When a man comes into counselling because something has changed sexually, he will often arrive with a very clear explanation of what he thinks the problem is: “I cannot get an erection,” “I finish too quickly,” “I have lost my sex drive,” “I do not want sex anymore,” “I want sex but my partner does not,” “Everything was fine and then suddenly it stopped working,” or “Sex has become a problem between us.” Sometimes he will say it almost apologetically, as though he has arrived at the therapist’s office to report a mechanical fault. Something is broken; something needs fixing. And because men are often taught to approach problems through action, this can make perfect sense to them. If the car is making a strange noise, you find the fault. If the computer stops working, you diagnose it. If something is wrong at work, you identify the problem and try to solve it. Sex can become another problem to solve.
The difficulty is that human sexuality does not always work like a machine. This is where the work of Flemons and Green becomes particularly interesting. Their approach to brief relational therapy challenges the idea that sexual difficulties can automatically be located inside one person. The sexual symptom may be happening in one person’s body, but the meaning of that symptom can be connected to the relationship between two people. This is a significant shift. The question changes from “What is wrong with him?” to “What is happening between them?” That distinction can completely change the therapeutic conversation. To help facilitate this shift, counsellors might use questions such as, “How have things between you and your partner changed since this began?”, “What is happening in your relationship when the problem shows up?”, or “How do each of you feel before, during, and after intimacy?” Other helpful prompts could include, “When did you last feel connected as a couple?” or “How do you each respond to the changes that have occurred?” By inviting exploration of the dynamic between partners, these questions move the conversation beyond individual symptoms and into the realm of relational understanding.
For many men, sexual difficulties are experienced as a threat to identity rather than simply a physical inconvenience. A man may not think, “I am experiencing erectile difficulties.” He may think: “I am failing,” “I am not attractive anymore,” “My partner will leave me,” “There must be something wrong with me,” “I am not a proper man,” or “I should be able to do this.” That last statement is particularly important, there is an enormous amount contained within those six words. Men are often taught, directly and indirectly, that sexual competence is part of masculinity. Being sexually confident, desirable, capable and able to perform can become tied to a man’s sense of himself.
Consequently, when something changes sexually, the psychological impact can be much greater than the physical symptom itself. An erection becomes a test, sex becomes an examination, and the bedroom becomes a place where the man is being assessed. And once sex becomes an examination, anxiety can enter the room very quickly. He is no longer simply experiencing intimacy; he is monitoring himself: Am I hard enough? Will I stay hard? Is she enjoying this? Am I taking too long? Am I going to finish too quickly? What is she thinking? Does she still find me attractive? What if it happens again? And there is the paradox: the more he tries to control his sexual response, the more difficult it can become to remain psychologically present. He is having sex while simultaneously watching himself have sex.
This is one of the problems with treating male sexual difficulties purely as performance problems. The man becomes increasingly focused on producing the correct physical response, but sexual intimacy requires a certain degree of surrender. You cannot completely monitor yourself and completely relax at the same time, nor can you be both the performer and the audience indefinitely. This creates what I would describe as the performance trap. A man experiences difficulty once, and he becomes worried that it will happen again. The next sexual encounter therefore carries more pressure. He monitors himself, the pressure increases, his anxiety increases, his body responds to that anxiety, and the difficulty happens again.
Now the original problem has become evidence that the fear was correct. The man thinks, “There we go. It is happening again,” and the cycle becomes stronger. Eventually he may start avoiding sex altogether, and his partner may interpret the avoidance as rejection. She may think he is no longer attracted to her, and she may become frustrated or insecure. He notices her frustration, his anxiety increases, he feels even more pressure, and now there are two people reacting to a problem that neither of them fully understands. This is where the relational perspective becomes so important: the problem is no longer simply erectile functioning, as there is now a pattern between two people.
