Men want to fix their sexual difficulties by themselves – of course they do. But does this add even more stress and expectation?
I sat down with psychosexual and relationships therapist Carol Graham to discuss performance anxiety, PE, ED and more.
Drawing on her extensive experience working with couples, Carol explains the assumptions and expectations that can be devastating for men in the bedroom.
Jason: I’m here with Carol Graham, and you are a psychosexual and relationships therapist?
Carol: That’s right!
Jason: One thing I often hear about is struggles with anticipation before sex. So leading up to sex, whether it’s just before or hours before, if there’s a prospect of sex coming up later that day. Yes we want some excitement and some anticipation and a build up of sexual tension. That’s all good, isn’t it?
Carol: Yeah!
Jason: That’s all part of the experience. But guys often say that they feel a mix of feelings coming up to sex. So excitement, looking forward, anticipation but combined with worries and performance anxiety. Is this something that crops up regularly in the work that you do?
Carol: Yes a lot. I work with people who visit me with issues. They’ve got problems, worries around sex. Sex isn’t working for them properly. I don’t often hear people saying they’re positive, excited. The anticipatory anxiety is normally quite negative. And it just spoils the whole process for them, to the point where quite often people are avoiding sex and hoping it’s not going to happen.
But yes certainly, performance anxiety. Are they going to be able to get an erection? Are they going to be able to maintain the erection? Are they going to be able to last long enough? Are they going to be able to please their partner? Lots of different things.
What happens is that person gets very much in their head and they’re spectatoring. And once they’re in their head, they’re out of their body. They’re not noticing the the pleasurable sensations. They’re just worrying. The nervous systems is fired up then, for flight or fight.
Jason: So any any work that’s done prior to sex, about getting in the mood, quite quickly goes AWOL. So this is where guys might find their erection fails or they’re just so anxious that they come too soon. That’s a big part of the work, kind of getting a balance. Because I often hear guys say on one end of the spectrum, “I don’t feel anxious – I’m excited. I feel positive but I’m over-excited. I’ve built this up in my mind and probably put myself under a bit too much pressure.”
Or the opposite, or somewhere along that spectrum, is more like “I’m full of dread actually. Yet I want to have sex“.
Carol: They’re the clients I get. More like that, definitely.
Jason: So I suppose in terms of finding that balance, we talk about things like having a bit of a routine, a ritual before sex to calm oneself down. Maybe with a bit of breathing. But not making it too much of a ritual, otherwise it adds to the expectation.
Carol: I’ve worked with somebody recently who almost fixated on breathing and relaxing. To the point where that put them very much in their head. And they got anxious about “am I breathing right, am I relaxing enough?“. You know, it’s very difficult. Because that’s a big thing.
Jason: I agree. A lot of the self-help advice for men, and some of the things that I talk about with guys, is breathing. Engaging the parasympathetic nervous system, breathing, relaxing the lower body. But that’s a lot to do in the moment.
Carol: Yes and get all geared up and practice it. It just adds to the expectation. I mean, obviously in an ideal world with sex, it’s all about pleasure. You want to just let yourself go, give yourself over, lose yourself in the moment. And that’s impossible when you’re thinking of everything that you need to be and everything you need to do. All the things I need to get right at the same time.
Jason: Yes the other bit of common wisdom amongst men, and I think there’s something to be said for it, is if you’re on the over-excited end of the spectrum, get yourself off before sex. Get the timing right.
Carol: Yeah not immediately before!
Jason: But if you can get the timing right, a few hours to reset the clock a little. To relieve some of that tension…
Carol: Okay if that’s going to help the guys sort of relax and think, “well okay, I’ve done that so there’s less chance now“. But because a lot of it is anxiety, it’s worry. So if anything that can alleviate the worry, that’s good.
It’s important to ascertain: is it premature ejaculation? I’ve worked with somebody recently who thought that you have to last, you know, an hour or whatever. Because their education came from porn, and in the porn industry it’s depicted that somebody can go on and on and on. And actually, that’s not the case. They’re editing the film.
Who is it premature for? Who is it too early for? Is it for the guy or is it for their partner? Quite often I think it’s important to really unpick, you know, how long is it and how long do you think it should last? How long would you like to last?
