Breaking the Cycle of Men’s Sexual Anxiety, with Kate Moyle

All right, Kate, welcome to the ManTalks show. How are you doing today?

I'm good. I'm good. Thank you. Thanks for having me on.

Of course. I'm looking forward to this. I think it's going to be very useful for a lot of people. Let's just start with a simple question. How do you describe your work when you're at a dinner party?

People either really want to talk to me at a dinner party or they don't want to talk to me at all. They're either thrilled or super, super disappointed to be sat next to me. So basically, I am a psychosexual therapist, which means that I am a talking therapist who specializes in sex and relationship issues. But my— I'm separately qualified as a relationship and psychosexual therapist, but psychosexual therapy is where I do the bulk of my work. And I think that we have lots of different understandings of what, like, sex therapy might mean, but it is a specific specialist branch of talking psychotherapy.

Beautiful. And what, you know, I've kind of dug into some of your stuff, and it looks like you've got it a good split of like 50/50 men, 50%, you know, women. What are a lot of the men actually coming to see you about? And when they come to see you about those issues, what is it sort of telling you about what's happening with men in general?

Oh, it's such a good question. I think there's so— for me, there's so much learning that we can take about what happens in the therapy room to outside of the therapy room. I think the biggest number one point is that the fact that to talk about these issues and difficulties, people need to come to a private, confidential, ethically governed space where they know that it's confidential, that it's protected and boundaried in terms of that— that for me, the biggest reflection is that because we haven't got these conversations right outside of a space like that, in terms of the most common presenting issues, changes to motivation for sex, interest in sex, what people might describe as desire, libido. When we talk about desire and arousal, one is the kind of motivation and wanting for a sexual experience, the other is the physical process of arousal, the kind of brain-body experience. In kind of layman's terms, like the turn-on side of it. And then there's a huge side of it, which is a lot of the bulk of my work around sexual dysfunctions, which is around erectile dysfunction, unreliable erections, difficulties with ejaculation, reaching orgasm. Sexual anxiety is a huge, huge part of my work. And then some kind of crossover with medical conditions or accidents or injuries, medications, the impact of mental health. And some people I see as individuals and some people I see as couples. But really, the kind of banner of anything that comes under a difficulty with sex can, can come to psychosexual therapy.

Do you think that the culture— I'll position it from my very clear biased position and then I'll ask you the question. I think that— I think when I look around, it seems like sexual culture within our society is pretty busted up. You know, it seems pretty broken or dysfunctional. And, and I say that because when I look at the data around the research of what's happening with men specifically, because I work commonly with men, what I end up seeing is that men are having less sex, they're less likely to approach, they're more isolated than ever before. They are, you know, there's a huge segregation in terms of the, the amount of men that are actually even getting attention in terms of, you know, online and dating spaces. You've got sort of like the bottom 80% of men really struggle in dating situations and even in person. And so it seems, it seems like something's happened. And I'm curious if you think that that's true and what you think is contributing to it. I know you wrote The Science of Sex, and I think you talk about the broken sexual culture. And so I'm curious to get your perspective on, on all of that.

Yeah, I think we've got a lot wrong currently. One, is that we have such and have had such a focus more recently on sex as a performance. And that's the message and the version of sex that we see reinforced time and time and time again from everything from Netflix to pornography to the fact that we only talk about sex when it's going well. To when you think about the versions of sex you see represented, even things like perfume adverts, you know, people kind of in their swimwear on the side of the bus looking perfect. The versions that are presented on social media. They're not about— they're not about sex necessarily, but like every couple looking perfect, everybody looking perfect. And these are the versions, the assumptions that we then make about sex. And what we also see is that there is an assumption that everyone is sexual, that everyone is having sex, everyone is having perfect sex. And therefore, if we are the person struggling with sex, we are the only one. And that these issues, particularly things like unreliable erections, difficulties —difficulties with sex—what come under this label performance indicate something about masculinity. And that is something that I see coming up time and time and time again. And so instead of the reflection of the everydayness of people's sex lives that we see, everything is very condensed to this performance-driven, kind of perfect, faultless version of sex. And it's not representative of real people's sex lives or the sex that people are having.

Mm. So there's— what you're saying is that there's sort of this distorted story and narrative that we hold societally and like socially, and then what's actually happening in the bedroom is something entirely different. Yeah.

And what we see is this hunt for this idea of like good at sex, like it's a magic formula that we can learn and then just apply to every sexual situation and every sexual partner. And when we become so kind of bogged down in that, what we actually forget, we get so focused on the thinking and less about like the feeling of like, what does good look like for me, for this partner, for my next partner, in my last relationship? What does it look like when I'm on my own? And I think that we've got so— also, I think that social media and the kind of increasing role of the internet has played such an increasing role in this because everything is about how things look. And it's about what it— the visuals of it, how we appear. And it's very productivity focused. It's like more, better, faster, as quickly as possible. How can we be the best in everything? And it's all about optimizing. And actually, a lot of the time with sex and good sexual experiences and enjoyable sexual experiences and sexual satisfaction, we feel that people need to move away from those strategies and that actually people report the best sex when they're thinking about nothing at all, when they're just in it. And I think that this is where we see so many of the clashes that bring people to something like psychosexual therapy, because the usual strategies they're using don't apply here. So everything else that they've been doing in the rest of their life doesn't, doesn't work in the same way when they're struggling with a sexual problem. And that adds to the feeling of a word that I'm not using to describe this, but this is a word that people use, which is failure.