This is one of the most useful questions a counsellor can ask: what is happening between these two people when sex stops working? Perhaps there has been resentment building outside the bedroom, the couple have stopped talking, one partner feels emotionally neglected, the man feels constantly criticised, she feels rejected, he feels controlled, or they have unresolved arguments that never actually get resolved. Perhaps there has been a betrayal, they have become more like housemates than lovers, they are exhausted from work and parenting, one person wants more intimacy while the other feels overwhelmed by the expectation, or neither person feels emotionally safe enough to be vulnerable. The sexual symptom can therefore become the visible part of a much larger relational system.
When a man or a couple presents with sexual difficulties, it is vital for a counsellor to assess where the main factors may be coming from. This involves a careful and holistic assessment process. The counsellor will typically begin by gathering a detailed sexual, medical, and relationship history. Questions may cover the onset, duration, and course of the problem, any relevant physical health issues, medications, or lifestyle changes, as well as psychological factors such as stress, mood, or recent significant life events. To help determine if a problem might have a primary medical basis, the counsellor might ask about other physical symptoms, chronic conditions, surgeries, or the effects of ageing. Screening for depression, anxiety, and other mental health issues that can affect sexual functioning is also standard. Exploring the relationship context is equally important: Has there been a recent conflict or life transition? Has emotional closeness changed? Are there patterns of communication or intimacy that have shifted? If medical factors are suspected, the counsellor should refer to a general practitioner or specialist for further evaluation, while still inviting exploration of relational and psychological dynamics.
This does not mean that every sexual difficulty is caused by relationship problems; it is important not to oversimplify this. Medical conditions, medication, hormonal changes, ageing, stress, depression, anxiety and other factors can all influence sexual functioning, and a good counsellor should not assume that every sexual problem is psychological or relational. But neither should we assume that the body tells us everything we need to know. Sometimes the body is giving us one part of the story, and the relationship is giving us another.
There is another reason this approach can be particularly important for men. Many men have never been given a particularly sophisticated emotional vocabulary. They can tell you that they are angry, stressed, or tired, but ask them what they feel underneath the anger and suddenly the conversation becomes much harder: “I do not know,” “I am just frustrated,” “I am fine,” or “It is what it is.” Sometimes a man has spent so many years converting vulnerable emotions into more socially acceptable masculine emotions that he genuinely struggles to recognise what is happening inside him. Fear becomes anger, sadness becomes withdrawal, shame becomes defensiveness, loneliness becomes irritability, rejection becomes resentment, and vulnerability becomes silence. And sexual difficulty can become the place where all of this eventually shows up.
Because emotional vocabulary is so often limited, it can be useful for counsellors to introduce simple interventions to help men expand their emotional awareness. For example, some counsellors use an ‘emotion wheel’ or a list of feeling words to help clients pinpoint subtler emotions beyond the basics of anger and stress. A straightforward exercise is to check in daily and ask, “What am I feeling right now? What might be beneath that feeling?” Journaling can also help, even if just a sentence or two at the end of each day naming emotions experienced in different situations. Another approach is to invite men to identify sensations in their body and then connect those sensations to possible underlying feelings. In session, a counsellor might pause and gently ask, “If you had to guess at the emotion beneath that frustration, what might it be?” Over time, these simple practices can begin to stretch a man’s emotional vocabulary and create more space for emotional connection.
A man might not be able to say, “I am terrified that my partner does not desire me anymore,” but his body may communicate the pressure he is experiencing. He might not be able to say, “I feel emotionally rejected in this relationship,” but he may stop initiating sex. He might not be able to say, “I feel criticised every time I get something wrong,” but he may become increasingly anxious about sexual performance. He might not be able to say, “I do not feel emotionally safe with you anymore,” but intimacy may gradually disappear. This does not mean the body is consciously making a statement; it means that psychological and relational experiences are not separate from the body.