You know I work with a lot of couples, and a lot of women who say “it actually isn’t a problem for me, the length of time my partner lasts…“. It just isn’t.
Jason: And guys find that difficult to believe.
Carol: Yeah difficult to understand because that’s not the narrative. They’re following a cultural script. There’s this idea that, you know, there’s some foreplay, there’s some kissing and cuddling, but the actual main event is the intercourse. And it’s the the most important part and you have to stay hard and you have to last a long time. And actually, I find with couples I work with, the communication isn’t there. It’s just a best guess.
Jason: Yes when you don’t know what your partner wants, so it’s a mutual mind-read. There’s also an idea for a lot of of couples that he is responsible for his partner’s orgasm. He’s responsible for his partner’s pleasure.
Carol: I say all day long: communication is where it all goes wrong. It’s just a lack of knowing what the other one wants and needs. I think guys can sometimes have a bit of a raw deal because they think it’s all on them to perform. It’s all on them to make it right. It’s not!
Jason: When guys have – or think they have – identified a problem. A guy thinks “okay, maybe I’ve always come a bit too soon. It is a thing“. And his partner has said “look you need to work on this“. So when a guy identifies a problem, he’s a problem-solver. We fix things, so we’ll go off and we’ll research and we’ll get all informed and we’ll learn about the breathing techniques and relaxation and the things that we talked about. But there is the relationship, isn’t there?
Carol: So only half of the jigsaw. I find that the majority of the work I do ends up being with the couple. Because an individual can come and see me and say “I’ve got this issue” and it doesn’t matter how much we unpick it, what part does the other person play in this? How are they responding to this issue? Is their response or how they’ve reacted in the past maintaining the issue?
And you know, I truly believe that if one person in a couple has an issue with sex, it’s the problem of the relationship and not that one person. It takes two and actually understanding how they both feel and think about it, and what they’re both doing towards either maintaining the problem or fixing it, it’s important to know.
Jason: Guys can exaggerate the problem yes, and take it too much upon themselves. And from what you see, the guy’s partner sometimes can sort of say “well I’m sorry mate, but you’re the one with the problem.”
Carol: Exactly, and then he’s under even more pressure because he feels like “yeah I’ve got the problem, must sort it out…“. So many times, people come to see me and I say “we need to get your partner here.” “oh yeah but it’s my problem and well, they won’t come…“. Because they’ve just sent him here to sort it out.
It nearly always is a relationship problem. The dynamic of the couple, how they work together or don’t work together. And it’s not just about the sex either. It’s how they are the rest of the time. If there is a dominant partner? Is there an expectation that can’t be met at the standards? Just in general life, in every other area of their relationship? Which makes sex an even scarier thing, possibly. If there are factors in the relationship, outside the bedroom.
Jason: Yes, it’s a very big ask for us to do all the things we’ve worked on, and come together in the bedroom. For a guy who feels that he has a problem but he’d also like to get his partner more on board, and maybe that couple isn’t used to discussing these things. How do you advise people to actually make some some small steps?
Carol: Yeah it is tricky. Because if a couple don’t tend to talk about sex or don’t talk about their issues, or if they do it always turns into World War Three, it is tricky. I would advocate getting some therapy. Being able to talk in a safe space that’s facilitated if you know it’s an issue. I think just to be able to say “look I’m really struggling with this thing and I’d like us to be able to talk about it… and I think it’s important that we work on this together“. And you know , download an online course or go get a book from the library or go and see somebody that can help.
Vulnerability is great for human connection. And to be able to say “look I need I need your help with this” or “you know, can we sort this out together?”.
Jason: I agree. Do you think that if a guy finds himself in that situation, if part of the problem is the relationship, whether the dynamic or the expectations or the communication, if there’s some factor in the relationship that’s contributing to the problem… if he comes up against a brick wall and all he gets is “no sorry you haven’t sorted this out yet“… he can only do so much?
Carol: I know, I know, and you’ve got to wonder about the the health of the relationship. And the chance of it surviving because he’s never going to overcome that by himself. I think for all partners out there, if you’re with someone who has a sexual issue, it’s your issue too. It really is, and it’s for you both to sort out. With kindness.
