"Positive and satisfying relationships are essential for our well-being and can provide us with deep and profound human connections." -- sh
I work primarily with romantic relationships, which can sometimes get stuck, hit an obstacle, become overwhelmed with conflict and disagreement, or slowly grind to a confusing and monotonous halt.
There are many reasons for couples to come for therapy. Click on Relationship Therapy above for more information on my work with couples.
I also work with penis-related sexual concerns, anxieties, and dysfunctions. Penises are often rebellious and can refuse to follow the desires of their owners, which can have a significant impact on our own emotional well-being, our self-esteem, our sexual satisfaction, and ultimately our relationships. Click on Psychosexual Therapy above for more information on sexual dysfunctions.
There are a number of different conditions that we might refer to as sexual dysfunctions or disorders. Some are unique to males, some to females, and one or two that appear to have no bias whatsoever.
The male sexual dysfunctions are generally focused on erection reliability, the speed or latency of ejaculations, extremes of sexual desire, and sexual arousal.
The female sexual dysfunctions are generally focused on chronic genital or pelvic pain, extremes of sexual desire, orgasm ability, and sexual arousal.
"In psychosexual therapy I explore lifestyle factors, cognitive factors (keeping in mind that the most common distraction affecting penis function is performance anxiety), emotional factors (such as anxiety, depression, trauma, and loss), behavioral factors (such as pornography usage and masturbation style), socioenvironmental factors (family, culture, and religion), and relationship difficulties within 'the couple'." --sh
ED can be defined as "the persistent inability to attain and maintain an erection of sufficient rigidity to permit satisfactory sexual performance".
ED can be further cateogrised according to the duration of the condition, as: Lifelong (the issue has been present for the entire duration of the person's sexual life); or Acquired (the issue presented itself after a period of normal sexual function).
ED can also be categorised according to the situations in which it presents itself, as: Generalised (the issue is not limited to certain situations or partners; or Situational (the issue only presents with certain situations or partners).
ED is extremely common. Indeed, a UK based population study in 2013 suggested that 12.9% of men under 40 reported an issue with unreliable erections (compared with 18% in the US). Further studies found that the percentage increases with age, where it rises to 20-40% of men in their 60s, and 50-75% of men older than 70.
In the treatment of ED, it is important we consider an integrative approach where both the physical and psychological factors are understood, assessed, and form the agreed treatment plan. For this reason, I will always insist you discuss your condition with your GP so they can directly consider the physiological factors that can contribute to, and have been associated with, ED. Then you and I can work together on any psychological concerns that affect your sexual function.
If you want help with any issue related to your erections, please contact me.
WHAT IS ERECTILE DYSFUNCTION (ED)?
WHAT IS PREMATURE EJACULATION (PE)?
PE is as common amongst men as ED, and is sometimes associated with with ED. PE may also be referred to as Rapid Ejaculation and, despite attempts to relable the condition, the acronym RE hasn't really caught on, possibly due to a misunderstanding of the word 'rapid', as it suggests we are measuring the speed that semen leaves the penis. In fact RE and PE both refer to the latency time between penetration and ejaculation.
About one third of men who suffer from ED, also have an issue with PE. This can sometimes happen if erections are experienced as a rarity and one has the temptation to then rush sex whilst the erection lasts.
There is an important PE related acronym worth mentioning. IELT stands for intravaginal ejaculation latency time. This is a fancy phrase for measuring how long a penis can move back and forth inside the vagina before ejaculation occurs. This acronym is clearly problematic because not all penises go inside vaginas. From now on, we shall assume IELT stands for intraanything ejaculation latency time.
The word 'premature' when judging the IELT is subjective. If a man is distressed because he has an IELT of five minutes, he is unlikely to get help for PE, but perhaps might find sex coaching or psychoeducation helpful. Nonetheless, it helps if we have some criteria to determine PE, and most definitions include, 1) a short IELT of less than 90 seconds; 2) a percieved lack of competence, adequacy, or control about the IELT; and 3) an obvious distress related to the condition.
As with ED, PE can also be further categorised into subcategories. Lifelong PE means the issue has been present for the entire duration of the person's sexual life. Acquired PE means the issue presented itself after a period of normal sexual function.