Yeah. Yeah. I mean, it's interesting because I think as you're describing great sex, when you're not really thinking much at all, and it does seem like great sex is really a practice of presence in some ways and being fully in the moment with experience, with sensation, with the interaction, with the exchange of energy and, and all those pieces and you know, our, our society and our culture is not very conducive for creating and, and helping us to be present. You know, we're— we— I think we're in the probably the most distracted time in human history. And, and so it's so hard, I think, for most people. And then I think when you pile on top of that, that from what I've seen, and maybe I'm curious to get your take on this, sex seems to be that place where all of your psychological challenges or mental health challenges or the things that you're grappling with inside, your stress, your overwhelm, your insecurity, it all shows up there. You know? It all meets in sex. Yeah, it all meets in sex. And so, it's like this funny place where the place where you least want your insecurities, fears, inferiorities to come up, that's where they almost always manifest. Why is that? Do you have a—

There's nowhere to hide. Yeah, because there's nowhere to hide. And I think it's— this is something I've said to you previously, is that all of the strategies we have in the rest of our life for coping, for managing, for covering up, for dealing with— there's nowhere to hide when it comes to sex. And so we have to face them head on. And that's why we see so many people struggling with sex, with dating, with the avoidance of sex. But it's— if we're feeling insecure in ourselves in general, and then we have to undress in front of someone or get intimate with someone, and we're feeling that way about ourselves, how do we feel like that when we're being witnessed by someone else? If we are struggling with anxiety and distraction, how do we try and navigate that when we have someone super close to us? And in front of us. And, you know, you said earlier about distraction. I would argue distraction is one of the biggest problems that we have across the board with sex at the moment, alongside anxiety. And, you know, there's obviously a huge relationship between those two things. But it's— we can kind of dress things up, hide things, manipulate situations in a way in the rest of our lives. We can take ourselves out of a situation, we can change a context, we can distract, we can make ourselves super busy. When it comes to sex, we have to be there. And whilst there are things that might help people to manage in those situations, ultimately, if they feel completely disarmed or they feel like they're struggling to cope, it's quite immediately obvious.

Yeah, I think it's interesting because you're almost describing great sex as like a meditation, you know, like, you know, in meditation practice, you're really trying to just be fully present in the moment. Although there's a, there's a different part of meditation, which is you're trying to sort of let go of any thoughts, just, you know, just be the witness to what's happening, which is maybe a little bit more disconnected. But anything else that you would attribute to the sort of broken sexual culture, distraction, the, you know, the sort of the challenges and the fears and the insecurities that people are carrying that then manifest? And that seems to be on the rise, right? Again, when you look at the data. People are more anxious than ever before, more depressed than ever before. And so, that obviously filters in. What about the very rapid change in social roles between men and women? Because it seems like in the last few decades that has dramatically changed. And, I would imagine that that has played some role on that. I'm wondering if you see that in the therapy room as well where people's fears or the pressures of how they think they should be within their relationship then filter into how they're showing up sexually?

Yeah, should is the operative word there, because shoulds play such a big role in our sex lives. And of course, our expectations, our expectations of our relationships, ourselves, our partners. And I think that changing roles have played such a huge part in our sex lives. And To be honest, there was such a shift that was needed, and it's been for a long time. You think about even something like the contraceptive pill, like the 1960s is when that first came in, and that played such a huge role. But I think that it has massively changed people's perceptions of what they think is expected of them. But also there are so many gender norms and stereotypes, and particularly when we feel like we don't fit within what is considered the norms of where, again, we should be, that can create a struggle. Now, one of the things I often do with people in therapy is we break down the kind of myths that they feel that they hold about sex, or these ideas that they hold about sex, and we break them down one by one and talk about them as whether they're truths or myths, or where they came from. And so often when we get into that, people will say, that's just an idea that I've had my whole life, a script I've been following my whole life, but I've never challenged it. I've never questioned it. And now we're talking about it. Of course it makes sense that that's not the case. But until I actively address that and/or I actively think about it or actively challenge the script, I haven't realized what a kind of dominant role it's been having in how I've been thinking about sex, how I've been having sex, what I've been following as that idea. You know, we have to kind of sometimes rewrite the scripts in some way.

You— if maybe I'm wrong on this, but it sounds from my understanding you operate from a biopsychosocial framework. Can you just elaborate for the audience what that actually means when it comes to a therapeutic practice?

Yeah. So biopsychosocial basically is this kind of understanding that when we look at a sexual problem and not just a sexual problem, but lots of things in therapy and is that it's not just a purely medical model. It's not just a purely social model and it's not just a psychological model. It's the interaction between these three things. So if let's take erectile dysfunction as an example, it wouldn't just be the physicality, biology and physiology of what's happening, but it would also be like the social understanding and impact, what the kind of impact on someone, how they feel socially in their relationship, the other impact of that. And then the psychology, how does that person think and feel about what's going on? And for me, we can't really look at anything when it comes to sex without, without that wide-angle view of all of those things, but also the importance of how those things interact. So a stronger interaction at one corner can completely change the other factors. And so we look at how they all relate to each other.

Well, what would you say are some of the more purely psychological or social factors that men tend to overlook when their desire drops or there is disconnection or dysfunction in the relationship you know, things like what are the things that generally have nothing to do with a drop in testosterone that are impacting their desire, their ability to get and maintain an erection and be aroused and want to initiate and that type of stuff?