Jason: I also speak with guys who are currently single, between relationships. And, based on their previous experiences, they’ve identified that they they want to work on their skills a little bit. So okay they’ve got the opportunity to become informed and to practise things. Relaxation and all these things.
When you meet a new partner and you’re first starting to get sexual, you don’t lay out all your previous sexual history and problems? “Oh by the way, I struggle with premature ejaculation“… or do you?
Carol: I personally advocate to always communicate. And you know, it depends on the partner. If we’re talking about the partner being a woman then, I’m generalizing here, but women generally seek emotional intimacy. They like the whole communication thing. Being able to say “I’ve had some issues in the past” or whatever.
I think so many people get really hung up on, as I say, penis and vagina sex being the main event. It’s not for women. That’s the script. So everything that comes before is more important. So I think just spending some time getting to know each other. Intimacy, foreplay. There’s a whole lot of pleasure to be had, so you get to know each other a bit better. To the point where you can sit and have that conversation maybe, and say “yeah I’ve had some issues in the past I need to try and work through“.
Jason: I know we’re generalising here, but in that scenario she may well hear that as a compliment. Because that shows he’s invested and he’s thinking ahead…
Carol: Absolutely yes – it just shows emotional maturity, all day long. That’s going to be attractive, I think. There’s a top tip from a woman’s point of view.
Jason: Yeah that’s a really valuable insight. I don’t think we can do enough to try and counter those messages that guys pick up from porn and culture. Whether it’s in a relationship or whether it’s casual, guys assume that they have to be the power behind the sex. They deliver, they lead it, and if they don’t… if anything doesn’t go to plan, they’ve failed. And it’s devastating.
Something that often crops up regularly is erection problems. So it might be ED or just sort of unreliable erections, lack of confidence in that department.
Carol: Yes I mean obviously, with aging and as men get older, they find that erections aren’t as prominent. They’re not there all the time, maybe like when they were younger. And different health issues as you age can impact erections as well.
But actually, a lot of young people I’m seeing are coming into the therapy room with these worries. Years ago, it tended to be more middle-aged sort of people, in their 40s or 50s or 60s. But there’s more and more younger people coming in particularly with erection issues. Plus performance anxiety for women, including vaginismus and sexual pain disorders.
And I don’t think it’s any coincidence that these are the youngsters that have been brought up in the digital age. They’ve had porn as their sex education, which just isn’t realistic. They see, you know, this sort of well-endowed guy and the perfect girl. And they’re having amazing, earth-shattering orgasms from the minute penetration starts and actually it continues for a long time and and they can last forever.
And young people feel that “I’ve got to look like is and be like this“. And hence the performance anxiety in young people, which obviously is going to affect erections. Because as we’ve said earlier, the spectatoring and getting in your head worrying.
Any sort of stress, that sort of fear cuts off arousal. Guys come to me and they’ll say “I can’t get an erection” or “I get one and then I lose it“. But you speak to them about their masturbation habits there’s no problem with erections at all. So it’s not biological, it’s not organic, it’s not a physical problem. It’s all going on up here. There’s a lot of pressure and I’m not anti-porn at all, but porn is for stimulation, for titillation and fantasy. It’s just not real.
And I think unfortunately, it’s the cause of a lot of sexual dysfunction in young people. I’m seeing more and more of it.
Jason: I agree and I’m hearing from younger guys who are using Viagra. But it’s not because they have erectile dysfunctions, it’s for confidence.
Carol: Yes, if people are going to see their GP because they’ve got performance anxiety, quite often GPs will prescribe Viagra. There’s more of that being prescribed for confidence than erectile dysfunction.
Jason: Really?
Carol: Yes and it’s ideal because at least it takes away that worry.
Jason: So Viagra is useful here, as long as you don’t become reliant on that.
Carol: People think “I don’t want to start taking Viagra because I don’t want to be relying on it” but I think once you’ve got your confidence and you’re more regularly having satisfying sex, you get out of the habit of that worry. The ruminating that you’ve been doing is gone. I think if you get out of the habit of stressing and you get used to relaxing, Viagra isn’t really needed then as a support.
