselves we should not name. Drugs had provided a way to express himself sexually without having to feel any of it. Without language for the emotional life of sex, he had reached for chemistry instead.

Shame is not always somebody telling us we are bad. It is just as often what is not said.

This is important: identifying shame is not about blaming anybody. It is not necessarily anyone's fault. It is a product of the relational, social, and cultural context we grew up in, and the messages, including the silences, that come with that.

D.H. A man in his fifties, heterosexual, of mixed Black British Caribbean origin. He came to clinic struggling with the compulsive use of sex workers, which had recently been discovered by his wife of over ten years. The marriage had broken down. He arrived in deep shame about the harm he had caused her.

In this case, the shame was visible from the first session. He could name it, sit with it, articulate his regret. But as we explored his relationship to sex itself, a different story emerged. Growing up, sex had been linked to social power. Having multiple partners had been a source of credibility within his friendship group and even within his family system. The act itself often felt good, but the meaning sex carried for him was about agency, masculinity, and social currency. He did not initially see shame as having played any part in his own sexual development. If anything, he felt the opposite. Sex had always been something to be open about.

Where shame did sit, when we found it, was around emotion. He had been taught that emotional expression in sex was not something to do. Sex had become a performance. Transactional sex made him feel powerful and in control. Sex inside a long relationship, where emotional expression was being asked of him, felt dangerous. He spoke about the idea of expressing emotion in sex as something that would make him less of a man. The work became uncomfortable for him, and the discomfort was the work.

He began to consider how some of the messages he had carried, about what sex was supposed to mean, might have been wrong, even if they had given him a sense of mastery in other parts of his life. Sitting with the possibility of emotion in sex opened up the possibility of a different kind of relationship going forward.

These two men carry shame very differently. One denied it. One named it on day one. One had been taught nothing about sex. One had been taught a great deal. Both arrived in patterns of behaviour that had stopped working. Both were, in the end, doing the same work.

If something in those stories landed for you, that is where this work starts.

Where the messages come from

The messages we receive about sex are hugely diverse and vary from person to person.

Some are explicit and direct. Being gay is wrong. Being gay is incompatible with our culture, our religion, our family values. Some are more subtle. Having sex in particular ways is not okay. Wearing certain clothes is not okay. Monogamy is the only relationship we should aspire to. Multiple partners makes you promiscuous, less worthy of love.

The messages can run the other direction too. Being very sexual is what's important. Owning your sexuality. Being openly, demonstrably sexually active is what you should aspire to. These are equally prescriptive. They give an implicit standard we are supposed to meet, and if we are not meeting it, we are doing it wrong.

The most dangerous, in my experience, is silence. When sex is just not talked about, we fill the gaps ourselves. We have no models. No visibility on other people having sex, having relationships, expressing sexuality openly. No one who looks like us. From that absence we draw the implicit conclusion that either we shouldn't, or what we want is wrong. The man in the first case carried that kind of shame. The shame of a silence he was never given the words to challenge.

The most dangerous, in my experience, is silence.

The work is to bring all of this out. To think gently about where the messages came from. And then, as an adult, what agency someone has over how they respond to those messages now. Do you want to continue to accept them as accurate? Do you believe they are right for you? We become curious about the relationship someone wants to have with the messages they receive from the outside world.

We take time to think about what a more compassionate view might look like. What a kind voice would say about what is good enough, what is acceptable, what is allowed. Sometimes we think about a person's younger self. What were they taught? What were they told? What were they denied? What would you say to them now? How would you treat a younger person being given those messages? How would you speak to your own children, or to the next generation, about what is and is not acceptable, and which parts of ourselves we want to nourish.

Shame cannot be removed, and we should not try

The most important thing I have learnt is that trying to remove shame, or deny it, or push it away, simply does not work.

Trying to remove shame, or deny it, or push it away, simply does not work.

Shame is human. Shame is normal. It is part of our emotional repertoire, and it will continue to be. Sometimes it is there for a reason. Sometimes it has protected us. Sometimes it has allowed us to exist in relationships and spaces that have kept us safe. The aim is not to cut shame off. It is to change our relationship to it.

Sometimes shame is something we can tolerate, or live alongside. At other times it stops us from being ourselves. It cuts us off from how we want to live, and it denies parts of ourselves. It is when it starts to harm us that we have to become curious about it, and about what it is doing to us.

What gets in the way

Working with shame is hard. The messages are entrenched, and they don't stop arriving in adult life. They are still around us, in our culture, our friendships, our families, our workplaces. Changing your relationship to shame is not only internal work. It involves the people around you, who often, without meaning to, keep sending the original messages.

Some of this work involves painful realisations. That people we love may have inadvertently shamed us. That some relationships survive the work, and some do not. This is not about blaming parents or partners. It is about recognising that we are all part of a system in which shaming messages exist, and they affect us all differently. Holding that, gently, is part of the work. It allows relationships to continue, even when the people inside them have got things wrong.

What patients have said

Towards the end of this work, men often say something close to this:

> "I didn't even know I had shame. But now I know how to respond."

That sentence captures, in its quiet way, the whole point of what this work is for. The aim is not to remove shame. It is to know it is there, to recognise what it is doing, and to have a different set of responses when it shows up. The shift from being driven by something a man cannot name, to recognising it and having a relationship to it that he chooses, is what most of the change in this work actually looks like.

What change actually looks like

What changes for most people is not that shame leaves. It is that the relationship to it changes.

What changes for most people is not that shame leaves. It is that the relationship to it changes.

People come in either unaware that shame is shaping them, or aware of it in one area of life and oblivious to how much it is shaping others. The first thing that tends to shift is just understanding. Understanding that shame comes up at different points, in different ways. Understanding the link between the shame underneath and the behaviour on the surface that brought them in.

Then comes something more embodied. Sometimes the word shame is abstract. It doesn't mean the same thing to everybody. But the body knows. We know when the stomach tightens. When the chest closes. When thinking becomes clouded, critical, judgemental. That is shame in the body. Recognising the bodily signals gives us a clue that shame is around, even when we cannot name what triggered it. Knowing it is in the room, in us, allows us to make choices about it.

Most of the men I work with leave with that deeper understanding, and with a set of ways to respond differently. The real question of the work is: what do I want my relationship to shame to be like? When shame comes up in my body, when I feel it, what do I want to do? Talk to it differently. Pause. Reach out to someone. Speak to that part of me, the one that is still hearing the old messages, with kindness rather than contempt.

Equipping people to actually change their relationship to shame makes a meaningful difference. Knowing how to talk to shame, knowing how to be kind to it, allows it to impact us less.

It doesn't mean we feel good in every situation. It doesn't mean shame will never come again. It will. But we can be in a different relationship to it. One that allows us to make different choices.

That is what change looks like. It is slow. It is not always linear. It is rarely overnight. But it happens. I see it every day.

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.