A lot of stresses that are outside of sex, but we have particularly historically always looked at sex as this kind of protected, sectioned off part of our lives. But this is a, this is a kind of hybrid example. This is not an actual client of mine, but this would be an example that we might use, which is that someone, let's say, got passed up for a promotion at work that they've been really focusing on. They've been putting loads of effort into sleeping less because they were really kind of prepping for it, thought they were going to get it and didn't. And it was a real knock to their confidence. And say they got home later that evening or the next day and their partner started kind of indicating that they might be in the mood for something sexual. There's— the person is still quite in their head. They're still quite disappointed, still quite distracted. It doesn't feel like things are starting to— like, they're like, I'm not really turned on, but my partner's kind of kissing me and I should probably just carry on. And they get into that and then they start to notice that their erection might be taking a bit longer than usual. Then they're really distracted by that thought. And then they're thinking, okay, well, what's that about? And then they're really in their heads. And then the partner says, everything okay? Like, what's going on? This isn't like you. It's a really basic, wide example, but it's one that we hear so many different versions of. So out of work stress, pain is one that doesn't get talked about a lot. Whether someone is super distracted by, say, like the noise of the baby crying, or that there's someone else in the house, or that their phone is on the bedside table and they can hear the vibrations going off as they're getting emails from their boss. If they are experiencing body anxiety or that they're really struggling with their body image at that time. Depression, low mood, a generalized anxiety that can leak back into sex, preoccupation with something else that's going on. If there's difficulties in the relationship, if there's been an issue of trust or a rupture of trust in the relationship, if it's been a long time, since they've had sex. So, uh, people with young children, also super distracted, don't have much time together. Birth trauma that they might have— they might have witnessed. Difficulties getting pregnant, infertility, male infertility as well, not just female infertility. Recurrent miscarriage. I mean, the list could go on and on and on and on, but basically, in a real nutshell, anything that can change the kind of meaning of sex or how we're holding the idea of sex in our heads. It moves from something I did for fun, pleasure, connection, something I didn't really probably ever think about that much, to something I now feel like I can't stop thinking about in a way which is coded to be less positive. And that's not irreversible, but it kind of often happens without us really realizing, and then we have to rework it, and that takes more conscious work.

It sounds like there are There's like an infinite list of suboptimal conditions for arousal and sex to take place. And, it's funny because as I'm listening to you talk about some of these things, the more I'm getting a picture of how modern culture and the way that our days and lives are kind of set up are actually antithetical to having really great sex or having the libido and the desire and having the conditions, I guess you could say, for a lifestyle that's conducive for sex because it sounds like there needs to be space and ease. There needs to be, you know, you need to be not so distracted all the time. You have to have some level of presence and connection for those things to unfold. What would you say are some of the simple things that do allow for the "right conditions" both mentally and emotionally within a man to be able to have a good connection with his own libido, his own drive, and, and create the environment with his partner?

Well, attention is one. You know, we're in an attention economy right now. And, you know, it's interesting you use the word conditions because we have a theory in psychosexual therapy which is about conditions for good sex. It's a magic triangle. It's written about by a colleague of mine called Dr. Karen Gurney. And it's the, the kind of triangle of good conditions is basically being in the moment, physical stimulation, or the right kind of physical stimulation, and psychological arousal. Now, when we get all of these things, these three things met in a way which is as close to, like, our perfect version as possible, these are the things that really kind of put us in the right context for sex. Now, if when, when we're kind of talking about arousal, when you say all of those things kind of as a dampening effect, Also remember that someone might not have something physically wrong with them. There may not be any changes to their physiological arousal, but if they are hyper-anxious about sex or hyper— kind of have really intense performance anxiety, we see a responsive drop in libido. We don't want the thing that is causing us distress. We're not moving towards that. And so where often we see people who are really kind of nervous or preoccupied or really anxious about sex, they might say, you know, I used to think about sex a lot, I used to want to have sex a lot, I used to masturbate a lot, and now I don't want any of it, but nothing's changed. But actually it's because of that, suddenly sex has taken on a different meaning. And the good conditions really, like you say, are about having those things in place. So touch that feels good and that we're able to give attention to, that we're able to be in the moment, and that we are kind of in a context where we want to be having sex, where it is psychologically kind of arousing us, where we're in that kind of yes state. But also, if you think about the versions of sex that we're given all the time, it looks very spontaneous and kind of out of the blue. Like, if you think about all of the sexual scenes that people talk about on Netflix, it's like through the front door, kind of like can't get each other's clothes off enough. It's like really intense, really spontaneous. And actually, particularly sex in long-term relationships isn't happening in that way. But again, because we think it's changed, we often consider socially that to be that we've lost something instead of the idea that it's changed.

Yeah, I mean, I do think that there is a certain quality, there's a certain pressure that I think people get from just watching sex scenes. It's like, "Oh, that's how it should look." I mean, I remember in my 20s, a lot of my expectations on myself as a sexual partner were predicated on what I had seen in pornography, which wasn't great. I had certain expectations of how long I should last and it was a lot of self-reflection and sort of pressure internally. And I think that's the case for, you know, a lot of men where porn starts to influence their perspective. And then I think for women it's not as much porn, but I think it's these, you know, it's like the romance novels and the sex scenes on Netflix where there's like, you know, all of a sudden they're talking in the car and all of a sudden they're having sex in the car. And there's this kind of— yeah, there's this kind of fabricated sort of elusive version that we then pressure ourselves into thinking like, oh, if it's not that, then there must be something wrong. So what role does, does social media, does pornography, um, create? Because I think if— I think you've said that porn and social media sort of create this unprecedented pressure, especially around men, around sexual performance, sexual arousal. And so what do you see obviously, you can't talk about your clients specifically, but what, from a broad sense, do you see men internalizing that they're receiving from this content that then is influencing, maybe in a negative way, their ability to connect sexually in relationship?

Yeah, absolutely. I think we internalize— we internalize everything, don't we? We take on information from the world around us. And we are, you know, a word that's used very much now, but we are influenced. And the thing about pornography is, for a start, all pornography is not created equal. And one of the things that it became by accident and because of accessibility was it became a lot of people's default sex education because it was the thing that was most easy for them to find. They didn't have to approach another person, ask awkward questions. And there is a— it was never designed to be that tool. It is— it was designed to perform as a performance. It was designed for arousal. It was not designed to be an educative material. And I think, you know, Netflix as well, and the versions of sex that we see on film, you know, they were designed to be entertaining. Now, when we— when these versions of sex are the most common that we see, then of course, we take on ideas that that's what it should be like. And rarely does sex look like it does in those versions, although they're not representative. But as you said, like watching it in your 20s, you know, we now see intimacy coordinators on the sets of lots of these series and lots of these films, because a lot of the sex that used to be seen wouldn't actually physically have been possible. Like the positioning wouldn't have been possible. And So people would then go home and kind of try something, be like, that's not even— how did they get their leg up there? How did that even kind of— it doesn't work. Whereas actually intimacy coordinators are playing a role in making sex more representative in lots of ways. But yeah, we take on what we think is expected of us sexually, and often what we assume then in a sexual situation is that that's also what the person that we are having sex with wants. Or what they expect of us. Now, unless we start to unpick and kind of disassemble that, we don't get to the bottom of it. And often a lot of people are just working on their assumptions of what they think that is expected of them and what they think the other person will expect of them. And only when we start getting people talking do we start to uncover that a bit more.