Jason: That’s interesting. The other thing I often hear from all age ranges, not just older guys, is erection difficulties and premature, early ejaculation coming along together. Which feels like a double whammy of difficulty.
Carol: Yes. Again with performance anxiety, with spectatoring, if you’re worrying you’re going to come too soon because you’re in your head… because you’re worrying, because you’re anxious, because you’re fearful, you lose the erection. So it’s a vicious cycle.
And then when you have an erection, you’ve lost your confidence that it’s going to last. So maybe you you move in a way to make the most of that erection while you’ve got it. So you go overboard and you get too stimulated and you come too soon.
This is a complaint I often hear from women. Because he’s anxious, thinking “oh great I’ve got an erection“. So they immediately start penetration but there’s not enough foreplay. There’s not enough intimacy, there’s not enough emotional connection happening first. So yes, they’ve managed to have sex whilst he’s got his erection. But it hasn’t actually been good. And actually, the partner may have preferred just to have a a lot longer foreplay.
Only something like 20% of women have an orgasm with just penetration alone. So there isn’t enough foreplay, there isn’t enough stimulation. And he’s sort of thought “great I’ve got erection, let’s get on with it“. He may be having good sex but it’s highly unlikely that she is.
Jason: And if he’s been in that mode of “quick before it melts, let’s do this” more often than not…
Carol: Yes again, that’s the overriding messaging. It’s back to this cultural script that the main event is penis and vagina sex. You know, there’s so much more.
Jason: Another thing that’s quite interesting… the TikTok sex trend 4-minute foreplay. Before rushing to intercourse and going straight for each other’s most obvious erogenous zones, set a timer on your phone and do four minutes of foreplay that feels right and is consensual.
Now the fact that this is a out-there, crazy, viral sex tip in this day and age – that four minutes of foreplay is a good thing to do – what does that tell us?
Carol: I mean, if they’re saying that some kissing and cuddling and caressing or whatever, four minutes of that before anything sexual, yeah that might be good! But it’s not much, is it? If we’re talking about foreplay as in manual stimulation, oral stimulation of the genitals, four minutes isn’t enough. It might be for him it won’t be for her.
It takes a lot longer for the the clitoris to be fully aroused and ready, and for a woman’s body to be prepared for penetration. If that’s where it’s going. I mean, there may be some people out there that would just be glad of four minutes.
Jason: In that respect, it’s good advice and I’m assuming any message from TikTok that advocates foreplay is positive.
But it struck me that maybe in your typical porn clip, that might be ten minutes long, there’ll be maybe some foreplay. But it’ll be her going down on him for a minute or two. Probably not for four minutes. And that will be the extent of it. So I guess four minutes foreplay that’s with more variety is progress…
Carol: Yes. I think if there’s currently no foreplay at all, then four minutes is better than nothing. It’s one of the questions I do ask people: are you satisfied with how long you spend kissing, caressing, touching before penetration happens? And more often than not, the answer is no. It’d be good if there was more.
It’s amazing how few couples, especially those in a long-term, committed relationship, don’t actually have a good old snog anymore. They just have this routine of a a bit of a touch and a bit of a feel and then straight on with sex. And then they’re in my room, wondering why orgasms aren’t happening or there’s pain or things aren’t feeling as good as they used to.
Jason: That’s very insightful. Also, when a guy is struggling with premature ejaculation, foreplay is a very positive thing to do. Because it lets him acclimatise, to relax into it. But foreplay, any kind of foreplay that involves his penis, tends to go out the window. Because partners get their hands pushed away, “oh no no, not too soon“. And after that happens a couple of times, the partner will stop offering.
Carol: Yes rejection is like that. And the couple are missing an opportunity to gently stimulate and build up to it. It’s interesting, isn’t it? I think with foreplay, if a guy is concentrating on his partner’s pleasure, if the guy is giving his partner manual stimulation or whatever, quite often he will lose his erection at that point. Because he’s concentrating on something else.
