The evidence behind the work

Most of what we know about how to treat compulsive sexual behaviour in men has been built on the wrong shape of evidence. Built on heterosexual templates. Built on addiction frames. Built on the assumption that the man in front of you is the problem. The men I have seen in clinic, over more than a decade of NHS psychosexual work, have rarely recognised themselves in any of it. They have arrived telling me what they have already tried. They have tried one-to-one therapy that did not seem to understand the world they were trying to describe. They have tried twelve-step programmes that asked them to put their lives inside a frame of disease and abstinence that did not quite fit. They have tried, more than anything, to manage on their own. By the time they reach me, what they describe is exhaustion. They are not just struggling with the behaviour. They are struggling with the feeling that nothing on offer has ever properly belonged to them.

This piece is about what we built differently, and what we have now learned about whether it works.

What we were seeing

When I took over the psychosexual service at 56 Dean Street in 2020, I inherited a waiting list. Not just any waiting list. A waiting list weighted with a particular kind of man. A gay or bisexual man, often in his thirties or forties, often with a successful enough professional life on the outside, often with a sexual life on the inside that had become unmanageable. App use that had started to interfere with all aspects of everyday life. Sex in saunas, or on the scene, or in public spaces that he had told himself a hundred times he would step away from. Drugs and sex, including chemsex, that had stopped feeling like enhancement and started feeling less and less of a choice.

56 Dean Street is a large NHS sexual health service in central London. It has served the LGBT+ community since the early years of the HIV crisis. The men who come through its doors are not a niche group. They are at the centre of one of the largest psychosexual services in the country, and the levels of compulsive sexual behaviour we see there are probably higher than anywhere else in the United Kingdom. What was missing was not the need. What was missing was something to offer them that would actually meet that need.

Why a different shape was needed

The available treatments were not bad. They were aimed at someone else.

Most of the existing models had been built on heterosexual, monogamous templates. They located the problem inside the individual, as if it were a personal failing, rather than something shaped by life history, by culture, by the particular pressures of growing up gay or bisexual in a world that did not always have a place for you. Many of them framed it as addiction, with all the language and the architecture of disease that comes with that. The men I was seeing rarely arrived at the door thinking they were addicts. They arrived thinking they were broken.

And almost nothing on offer looked forward. Most of what they had tried had focused on what to stop. Rarely on what a different, sustainable, hopeful sexual life might actually look like. For a man trying to imagine a way through, that absence matters. You cannot move toward something if there is nothing in front of you.

The other thing I kept hearing in individual sessions was loneliness. There must be other people going through this. But where? The bars, the apps, the wider gay social world, did not feel like places where it was possible to be vulnerable about struggling. The cultural narratives on offer there were about confidence, sex positivity, being in control. The men I was seeing had built lives around looking like they were in control, while quietly being anything but. What many of them wanted, more than the right therapeutic technique, was to be in a room with other men who knew what this was actually like.

A group, we thought, could be part of the answer. Not just for efficiency. The group itself could be part of the work.

Compassion as the way in

The model we built the work around is called compassion focused therapy. It comes from the work of Professor Paul Gilbert in the UK. Its starting question is not what is wrong with this person. Its starting question is what is this behaviour doing for them.

That distinction matters more than it sounds.

Compassion focused therapy describes three emotional systems we all carry. A threat system, which keeps us alert to danger and to overwhelming feelings. A drive system, which pushes us toward what feels rewarding and provides motivation to seek out resources we think are important. A soothing system, which helps us calm down, feel safe, and feel connected. When the threat system has been overactive for years, and the soothing system has often not been built up to balance it, the drive system gets pulled in to fill the gap. Sex, particularly sex that has become repetitive and compulsive, often sits exactly there. It becomes a way of coping with threat and overwhelming feelings when there are no other coping mechanisms in place. It often feels good to begin with, and usually does allow us to avoid, reduce, or change the amount of threat we experience. Over time, however, the sex we have starts to produce consequences we did not intend or expect, producing threat of its own. Without always knowing how to cope with this, we can start to use sex more to cope, and the cycle can quickly escalate.

For men who have grown up with shame, with isolation, with messages telling them that some part of who they are is wrong, the threat system has often been working overtime for decades. The soothing system has often not been built up at all. The drive system, with sex inside it, has had to do too much work for too long. That is what we see in clinic.

A model that starts there, rather than starting with the behaviour, gave us a way of working that the men I was seeing could actually recognise themselves inside.