PE can also be categorised according to the situations in which it presents itself, and so we will refer to the condition as being either Generalised, when the issue is not limited to certain situations or partners; or Situational when the condition only presents with certain situations or partners. There is also a further category called "anteportal ejaculation", which is reserved for ejaculation that occurs prior to penetration, and is considered to be the most severe form of PE.
The current clinical thinking around PE is that it is a psychological or learned condition in the majority of cases. One of several forms of anxiety tend to be the primary etiology, such as a fearful or phobic response, a conflict between contradictory urges, or a crippling performance anxiety where there is a preoccupation with failure and performance.
I also see men in my clinic who have a lack of sexual sensory awareness. These men have failed to learn and develop a sensory feedback loop around their sexual arousal. It is typical for these men to go from almost no arousal to ejaculation very quickly without any awareness of the arousal process that is taking place within their body. Therefore, sensory exercises and masturbation exercises, either alone or with one's partner, are frequently used to retrain the body in the treatment of PE.
If you have an issue with PE, I would love to help you. Please contact me.
"Anxiety is high on the list of sexual function saboteurs." --sh
WHAT TYPE OF SEXUAL ISSUES DO YOU TREAT?
WHAT IS DELAYED EJACULATION (DE)?
Delayed Ejaculation typically refers to men who struggle to ejaculate. We also use the IELT measurement (that we used for PE, in the section above) when discussing DE and typically we would expect to see an IELT of greater than30 minutes and accompanied by personal and/or relationship distress.
Although not as common as ED or PE, millions of men suffer from Delayed Ejaculation. It is usual for men with DE to have reliable and long-lasting erections and they can often ejaculate successfully via mastubation, and will often present for help with a complaint or concern about their relationship.
It is common for men to suffer this condition for some considerable time before seeking help. This is largely due to there being less of a stigma than is associated with ED or PE, plus it being generally less well-known as a condition or dysfunction, and also men tend to seek help once they wish to start a family and intravaginal ejaculation becomes necessary.
There has been a long-standing clinical opinion - albeit much less common now - that DE suggests an unconscious and unexpressed anger and hostility towards women; or that men who suffer from DE are unable to let go of control or receive pleasure. These concepts are still worthwhile exploring, especially when there are obvious relationship concerns around anger and resentment, and also when the couple wish to conceive.
Consistent with ED and PE, anxiety is also common within DE, and may include a fear of pregnancy, a fear of hurting one's partner, depression, a lack of confidence, religious anxiety, or poor body image or self-esteem.
It is also extremely common for men who were unable to develop sexually through self-exploration and masturbation - perhaps through a lack of teenage privacy, insufficient education, religious and cultural concerns surrounding sex and masturbation - to present in therapy with DE. For young men who were able to masturbate, some developed a style and technique of masturbation that is impossible to be duplicated by a partner. Then, when the time comes to penetrate their partner, the speed, pressure, position, or intense focus on a very specific genital area, that was required to complete masturbation, cannot be found within the partner.
Arousal plays an important role in ejaculation and some men have a disparity between the sexual fantasies they use for masturbation, and real life sex with their partner. In working with DE, it is vital that we explore historic and current masturbation techniques, habits, and fantasies.
Why do couples come for therapy?
To have a difficult conversation. Sometimes we need to talk to our partner about something that is incredibly difficult or sensitive and the safety and holding of the therapist can enable the conversation to take place - especially when conflict is likely.
Sexual dissatisfaction. Sex is often the number one topic that couples seek help with. It can be very tricky terrain to navigate alone, especially when needs aren't being met and dialogue is either painful or has broken down. Sometimes a couple may have a sexless relationship and one partner is unhappy; or there maybe a mismatch in sexual desire and therefore the sexual frequency or quality is causing conflict; or sex has become domestic and mundane and it needs a new passion or fire; or perhaps sex is difficult because of illness or a chronic medical condition; or perhaps a couple wish to experiment with other forms of sexual expression or open up their relationship and try ethical non-monogamy.