Yeah, it seems like there's maybe the biggest sort of false perspective is that great sex just happens. And that there's like, there's no real communication that's necessary. And there's no transparency, there's no risk involved. It's just like, it just magically happens, you know, and it's passionate and it's— and both people get exactly what they want. They know exactly what they want. It's just like this magical, you know, unicorn experience. All right, my friend, exciting announcement. I have free monthly office hours or community calls that you can join now. So once a month, I'm going to be bringing people together like you to support you. I'll be teaching, I'll be leading some presentations and doing some workshops. I will be answering your questions. So wherever you are, whatever it is that you're going through, whatever you are working on in your life, this is an opportunity for you to come and get some free support. So you can go to mantalks.com/office. Again, it's mantalks.com/office to sign up and to join me. The first call is going to be on July 28th, I look forward to seeing you there. I'm curious about what you've seen in your practice and in the research. What is required? Like what level of transparency, what level of confronting your own sort of blocks and hurdles is required for great sex to take place in a couple?

Well, if we think about sex as a skill to be learned, that it's not a magic formula that we just kind of get and then apply universally. It's when we think about good sex, actually, what I would say it's about, it's about, you know, number one, consent, about communication, about body knowledge. So I know that this is what I like about my body, and I understand, you know, I have an idea of anatomy and what the kind of person that I'm having sex with's body is like. But also the checking in bit, because how can we— can't just assume that Everybody likes the same type of sex. You wouldn't just make someone a cup of tea and put it in front of them without being like, oh, do you like milk or sugar? Like, can I get you— what type of coffee do you want? We don't have this level of expectation in any other area of our lives. Think about food preferences, for example. Some people like salt, some people like pepper, some people like ketchup, some people hate spice. They like one cuisine but not another. Some people have a real kind of ick about one texture. They are like, oh, they'll never eat that. And other people are like, oh, that's my favorite. Some people like to snack, some people like to have 3-course meals. And it's— we don't have this level of acceptability of all of the variability in sex that we seem to in almost every other walk of life. Look at our gym culture. Some people do Pilates, some people weight train, some people run marathons, some people— and it's all considered— it comes under the banner of exercise, but there's so much within that. And I think that We need to bring a bit of that approach. But this idea that we should all have it worked out, that we should all be experts and that we're expected to be experts, but without really good education, without the ability to ask questions, to check in, to get it kind of to say, is this working for you? I don't know. We seem to think that that's a weakness or a fault in some way, but also that Talking about it, I believe, to be preventative for sexual difficulties, sexual problems, but also kind of sex going wrong. And actually, that it's— but we consider it to be that if we have to talk about it, that must mean we in some way don't know what we're doing. And we've got that the wrong way around, I think. And yeah, the assumption also, you said in couples— sorry, that you said in couples there, I think the assumption that if we have to talk about it, that must mean that we have or we are a problem. And actually, how do you deal with anything else in your relationship? You talk about it. But there's an assumption that— I think this is one of the biggest myths we have, is that sex is a static entity and that once we kind of have, have it, inverted commas, that it should never change. And so we fear the change, whereas actually I would argue that it's adaptable the whole way through our lives, relationships, sex lives, sexual relationship with self. And that's the thing that we should be focusing on.

Yeah, I mean, it's, it's interesting because it sounds like— because I'm, I'm trying to listen to what you're saying through my audience's perspective, and I'm always trying to listen to my guests based on that and then, you know, ask a question to pull something out so that they can you know, really sort of take something home with them. And, it's funny because as I'm listening to you, it sounds like attunement is one of the most important skills that a man could have. Like, attunement to self, attunement what's going on inside of me, attunement to what do I actually really like and enjoy, attunement to the other person, and then the willingness to check that that attunement is correct. Is that like an okay way of saying it or how would you adjust that? Because I want to like I want to disseminate this so that the guys that are listening are like, okay, here's the skill, right? Because it's like, I think the majority of men that I've worked with and talked to, it's like they want to be a good sexual partner. Yeah, you know, they really do. And but as you're talking about, education has mostly come from porn. There's not a lot of talking about it. And usually when guys talk about it, it's like, here's the highlight reel, but I'm never going to talk about the shit show that happened. And so sometimes having the conversation about like, okay, what is the actual skill. So being able to, being able to ask attunement, how would, how would you describe that? Am I, am I articulating that accurately? And what else would you add or adjust?