For some couples, sex slowly stops being a place of connection and becomes a place where the relationship’s unresolved problems are concentrated. One person initiates while the other withdraws; the initiator feels rejected, and the person withdrawing feels pressured. The pressure increases, the withdrawal increases, and eventually both people are protecting themselves. He might stop initiating because rejection has become too painful, and she might stop initiating because she interprets his lack of response as evidence that he no longer wants her. Neither person necessarily knows what the other is actually experiencing; they are responding to their interpretation of the other person’s behaviour. This is how relational cycles develop. And once a couple is caught inside the cycle, it can become very easy to blame the person who displays the most obvious symptom. The man cannot maintain an erection; therefore, he has the problem. But what if the erection is only the most visible part of what is happening? What if the real problem is that the couple no longer feels emotionally connected? What if sex has become associated with pressure? What if both people are frightened of rejection? What if there is unresolved resentment? What if neither person knows how to talk about what they actually need? These questions do not excuse anyone’s behaviour; they simply widen the lens.
Another useful idea within a relational understanding of sexual difficulties is that the symptom may sometimes serve a protective function. Imagine a man who has become terrified of sexual failure. If he initiates sex, he risks being rejected; if he becomes aroused, he risks losing the erection; if he loses the erection, he experiences shame; and if he experiences shame, he feels inadequate. So eventually he stops initiating. On the surface, this looks like low desire, but perhaps he still desires his partner and has simply learned that avoiding sex feels safer than experiencing another humiliating sexual encounter. The avoidance has become protective. The same can happen with performance anxiety. A man who is terrified of failing may unconsciously become so focused on preventing failure that he can no longer relax enough to experience intimacy. The symptom is therefore not necessarily the enemy; it may be the body’s response to a situation that has become emotionally threatening.
It can be helpful for counsellors to gently reframe the symptom in language that is compassionate and non-pathologising. For example, instead of saying, “You are avoiding sex,” a counsellor might offer, “It sounds like your body is trying to protect you from painful feelings or experiences.” Rather than, “You are struggling to perform,” a reframe might be, “It seems your body is responding to a sense of pressure or fear, and is signalling that something feels too overwhelming right now.” Another way to reframe could be, “It makes sense that part of you would want to withdraw from intimacy if being close has started to feel risky or unsafe.” By using language like, “Your response is an attempt to look after yourself,” or “This symptom is not a failure, but a sign that something in your emotional world needs attention,” counsellors can help men view their experiences with greater understanding and self-compassion.
This is why simply telling a man to relax can be so unhelpful. If he could simply relax, he probably would. The question is not, “Why cannot he just relax?” The better question is: “What has made sex feel like something he has to survive rather than something he can enjoy?”
Sexual difficulties can be extraordinarily shame producing for men. There are things men will discuss in therapy quite openly that become almost impossible to talk about when they involve sex. A man may be able to tell you about losing his job, his divorce, his father, or his anger. But when you ask him about what happens sexually with his partner, he suddenly looks at the floor. His voice changes, he becomes embarrassed, he minimises, he jokes, and he changes the subject. This is where humour can sometimes become important—not because the therapist should make light of the problem, but because men often use humour to create enough psychological distance to discuss things that feel deeply exposing. A good therapeutic relationship can gradually create a space where the man does not have to perform. That is important, because he has probably spent enough time performing already.
Perhaps the biggest shift for men is moving from the question of performance to the question of intimacy. Performance asks, “Did I do it right?”, whereas intimacy asks, “Were we connected?” Performance asks, “Did my body work?”, whereas intimacy asks, “Did I feel safe enough to be present?” Performance asks, “Did I satisfy my partner?”, whereas intimacy asks, “Could we communicate what we wanted and needed?” Performance asks, “Was I good enough?”, whereas intimacy asks, “Could we be ourselves with each other?” That is a very different way of thinking about sex. It takes sex out of the narrow framework of achievement and puts it back into the wider context of relationship.