Infidelity. Sometimes couples have suffered a huge rupture in their relationship and they need help to either rebuild it, or to work out how to navigate an ending. Rebuilding a relationship after infidelity takes a lot of hard work, commitment, and courage from both people. Honest dialogue, introspection, and taking responsibility for the individual part we play in the relationship and ultimately in the rupture, is key to the work. Many couples - after working through the issues that led to the infidelity in the first place - have a much stronger and more intimate relationship than they did before.
Fighting. Sometimes couples are caught in a cycle of arguing and fighting and need help picking it apart to work out what's going on. Often there are dysfunctional methods of communication and we work on bringing both parties back into the adult position and have honest and open dialogue. Often there are wounds that need attending to or there is a long history of unmet needs and unspoken hurts.
Intimacy/Attachment mismatch. It is extremely common for a person to call me and complain that their partner is cold and cut-off emotionally and doesn't do intimacy, in-depth conversation, or affection. Often this is linked to one partner being anxious or preoccupied in their attachment style, whilst the other is avoidant or dismissive in theirs. This relationship trap means the anxious partner experiences the other as being distant and uncaring, whilst the avoidant partner experiences the other as being needy or clingy - and both are unhappy. This is deep and in-depth work but can literally be life-changing.
Significant life events like childbirth, infidelity, moving careers, etc. If we are not careful in how we manage stress, anxiety, fear, or loss, we can retreat into ourselves and lose each other. Being counselled through difficult life stages can be extremely helpful and rewarding.
Individual trauma. Most of us bring along some 'baggage' into a relationship and sometimes it's perfectly manageable or doesn't cause enough conflict for it to be an issue. Sometimes, however, we have individual unresolved trauma or loss that causes a significant disruption that needs attending to. Sometimes we can deal with the difficulty within the relationship and sometimes the partner may also need individual therapy.
In psychotherapy jargon speak, the concept we are often working on in relationship therapy is called differentiation. This is about how we define our sense of self in the relationship, how we reveal it, how we then create and manage our boundaries, as we also manage the anxiety that comes from the risk of increased intimacy or separation.
This requires that we look at ourselves in order to understand and communicate what we think, what we feel, and what we need or desire. The therapist is key here because this is about holding you steady (as you then learn to hold yourself steady) as you communicate your thoughts, feelings, and desires to your partner.
Ultimately this comes down to you learning to manage the anxiety that arises with the realisation that your partner is different to you and may well have different thoughts, feelings, and desires.
Both of you must...
...develop a solid sense of self that comes from your ability to tolerate internal conflict rather than arguing with your partner.
...learn to be mindful and to sit with your discomfort, observe it, and allow it to pass.
...remain grounded in how you respond to your partner, other people, and situations.
...learn to be calm, self-sooth, and to regulate your own emotions, rather than blaming others.
...learn to endure, even when it gets tough and you are frustrated, disappointed, and tired.
These are the qualities and skills that we aim to develop in relationship therapy.
How do we get the most from relationship therapy?
The goal of our work together is to develop your knowledge about yourself, your partner, and how the two of you interact or relate. Your job is to apply what you learn, begin to break your old habits and patterns, and start to develop better ones.
I will ask you what type of life you want to build together, what kind of partner you want to be, and then help you spot the blockages and blind-spots that stop you from acheiving those goals.
You will need time, and plenty of it. The hour we spend together in the session each week is not enough. You need time to play and hang out and plan and support each other and make mistakes and learn.
You need to tolerate emotional discomfort. This means listening, watching, learning, speaking honestly, and being curious about your partner, rather than attacking or withdrawing. There will be easy sessions and difficult sessions. There will be sessions where it feels hopeless and it feels like we are going backwards. Discomfort is part of the process and you will never explore the new map that the two of you are creating if you don't step into unchartered territory.
You need energy because this can be hard work. Learning to be more respectful, more generous, more forgiving, more appreciative, and more aware of your own internal mess, and then making the necessary adjustments, all take effort.
Discussing an argument or fight that has happened during the week is not a productive use of our time together, unless the purpose is to examine it and learn from it. A better use of our time is for both of you to reflect on the reasons you are in therapy, what you are doing to get through your next step of being the kind of partner you want to be to get to the kind of relationship you want to build. Then, which is a universal truth in all therapy, ask yourself the question, "What do I need to attend to in myself?"