I think it's a really good word for it. Pleasure over performance would be my top line focus, because we've got it too much the wrong way around. Now, it flipped too far. And what people are then struggling with in terms of satisfaction is actually having sex that they enjoy and enjoying having sex where they're not super preoccupied, super in their heads. And you talked about meditation earlier. What we actually know is that mindfulness has really positive effects on sexual desire and arousal. This research comes from Dr. Laurie Brotto, who is based in Canada. And but what that requires is also the permission to kind of let go of the expectations and the thoughts that are keeping us in our head. So if we take that word attunement, absolutely. So we're going into a sexual situation kind of open to see what happens with consent, with communication. Like, is that feeling good for you? That feels really good. Like that kind of checking. But checking shouldn't be a bad thing. Now, some people might really know their partners really well and they have a really good read on them. They can tell that their partner is enjoying it and that's great. But the focus on what we can do is being able to give ourselves permission to kind of be in our heads and not so preoccupied with how we are doing, but focus more on how we're feeling. But we got so stuck on the performance side of it, the how we're doing, like, how am I doing? How long am I lasting? Is that good enough? Am I doing a good job? Now, we can have a focus on that in a couple-focused or in a partner-focused way, which is a positive thing. But when it is a complete preoccupation, that's where we start to struggle because we are so focused on what's happening in our heads, we don't notice what's happening in our bodies. Now, if you are someone struggling with unreliable erections and you are constantly checking— so that process of checking, like, how hard am I? Am I hard enough? Is it working? You know, these are the phrases that men use all the time.

And how long is it going to last? Doom spiral right there. Yeah, exactly. That's the spiral of death.

Absolutely. And you are taking your attention off the pleasurable sensations that you are experiencing, which are the things that you're going to boost and maintain your arousal. And it is a— that, that kind of doom spiral, that kind of doom spiral, if you're talking about it like that, is a, is a predictor then of sex not working or erections becoming more unreliable. Now, the more we expect them to be unreliable, the more anxiety we feel, the more anxious we feel. The more likely this is to happen because we— and then we have a whole host of kind of behaviors that go with that. And this is why we see so many men reaching for the medication group, which we call PDE5 inhibitors. So your Viagras, your Cialis. In the UK, they're not— they're no longer required to be through prescription. So people can self-medicate through— they can go to a pharmacy, fill in a form, and these— what these medications do is they stop erections from draining, but they're not an aphrodisiac. We don't take them and just suddenly get turned on. They have to inhibit a reaction that's already started. And so what— whilst then being available like that, it's positive. It won't manage— it won't deal with the source of the anxiety. It won't kind of solve the psychological side of it. But it might offer men the reassurance that they need about losing their erections. But if they're hyper, hyper anxious, there still is a likelihood of that happening, even with the medications on board. So there's— there's— it won't help you investigating the kind of underlying reasons for your anxiety. But people— when you see that there are lots of people self-medicating with, with those group of medications now, and that you can get them on prescription, on subscriptions here, particularly as well.

You guys in the UK are doing some funny stuff. Like you don't need a prescription for Viagra and you won't be able to buy cigarettes soon if you're like that. Is there some funny legislation that seems to be going on? That's a whole different topic. And I'll admit that the 15-year-old boy in me was chuckling at unreliable erections. Just that phrasing. Is, I think, very relatable for, for guys. Okay, well, I think— go ahead.

I was going to say, I think the reason that I use that term is because lots of people that present for something like psychosexual therapy might not hit the clinical definition of erectile dysfunction, but it doesn't mean they aren't highly distressed about what is happening. And providing that you know, we're able to establish that because they don't want to wait for 6 months for it to kind of fit the clinical definition. And so that's why we use that term. But also, and, you know, you talked about this in terms of like the sexual culture and messaging earlier. If you ask the majority of people if they had at any time in their lives had a struggle with sex at some point or a difficulty with a sexual experience or worry about sex or a question about sex, I think you would struggle to find anyone that wouldn't admit to having had at least one negative thought, one anxiety, one worry about sex. But then why do we still have the assumption that nobody else has? Right. And unreliable erections. I am— if you— and particularly as we see the percentages increase with factors like age, if you ask most men and they were being honest, they would probably say, yeah, at one point at least I've worried about it. I've had an episode of it or some episodes of it. Oh yeah, a period of my life where my erections were unreliable. And I think that that's— it's a really useful kind of terminology, but it's important because there is a level of the everydayness that we are missing about this stuff. Yeah.

I mean, it's— I mean, on one hand, I'm making light of something that's serious because sometimes we have to bring some lightness into it. And of course, yeah, I know my— I know my, my audience, they like a good chuckle sometimes, but also Also, it is interesting. I mean, the majority of men that have come into our ecosystem and that I've worked with over the years who are struggling with arousal or erections in some way, shape, or form, getting or maintaining, it's quite rare for it to be truly a medical situation. And it's more often than not just psychological in nature. And when I say just, you know, it's— that's challenging, it's confronting. And almost sometimes harder in a way because if it's medical, it's like, "Okay. Well then, here's a very clear linear path that I can go and take." And, when it's psychological and you're dealing with performance anxiety, they can feel daunting, overwhelming, complicated, extremely confronting because usually there's some conversations that have to coincide with that. And so, we're kind of circling around performance anxiety. Let's go straight into it. I think it's one of the things that you've done a really exceptional job talking about, seems to be something that you really work with a lot of men on. Walk me through the psychological mechanism behind performance anxiety and how a man's mind sort of turns against the body in those moments and what's happening. And then, we'll talk about what to do after.

Yeah. And, I think when a lot of people come to my clinic with something like performance anxiety, typically they describe exactly what you just said, which is, I went to my doctor, I've had my testosterone checked, um, I've had an examination, and slightly disappointingly, everything seems fine. And it would be so much easier to have a clear medical answer for what's going on, because also it can feel like harder work to have to work with a psychological reason. And I think that it's a really important thing that we say. We're not saying that it's easier, but we're saying that a lot of time a lot of people might feel relief in some way. They're like, oh, there's a clear explanation for why this is going on. And psychological erectile dysfunction or difficulty with erections and performance anxiety can sometimes be really hard to describe. How do I say to my partner that I've been having sex with for 5 years that suddenly I'm really anxious about sex when from the outside it doesn't look like anything else has really changed. Um, and it's very difficult to put words to, particularly to the person that we're having sex with, particularly if we're in a relationship that matters to us and we are trying to preserve at all costs. And particularly if it's bringing up conversations like, what's going on? Are you not attracted to me anymore? Like, what's, what's this about? Do you not want to try for a baby? Like, are you having an affair? Like, a lot of these questions come up.