What we built

The programme is structured in three phases of work, facilitated by a qualified clinical psychologist.

The first phase is about understanding. The men work through what we mean by out of control sexual behaviour. We introduce the three emotional systems. We talk about how compulsive sexual behaviours can develop as a way of managing pain when the soothing system has not had a chance to develop. Each man begins to map his own pattern, in his own terms.

The second phase is more experiential. The men learn specific psychological skills, and they sit directly with shame, with loneliness, and with the inner critic, which is the voice in someone's head that judges and attacks them, often in the words of people who criticised them years ago. We talk about how sexual development has unfolded for many gay and bisexual men, including the early separation of sex from intimacy in adolescence, and the way gay culture and the wider culture shape what men come to believe about sex.

The third phase turns toward sexual life itself. What each man actually values in his sexual life. The relationship between sexual health, pleasure, and safety. Sober sex, and what makes it difficult. By this stage the men are working out what their preferred sexual life looks like, and what would help them move toward it.

Two design decisions sit underneath all of this and matter beyond the structure.

The first is that it is a group, not one-to-one. Shame thrives in private. A room of other men working on the same thing is a different kind of intervention from an hour alone with a clinician. The work the room itself does, by its existence, turns out to be a substantial part of what the men get from it.

The second is that we did not exclude men using drugs in sex. Most addiction-shaped treatment treats the substance and the behaviour as two separate problems, and routes them to two separate services. For the men I was seeing, the drugs and the sex were not running in parallel. They were bound together. Separating them out would have meant losing the meaning of what was happening. So drugs and sex, including chemsex, was included as a presenting issue in its own right.

Who came

84% of the men who started the group, finished it.

Between May 2021 and June 2024, seven groups ran at 56 Dean Street. Seventy men were invited. Fifty-nine completed. That is an 84% completion rate. By the standards of group mental health work, that is high. Many groups in this territory lose closer to half.

The men were gay, bisexual, or men who have sex with men. They ranged in age from their early twenties to their mid-fifties, with most in their thirties. Most were White. About a quarter were from Black, Asian, or other ethnic backgrounds. About half came in with drugs and sex, including chemsex, as their main concern. Around seven in ten had used drugs in sex at some point, even if it was not the central issue now. The rest were arriving with sex in public, sauna and cruising compulsivity, app use, pornography, or paid sex. Most were dealing with more than one of these at once. Almost half were dealing with three or more.

This is not a group of men with one neat problem. It is a group of men whose sexual lives had become tangled, and where the tangle was costing them.

What we found

86% who completed the group reported a meaningful reduction in their compulsive sexual behaviour by the end of it.

86% of the men who completed the group reported a meaningful reduction in their compulsive sexual behaviour by the end of it. Their main difficulty, and any other behaviours they had named alongside it, had become less severe and felt more in their control. That is what the data shows, and it is the figure I would ask people to hear first.

61% reported a meaningful increase in self-compassion. In plain English, that means they were treating themselves more kindly by the end of the group than they had at the start. The voice in their head had become quieter and less attacking. They were less harsh with themselves about what they had done. The story they were telling themselves about who they were had begun to change.

Alongside those, sexual confidence and sexual satisfaction improved across the group. Men reported feeling better about their sexual lives at the end of the programme than they had at the start. Depression and anxiety came down too, less dramatically, but in the right direction. The mood changes were more modest than the changes in behaviour and self-compassion, and I want to be straightforward about why. The group was not designed to treat depression and anxiety. People were not coming to us for those things. They were coming because their sexual lives had become unmanageable. There is also something else worth saying. Anxiety can rise at the end of a piece of work like this, not fall. Men finish the group having decided to do something different with their sexual lives, and then have to go out and do it. That is hopeful work. It is also frightening work. Some of what we are measuring at the end is the entirely reasonable anxiety of stepping into a new pattern, not residual pathology.

And then there is a third finding, which I want to call out on its own, because it matters clinically.

Men whose main difficulty was drugs and sex, including chemsex, did just as well in this work as men whose main difficulty was something else.

Men whose main difficulty was drugs and sex, including chemsex, did just as well in this work as men whose main difficulty was something else.

That sentence is small. The implication is large. The assumption across many services has been that drug use makes therapeutic engagement impossible, or that outcomes for men who use will inevitably be poorer. That assumption has been used to exclude exactly the men most in need of support. Our data does not support it. When men using drugs in sex are taken seriously as men, rather than as cases to be sent elsewhere first, they can engage with this work and change inside it.