Your attitude is absulutely key. Your focus needs to be on change in yourself, not change in your partner. What you need to change and how is one thing, the bigger question is why you don't do it. You can learn a lot about yourself by understanding what annoys you and how you handle it. The more you believe your partner should be different, the less you will look within yourself and the less you'll change the patterns between the two of you.
Communication is still, and always will be, paramount. Good communication is difficult. Good negotiation is even tougher. We must each speak from the heart about what really matters to us. We are individually responsible for how we express ourselves, no matter how other people treat us.
Points to remember...
...Communication is the number one problem in relationship therapy.
...we can sometimes choose the partner we need, but not the partner we necessarily want.
...if you don't know how you feel about the important areas of your relationship, it is like playing darts with a blindfold on. You are likely to miss the board a lot and, let's face it, it won't be long until someone gets a dart in the face.
...if you always want to feel emotionally safe in your relationship, it will come at a cost. The cost is you becoming lifeless and dull.
I hope some of this helps. Contact me if you need help with your relationship.
I am passionate about helping people stand up to their full height as a better and fuller version of themselves. Even if your difficulty is not related to anything sexual, I would still like to work with you. I have many areas of interest covering a variety of different subjects, topics, and concerns, so please contact me to discuss. If I don't feel I can help you I will gladly refer you on to a colleague or point you in the right direction.
Contact me if you...
Whatever you need help with, please contact me.
All psychotherapy sessions are for 60 minutes.
Individual psychotherapy: £70
Psychosexual therapy: £80
Relationship/couple therapy: £90
We will meet once a week for as long as you need.
Q1: What if my partner doesn't want to come for therapy. Can you help us with our relationship if only one of us engages?
A1: Usually, yes. Naturally, it would be ideal if both of you were able to attend, but I appreciate it's not always possible. The two people in a relationship are both responsible for the relationship they've created. You taking responsibility and dealing with your part of the relationship can have a dramatic impact on your partner and on the relationship. It also means you get to grow and develop and become a better version of yourself in the process. Your growth and development will not go unnoticed by your partner and who knows what affect it will have on them?
Q2: Why do you focus so much on penises? Don't you care about vulvas and vaginas?
A2: I care very much about vulva and vagina dysfunctions and I enjoy working in that field. However, there are not many male psychosexual therapists and many men who need this type of help, often find it easier with a male therapist.
Q3: How do I/we know if you can fix me/us?
A3: This is a great question. We often think like this, don't we, because our day-to-day experience is that we go to the doctor with a problem and he 'fixes' it. Actually, if we look closer, that's not quite true. Our broken leg doesn't get fixed by the doctors, nurses, radiographer, and orthopaedic plasting technician. The team all work together to provide the attention and create the necessary environment for your body to do the actual healing of the bone. They treat it, but you mend it. And you usually do all the mending in your own time, outside of the time you spent in the emergency department. Psychotherapy is similar. I may be seen as 'treating' your concern but actually in the time we have together I am providing the attention and creating the necessary environment for you to do the healing. The healing of your broken leg is dependant upon you resting it in the following months. If you walk on it every day, it's not going to mend well. In the same way, you need to attend to the work we do together in therapy. I will provide the space and the context and 'hold you' whilst you do your healing.
Q4: What if I don't know what my problem is called?
A4: That doesn't really matter. We like labels and an accurate diagnosis, don't we? Penis issues like Erectile Dysfunction, Premature Ejaculation, or Delayed Ejaculation; and indeed vulva and vagina issues like Vaginismus, Vulvodynia, and Dyspareunia, often have some overlap and they're not always as clearly defined as we'd like them to be. If I am in any doubt about your condition, I will send you to the appropriate doctor to get checked out anyway. If the doctor is of the opinion that the root of your condition is not physical, then I will use my working definitions of what Premature Ejaculation is, for example, even if it doesn't match perfectly with what the diagnostic manuals and guidelines suggest.
Q5: I/We need to see you urgently, do you have space?