Well, and I think what's interesting, maybe you've seen this as well, is the majority of men that I've seen, and again, it's not all, but a lot, it's like the more they want the relationship oftentimes correlates to the more stress, pressure, and anxiety they actually feel, you know. So it's like the higher the desire for their partner, the more they want the relationship, the more that they're that they like love that person, almost not always, but usually correlates to this performance anxiety that starts to manifest. And they're like, but I haven't experienced this before, you know, like, what's going on? So that's also a sort of strange experience, I think, for a lot of guys.

Yeah, you've hit the nail on the head. There's more to lose. It's more costly. The impact is bigger. If it's someone that we're not really interested in, we are thinking, do you know what, we've been on a couple of dates, like, it could go somewhere, but I'm not invested in this yet. We can walk away from it, and we can also— often we can reframe it as something else. Maybe I wasn't that into them, you know, like, we didn't feel like we really did. We can kind of— we can talk ourselves around it. Um, but you said, like, what are the mechanisms? So essentially, it is the version of self in a sexual situation. So the We talked words, we've talked about shoulds, expectations, the scripts. This is who and what I should be in a sexual experience. These are the— if you want to talk about it really clinically, the deliverables and the performance and what I should be like sexually. When I feel like I don't meet those expectations or I don't match up to that or I'm not delivering on them, I start to feel concerned about it. I'm distracted. The more distracted I am, the more preoccupied and the more anxious I can become. Now, when you are super anxious, like in anything in life, you are— your brain is also on kind of at its most basic, like threat alert, and you are redirecting your resources to the preoccupation with that, the kind of eye on the door, essentially, you know, whether it's for worrying about orgasm, pleasure, maintaining an erection, gaining an erection. That's where your focus is going to be. And that makes it very difficult for you to focus on the pleasurable sensations that you're experiencing, which are the things that are going to increase arousal. You can't be in kind of two places at once, like super aroused and super stressed and anxious. And if you think about the most basic part of it, and we often hear people kind of saying this, it's, you know, back in the, you know, human history, back in the day, it wouldn't have been that functional for you to be like lying down having sex if you're being charged by a saber-toothed tiger or whatever, whatever animal is coming for you, it's not a good moment for you to prioritize sex because you're gonna be, you know, eaten alive very temporarily. Now, what we then see is the clash between the prioritizing of the anxiety and the psychological kind of like front brain part of, but this is the person I love, This is the experience I want. This is the person I feel close to. I— my priority is having sex and feeling connected in this situation because you are basically on high alert for sex going wrong. Now, when you're on high alert for sex going wrong or not going the way that your definition of wrong, like the way you expect it or hope for it to go, you're hypervigilant. You're kind of— people often talk about like examining themselves. They're checking on their let's— if we stick with erectile dysfunction, they're checking on their hardness like every kind of couple of seconds. They are kind of trying to keep focused. So again, they're not in the moment, they're completely off somewhere else. And this is where people really struggle because they can also get into what we call spectating. And the best way I know how to describe spectating is that experience of like in the movies when the camera is kind of on like the ceiling of the room and it's like looking down and there's a scene where people are kind of having sex, but one person's kind of looking over the other shoulder being like, 'Oh, I just kind of need this to be like—' They're not in it. Spectatoring is that, essentially, like outside of yourself checking in. And this is what the kind of things I hear people talk about all of the time. If sex then doesn't go to plan, often people might feel like they have to kind of have a conversation with their partner, or they don't know how to talk about it. They roll over, they separate from themselves. The amount of times we've I'm like, okay, what happens afterwards? Oh, well, I roll over, like, put my back to my partner. I feel really embarrassed, really ashamed. Or I get up and I, like, go for a shower, or I kind of, like, go to the bathroom, or I just— I can't stay with them in that moment because I'm feeling bad, or they're asking me all these questions and I don't know how to answer them. Partners often might think that they've done something, and so that can bring up questions and answers that they don't know how to answer, and it becomes messy. And then what happens is people start to try and avoid those situations. So they might work later or be like, I'm going to go to the gym later, or I've got to finish something off. You go up to bed without me. We go— they go for separate bedtimes. They try and avoid situations which might lead to sex. And the avoidance is the anxiety management strategy. And that is where we see people saying, my partner never touches me anymore. If I touch them, they flinch, they pull back. They— we never, like, cuddle in bed. And because we become so anxious and stressed about it, we pull away from anything that might potentially lead to sex. And now if we're having sex with the same partner on repeat, we don't expect that things will suddenly be different. Because it's the same person, the same scenario. And so that's how it can become really cyclical and that can happen really quickly.

That's tough because I think it gets like reinforced for a lot of guys, you know, and then these behaviors, the circumstances, and it just all kinds of starts to reinforce itself. And it's— I mean, it's a very— the male, from personal experience, the male, like personal, the male arousal system is quite interesting in the sense that the more you think about being aroused, the harder you try to be aroused, the less aroused you actually are. And, from a nervous system perspective, I think the most fascinating thing that I've found is that for everything to sort of "work optimally" or for us to be in aroused state, we have to be in a more parasympathetic relaxed state. We have to be in a more parasympathetic dominant state, which is almost counter to how you would think that you should feel in arousal because it's like should be intense and passionate and heavy breathing and all this kind of stuff. But, you really want to have a more relaxed interior so that the sort of exterior of your physicality can operate. And, the more tension and stress that you put your system under, the harder it is for the system to function. And so, the more you move into a stress state, the closer you either get to losing your erection or struggling to maintain it or you move to climax. And so, that's where premature ejaculation happens because you're in this overly stressed-out state and then that happens. So, it's a very— the more that I learn about like the male arousal system where I'm like, that's such a funny way of having it happen. So, how do we start to create— because it's like you're saying, it's a vicious cycle that you're describing where anxiety causes stress, which causes some type of dysfunction, which then creates more anxiety, and then this loop starts to happen. And, I think many men have found themselves in that loop. How does a man start to break that loop? Because I think the, the willpower to just relax that many men usually try and deploy just is not sufficient. So how do we break that loop?