What the men themselves said

The second of the two papers asked the men, in their own words, what the experience had been like. Three things came up clearly across the cohort.

They used the phrase ‘not alone’ over and over again.

The first was what the work felt like to be in. A room of other gay and bisexual men, working on something hard, in a service that already had a long history of being on their side. They used the phrase “not alone” over and over again. They talked about being able to bring all of themselves into the room, without having to perform, without having to explain who they were before they could begin. The atmosphere was not background. It was part of the architecture that allowed men to feel able to share, reflect and engage safely.

The second was a change in how they understood themselves. Many described moving from seeing themselves as broken or fundamentally flawed to seeing their behaviour as something that had once made sense, given the life they had lived. That shift matters more than it sounds. It is hard to change a behaviour you are still using to punish yourself for.

The third was the practical use of the work outside the room. The men described using the exercises and skills they had learned in the group, in the moments where the old pattern would have taken over. A change in how you see yourself is one thing. A repeatable practice you can call on when you need it is another. The men in this work got both.

What surprised me

The self-compassion result was the biggest surprise.

I had gone into this work knowing the model and trusting the framework. What I had not expected was the intensity with which the men would take up the language of compassion, integrate the exercises, and continue to use them. The assumption, often, is that men who have been brought up to approach their emotional lives in a particular way will struggle with the language of being kind to themselves, of comforting themselves, of taking care of themselves. The men in this work did not struggle with it. They embraced it. They named the techniques back to us with precision. They described using them on themselves with deliberate intent.

That tells me something about what some of these men have been missing. And it tells me something about what they respond to when it is genuinely on offer.

What this means for the wider picture

Most of the existing evidence for compassion focused therapy has been built with female participants. Around three quarters of the people in compassion focused therapy trials and studies, across all the difficulties it has been applied to, have been women. That has produced strong evidence. But it has left a real question hanging over the model. Does it work for men? The honest answer until now has been that we do not know, or that we have one case study at a time.

This work is a contribution to that gap. It does not answer it for every man. It answers it, with reasonable confidence, for one specific male population, in one specific context, around one specific difficulty. That is meaningful. It is also a starting point, not an end point.

Compulsive sexual behaviour in men is not solved by treating it as an addiction in disguise. It is not solved by treating the man’s sexuality as the problem.

What I would want anyone reading this research to take away is this. Compulsive sexual behaviour in men is not solved by treating it as an addiction in disguise. It is not solved by treating the man’s sexuality as the problem. It tends to be solved, where it is solved at all, by giving men a structured way to understand what their behaviour has been doing for them, by helping them build the capacity to comfort and steady themselves that many of them did not learn growing up, and by doing all of that in a room that takes their actual sexual lives, including the difficult parts, seriously.

What this work does not show

This is exploratory work, and the limits need naming honestly.

We had no control group. We measured the men in front of us, before and after. We did not compare them to men receiving a different treatment, or no treatment at all. We cannot say from this data alone how this group compares with other available approaches.

The men in this work were predominantly White. We did not find significant differences in outcome by ethnicity, but the non-White sample was too small to draw firm conclusions about how this travels across different communities.

We did not follow the men beyond the end of the group. We have the picture at the close. We do not yet have the picture at three months, six months, or a year. We do not yet know how durable the changes are.

All of this was done at one site, by one clinical team.

What this work is for

I have spent over ten years working with the men this evidence is about. The two published papers are not the end of that work. They are the first time we have been able to point at it and say, with the weight of peer-reviewed research behind it, that what we have built does what we hoped it would do, in the kinds of numbers and in the kinds of ways that matter clinically.

The men sitting in those rooms changed. The data says so. They say so. The challenge now is to make sure that this kind of work, for this kind of man, is not unusual. The challenge is to make sure that ten years from now, when another gay or bisexual man arrives in a clinic with the same exhausted set of things he has tried, he does not have to start from scratch.

The two published papers

Both papers are published in Sexual and Relationship Therapy.

Yates M, Hampson C, Langmans T, Irons C, McCormack C. A compassion-focussed group intervention for compulsive sexual behaviours: an exploratory study. Sexual and Relationship Therapy, 2026. DOI: DOI: 10.1080/14681994.2026.2614638

Yates M, Hampson C, Langmans T, McCormack C. Participant experiences of a compassion-focussed group intervention for compulsive sexual behaviours. Sexual and Relationship Therapy, 2026. DOI: DOI: 10.1080/14681994.2026.2639314

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.