This is where the relational approach connects with a much broader issue in men’s counselling. Many men have been taught to solve problems. They are rewarded for being competent, they are expected to provide answers, and they are often uncomfortable sitting with uncertainty. So when something goes wrong sexually, they want a solution: Tell me what is wrong, tell me what exercise I need to do, tell me what technique will fix it, tell me what I need to change. There is nothing wrong with wanting practical help, but sometimes the desire for a quick solution becomes another form of avoidance, because fixing the sexual symptom may be easier than asking what the symptom has revealed: Do I feel wanted? Do I feel respected? Do I feel emotionally safe? Do I trust my partner? Do I feel resentment? Do I feel pressured? Do I feel connected? Do I actually want this relationship? Have we stopped being intimate emotionally long before we stopped being intimate physically? These are much harder questions, and they require a different kind of courage.
This is where counselling can become particularly valuable. The counsellor is not there to judge sexual performance, to decide who is right, or to turn the man into a better sexual performer. The work is often about creating enough psychological safety for the man to understand what is happening to him. A typical session might begin by inviting the man to share his perspective on the problem and how it has been affecting his life and relationship. The counsellor may then gently gather information about the history of the sexual difficulty, the onset, and any relevant life or relationship changes. Attention is given to the relational context: How do both partners perceive the issue? What patterns exist in their communication before, during, and after intimacy? There is space to discuss expectations around masculinity, previous personal or cultural experiences, and feelings such as shame, fear, or inadequacy. During the session, the counsellor may blend this exploration with psychoeducation—for example, by normalizing the prevalence of sexual difficulties or by explaining the effects of anxiety and stress on sexual functioning. This balance between history-taking, relational exploration, and educational support helps build understanding and reduce shame. Sometimes the most important sentence a man can hear is: “You are not broken.” That does not mean the problem is imaginary; it means that a sexual difficulty does not automatically tell us something about his worth as a man. A penis is not a measure of masculinity, an erection is not a measure of love, sexual frequency is not a measure of relationship quality, and sexual performance is not a measure of human value. These distinctions can be enormously important.
One of the most powerful ideas in relational therapy is moving away from finding the culprit. Instead of asking, “Whose fault is this?”, we ask, “What pattern have we become caught in?” That does not remove personal responsibility; it simply recognises that relationships are systems. One person’s behaviour affects the other, and the other’s response then affects the first person, so the cycle develops. Pressure creates withdrawal, withdrawal creates rejection, rejection creates more pressure, and more pressure creates more withdrawal, until eventually both people believe that the other person is the problem. Therapy can interrupt that cycle—not by pretending everything is equal or excusing harmful behaviour, but by making the pattern visible. Once people can see the pattern, they have something they can work with.
This is ultimately what makes Flemons and Green’s approach so useful when thinking about men and sexual difficulties. Sex is not simply something the body does; it takes place within a relationship, within a history, within a culture and within a particular emotional context. For men especially, sex can become one of the few areas where questions about masculinity, worth, desirability, rejection and vulnerability all collide. That is why a sexual problem can feel so much bigger than the sexual problem itself. A man may believe he has come to counselling because he cannot maintain an erection, but underneath that sentence might be: “I am frightened my partner does not want me,” “I am terrified of failing,” “I do not feel close to her anymore,” “I am carrying resentment that I do not know how to express,” “I have spent my whole life believing that my value comes from being capable,” or even “I have no idea how to be vulnerable without feeling weak.” Those are not simply sexual questions; they are questions about identity, attachment, masculinity, intimacy and belonging. And perhaps that is the most important thing for men to understand: your sexual difficulty does not necessarily mean that your body has failed you. Sometimes it is an invitation to become curious about what is happening in your emotional and relational life. The goal is not simply to get the erection back, increase desire or last longer. Those things may matter, and medical or specialist sexual health support may sometimes be appropriate. But counselling can ask a deeper question: What kind of relationship are you having with yourself and with the person you are trying to be intimate with? Because when sex becomes less about proving yourself and more about being present with another human being, something can begin to change. The bedroom no longer has to be an examination room; it can become a place where two people are allowed to be uncertain, vulnerable, imperfect and honest. And for many men, that may be the first time they have ever been given permission to stop performing and simply be there.