Yeah, and there's one other part about it, which I think is important, which is that for men struggling with erections, it's external, and it's visible. And so that kind of checking on themselves and checking on hardness or kind of how long they're lasting for and things is something that feels very apparent. And I think there's something very kind of like very visual in the psychology of that as well. And so when we're talking about like the strategies for kind of managing this, I think one of the first things we have to do is acknowledge that it's happening because even if that's on your own and what I mean about that is What can also happen is that sometimes men can get into the process of checking. So they basically will try other strategies like masturbating or using pornography to check their erections. But they're not checking— they're not using, for example, masturbation as a pleasure experience, as a sexual well-being experience, as something that they do to kind of relieve stress or enjoy. They're doing it as a checking exercise where they are still in that stressed, anxious, preoccupied, worrying headspace. And so if you are doing that, which again is super common and really commonly reported, try and stop doing that because it's not going to help, because you're going to be— you're basically probably going to just be reinforcing that this is a real problem. Now, the caveat to this is if suddenly your morning erections that you're waking up with— so what we talk about, nocturnal erections, so erections that are happening throughout the night when you're sleeping and typically happen just before you wake up because you're in a period of REM sleep— if they suddenly change, if you've noticed a real change in quality and strength and regularity of those, that needs to be checked out by a medical professional because it could be an early indicator of something going on like heart disease. And that's because some of the smallest kind of blood vessels are on the penis. And if we're seeing— they— we see that often that's an early indicator. Now, whilst nocturnal erections change with age gradually, sudden changes to that should always, always be looked at by a medical professional. So that is a different side of it, which is an important thing that we, we do say.. But when it comes to the performance anxiety side of things, trying not to get into this checking yourself process is really good. Now, easier said than done, um, because obviously that's most people's instinct. The one thing I would say, unsurprisingly, and unsurprisingly as a therapist, is if you can try and explain to your partner that you're struggling about feeling anxious about sex at the moment, that can help them to understand as well, so that the two of you can start to kind of take the pressure off. And what can happen is it can get categorized often around a particular type of sex, so often intercourse. So what some men might describe is they're like, I'm fine until we get up to the point of talking about or thinking about penetration, and then suddenly I'm losing my erection. If that's the case, take the expectation, the pressure off the part of sex that's causing you the anxiety. And it's about doing different types of touch between you, pleasure where you're taking your time, where you're allowing arousal to kind of take hold and desire to take hold and just focusing on being in the moment for that bit rather than kind of fast forwarding and getting set on the goal. Because when sex becomes goal-oriented, people often measure it in pass or fail. And with that pressure, that's what, that's what tends to create the anxiety. So that is the kind of basic side of what strategies don't help, but people often try because they think they'll help, which is like the kind of practice, the checking. And really, we want you to get back to noticing the sensations in your body. So really basic mindfulness exercises, running through the 5 senses, kind of focusing on sensation, like talking yourself through sensation, because you can't be fully present and in the moment and also noticing those things that are happening to you in that moment. But that is a practice I recommend people start by practicing in the shower because it's a multisensory experience. We want you to kind of build up the practice for outside of sex before you then try and take it into sex.

But how can you— you know, I think one of the things that we haven't necessarily touched on that I think would be good is, you know, a lot of this for men is extremely shame-inducing. And most of the men that I've worked with that are struggling with some type of challenge, anxiety, etc., there's always a pretty thick layer of shame surrounding the challenge or, you know, that it's happening or the impact that it's having. Maybe just give some direction and guidance for guys to like, how do they start to address the shame? What are some things that they can do to tackle that? Because that can be a really reinforcing part of the loop is that the shame takes place and it's like, oh, there's something wrong with me. And it's a direct connection for a lot of men to their manhood, their masculinity, how they perceive themselves to be potent or powerful or strong as a man. And that can, you know, bring with it a good amount of shame. So, what can men do to start to address that shame?

Yeah, I was going to ask you what are the most common things that you see men reporting around that particular type of shame. And I think you and I are very much of the same conclusion, that it's about the shame of not being masculine enough or good enough. Or— and again, it's, it's all rooted in this idea of performance, that masculinity and performance go hand in hand. And those myths I talked about earlier, often they might be, um, so the assumptions men should should always be up for sex, that they should always have an instant and 10 out of 10 rock hard erection, that they should last a certain period of time, that this erection should never fail. And when we think about them, they're, they're not realistic because no part of anyone's body works 100% the time, always, forever, without fault. Like, it just isn't realistic. But The shame particularly is shrouded in those messages of not doing what I should be doing as a man, or not kind of keeping up to that standard. It's also a really particular type of shame we see around male infertility. So, and they are linked because of that version of what, uh, like the kind of tick box of like, okay, a man should XYZ. And so it's also something about the admitting of the idea of failing or the kind of vulnerability of that that is considered the failing bit. And once you get into the messages underneath with people, they'll say, oh, well, that's— you know, and I say, okay, well, where did this come from? Or like, who taught you that? Who said? And often the answer is society, question mark. Like, these are the versions of men that we're we're shown are aspirational, that are— this is what makes a man. And actually, once you start unraveling that with people, they start to see more nuanced versions of that, or more kind of open versions of that, the more vulnerable versions of that. But it's, it's very potent, that, that messaging.