A5: I generally have limited space but I will try and work with you and my schedule is often changing and evolving. Please contact me and I will do my very best. If I am unable to see you, I will gladly refer you to a colleague whom I trust.
Q6: I cannot commit to weekly therapy, can I see you on an ad-hoc basis when I need it?
A6: Unfortunately not. When I reserve a slot in my schedule, it's yours for the same time every week. Rhythm, consistency, and the depth of our relationship are important in psychotherapy, and I simply cannot build the type of relationship with you that is necessary for it to be therapeutic if I see you sporadically.
Q7: Is it true you have a thing about Rubik's cubes?
A7: Yeah, kind of. My personal best time is 22.24 seconds. The majority of my solves are under 30 seconds, which is slow by today's standards.
Q8: Do you show couples how to have sex?
A8: No, I don't do that. If you need guidance, perhaps a sex coach might be better for you?
Q9: Will you need to physically examine me?
A9: No, that is not necessary. Depending on your issue, it is likely that I might refer you to a doctor who can do the necessary checks.
Q10: What's the weirdest sexual thing, someone has ever told you?
A10: I rarely hear anything weird, actually. Or maybe nothing seems weird to me any longer. Or perhaps I just can't say. :)
Q11. Why do I sometimes feel aroused in my mind but my genitals don't appear to have got the memo?
A11. Males and females can experience what we refer to as Arousal Non-Concordance. This is when the genitals and the mind don't appear to be in agreement about arousal. The reverse can also happen when the genitals appear to be aroused, but the mind isn't.
Q12. Is it possible to have good sex in a long term relationship?
A12. Absolutely, and many people do. It takes energy, commitment, imagination, and creativity. Above all though, it takes a desire to want to nurture this aspect of your relationship. Esther Perel is superb on this topic and her wonderful book Mating in Captivity should be on every couple's bookshelf.
Q13. Are my sexual desires normal?
A13. I'm not too keen on words like 'normal'. You sexual desire may be common or uncommon - but either way, unless it's illegal, or unless it's causing you distress or concern, then try and embrace it. Please contact me though if it's something you want to discuss.
Q14. Is my penis too small?
Q15. Is my vulva normal?
A15. Vulvas come in a huge range of shapes, sizes, and fabulous colours, and they are all wonderful. Check out the amazing art project THE GREAT WALL OF VAGINA.
Q16. I have never had an orgasm. What's wrong?
A16. This is fairly common and we sometimes refer to the condition as anorgasmia. There is often a psychological reason for both men and women. Please contact me to discuss.
Q17. Is it possible for us to rebuild our relationship after an affair?
A17. Yes, it is very possible. However, it takes a desire for change, a willingness to look at why the rupture occured in the first place, and a commitment to do the hard work of forgiveness so that we can rebuild trust and then develop new foundations for the relationship. This is very much a process of building a new relationship, not necessarily restoring the old.
Q18. Can you change my sexuality or orientation?
A18. No, I cannot do that, and neither would I want to. If your sexuality, gender, or sexual orientation is a source of distress for you, then please contact me.
Q19. Can open relationships or ethically non-monogamous relationships work?
A19. Yes, they can. However, in my experience, their success rate is fairly small. Many couples experiment and find this lifestyle to be unsustainable or unsatisfactory in the long term. Many couples also find it fun and thrilling in the short-term and it may inject a new sense of life or vitality into the sexual relationship. My advice would be to discuss, discuss, and discuss. Then discuss it some more. Open and honest conversation about your fears, concerns, or anxieties, as well as establishing clear and firm boundaries is crucial.
Q20. Will you watch us have sex and then tell us what we're doing wrong?
A20. That's not necessary. I can get a full picture of your sex life through honest dialogue. Thanks for the offer though.
Q21. What do you think about kinks, fetishes, BDSM, and paraphilias? Do you work with them?
A21. It's a fascinating subject and I am open to the entire range of sexual experience. I may not have direct experience of your particular interest, but I have a good understanding of these subjects and the psychology that perhaps drives some of them. If you have an interest that is bothering you and causing you distress, please contact me. Be aware that there are some practices that are illegal, however, and I am obliged by a stric code of ethics, to act appropriately and professionally within the law.