Yeah, I mean, I think there's also something in, in the male psyche that wants to move towards— like, I do think that potency and virility are— that there's a, there's a connection there, you know, and that being in the male experience in some ways is to try and understand and grapple with your own power, your own potency, whether that's physically, intellectually, psychologically. And so I do think that sex is that place where men maybe overemphasize the importance on I have to be potent and virile and dominant and, you know, and move into that space. But I do think that for a lot of guys, there's a— I don't know how to say this. It's like there's almost like an innate built-in desire to be potent in some way, shape, or form. And I think what I've seen for a lot of men is when they don't feel potent in other areas of their life, like they don't feel effective, they don't feel capable or competent, that will bleed into sex. And, because there is something within us and we could talk about, is it purely social? Is it biologic in nature? I think there's multiple contributing factors, but I do think that it's an inherent part of the male experience of trying to grapple with our own potency. And, when we don't feel potent in other parts of our life, I think that it does really pressurize sex to like, okay, now, this is the place where I have to be potent because I don't feel potent or capable or competent in these other areas. And, that can then be crippling because then it's really a lot of pressure there or the inverse, right? You feel potent in other parts of your life and then this is the one area that doesn't seem to work and you're not potent and effective. And so, I think that can be challenging for a lot of guys. I want to just maybe close off on the couple, the dynamic between— in the relationship, because you've talked a good amount about how emotional disconnection in the relationship is often sort of operating underneath the emotional disconnection, you know. And so I'm curious, this is something that a lot of men struggle with, like, how does a man start to recognize that maybe the issues or the challenges that are happening in the bedroom are more of maybe a relational, emotional problem outside of it?

Oh, it's a huge question. I mean, there's not really any kind of exact or clear indicators because obviously sex— sexual issues can sometimes present as relational issues and relational issues can sometimes present as sexual issues. But I think that ultimately, if you are not in a place where you feel really connected as partners, where most couples will go through a stage where they don't really like each other, it doesn't mean they don't love each other, but they're like, I don't really like you at the moment. Something's changed. We're kind of at each other's throats with young kids and we don't feel like ourselves. And we tend to not be drawn towards people when we don't have that sense of reciprocal liking, particularly if there's been trust um, a trust rupture in a relationship, we can struggle to feel close to someone, and it might feel quite— sex might feel quite exposing, it might feel like too much, or we are distracted by the idea of like focusing on the trust problem when it's happened. So those two things are really hard, particularly if the anxiety we're feeling around sex— and, you know, the two examples you just gave are so common in my practice I've got everything else in life sorted and this is the only thing I can't sort. Like, what— why is that? It makes it also become way more of a problem way quicker. And also that I'm struggling in myself, my self-confidence, my self-image, my, my kind of work life. I feel quite overlooked or quite unseen. And then I'm also struggling with that in sex because it's all coming to the surface when I am here and I feel like I need to be playing a role in sex, or, you know, again, back to this word performing, which is the word that we as clinicians don't use, but the word that we hear men using all the time. I'm struggling with that. So how am I going to have sex if I'm struggling with it in the rest of my life? And so I think when it comes to relationships and sex, the thing is we have to kind of try and uncover what's going on for us. You know, when do I feel close or confident or attracted to my partner? When do I feel attractive to my partner? And we have to try and uncover that. And often sex can mean different things to both partners in a relationship. So for one person, it's how I feel loved, valued, um, how I know that my partner desires me, that if we haven't had sex regularly, like, I feel really kind of, um, left behind, like I'm not a priority for my partner. And another partner might say Oh, like, you know, we have sex occasionally. It's something that, you know, we used to happen a lot, but now we have a lot of other things. I don't feel— I don't, like, need sex so regularly to know if I'm loved by my partner. You know, we sit and have dinner together every night, we talk all day, we have 3 kids and a dog together. Like, those are the things that, like, commitment looks like for me. It's quite hard to untangle, but often when we— that's why we need to understand why sex is not just sex. The meaning of sex and what it's playing. Now, that can pull strings and have ripple effects into all other parts of our relationships. And so sitting down sometimes with our partner saying, shall we have a difficult conversation, which is that this change, this has changed, what do you think is going on? Because this could be my take, but none of us are taught how to do that.

Yeah, and even just saying, something's changed, and I'm not sure what it is. Like, have you felt it? Have you noticed it? I think sometimes with couples, my wife's a marriage and family, she's an LMFT. And so, sometimes we'll work with couples together. And it's interesting because oftentimes couples will feel that something shifted, but they just won't even acknowledge it. And sometimes it's just being able to say, hey, something's changed. Have you noticed? I've noticed. Okay, you've noticed too. What is it? Like, what's going on? And then being able to come back— sometimes it's the coming back together just in the acknowledgement that something's changed, that then you can get on the same page as a team and discover what it is. So, well, listen, I really love your work. Thank you so much for joining me and the way that you lay things out. For guys that are wanting to go a little bit deeper in your work, where can they find you? We'll put the links for all that in the show notes.

Yeah, thank you so much for having me on. I love these conversations. I think they're super, super important. So my kind of practice is Kate Moyle, which is just my name, my website, and my book is called The Science of Sex. And it's almost a kind of sex coffee table book in a way. It's got full kind of illustrations, medical illustrations as well. And every page is a question and an answer about the most kind of asked questions about sex with that biopsychosocial approach we talked about earlier. And I also have a podcast which is called Sexual Wellness Sessions, where every episode is a deep dive into a particular topic of sex. So whether that be desire, infertility, erectile dysfunction, body image, we have one on masculinity. And so that's, that's, we're on our 6th series with with a whole host of amazing experts or people that have had lived experience. And I'm on Instagram @kate_moyalltherapy.

Beauty. Beauty. Well, thanks so much for joining me. For everybody that is tuned in and listening to this episode, if you enjoyed it, make sure you man it forward, share it with somebody that you think would get something from it, benefit from it, enjoy it, maybe to have a conversation. This might be one of those things where you and your significant other tune into the episode together or separately and then have a dialogue about it. And we'll have the links for Kate's work in the show notes. As always, thank you so much for joining. Connor Beaton signing off.