So erections wax and wane, and there’s this immediate “oh my god, I’ve lost my erection“. Actually it’s just gone to sleep for a minute, it’ll come back. It will wax and wane, and it will come and go. But then as soon as it goes a bit soft, we go up in the head and anxiety, fear spirals out of control.
And of course, quite often women sort of say “oh, when he loses his erection I feel like he doesn’t fancy me“. I say to couples “so you’re fooling around, you’re having a nice time, you’re giving each other oral sex or whatever. So even if you come soon, you then concentrate on your partner’s pleasure and then they have an orgasm and then maybe you go again in half an hour“. But there’s so much pressure on. It’s got to be this, then this, then this. So change it up, do it differently.
So much of this comes back to addressing the script again. Those really unhelpful expectations. Quite often, you believe it’s the expectation of your partner but you don’t know if you’ve not talked about it.
Jason: In the advice that I give to guys, a lot of it is: you can do a lot with yourself here. You can relax, and get your head game sorted out. You can learn these useful techniques and I think they’re all valid. But I’m always conscious I’m leading guys up the garden path if I neglect the communication, the relationship. Not buying into the script, and I think that’s the therapeutic work.
Carol: Yes. I can’t imagine, it must be very difficult for you working with just the guys. I have the the option of saying “right, bring your partner in… let’s get this sorted“. It’s very hard to just work with one person. I struggle with that because you don’t know whether every bit of good you’re doing with that person, every therapeutic intervention, can be just undone the minute they get home if they’re not getting the the support.
And even if they are, even if their partner’s sort of saying “well that’s good, let’s try it out” or whatever… if there’s a a power imbalance in that relationship, if there is some sort of control dynamic going on, that guy already feels less than in the relationship. Sometimes it sort of feels like you’re setting somebody up to fail, doesn’t it? Because you’re still giving them all this good stuff to do which is really useful, but can easily be undone.
Jason: He’ll often feel “if I can just last a bit longer in bed, all the other problems will fall away. I’m going to fix this relationship with my penis“.
Carol: I’ve worked with many couples where she’ll burst into tears if he comes too soon. Especially couples maybe trying for a baby or something like that. And so the response is “oh my god, she’s having a terrible time because of me“. So I really can’t advocate enough: communication.
Talk about it, be vulnerable. Say “look, I want to be able to sort this out but I can’t do it by myself. It needs to be two of us and we need to work this through.” And it’s really, really difficult when you’re just working with one half of the relationship. Always remember that any issue, any sexual issue anybody has is a problem of the relationship. It’s up to both of those people in the relationship to sort it out.
Jason: And that mind reading and interpretation, trying to second guess what a partner wants. Sometimes couples have been together for decades and that’s still going on.
Carol: Oh I know. I work with couples and they’ve been married for 25, 30 years. And I will ask them questions in the therapy room and they will look at each other and say “well I didn’t know you felt like that“. It’s staggering, isn’t it? But it’s not unusual. The majority of couples don’t talk about sex.
A couple I saw this week, he said “well I know a lot of women fake their orgasms, and so I don’t know whether she’s faking it“. And she said “absolutely never, I never have!“. That’s good to know and I’m thinking isn’t it a shame, after all those years of marriage and he’s only just finding that out.
Jason: And sometimes, so much private pain on both sides of the relationship. So much private doubt and insecurity and worrying has gone on. That wasn’t really necessary.
Carol: And it’s all that stuff that causes these problems, these issues, these disorders, these dysfunctions.
Jason: You know, that’s really insightful. Thank you very much. If anybody wants to see a bit more about your work and the therapy that you provide, what’s the best way?
Carol: So my clinic is the North Hampshire Clinic in Basingstoke, at the top of the town.
I’m just putting together at the moment a sex education course for adults. Because we never got a sex education. None of us got the sex education that we should have got. Our sex education was always about how to make a baby, how not to make a baby, periods… but nothing about pleasure. Nothing about pleasure at all. So the course I’m producing is sex education for grown-ups, all based around pleasure and how how arousal works. It covers quite a lot of things so that will be available in July 2023.
You’ll be able to go online and download it. I think it’s helpful for a lot of people just to have a basic sex education. A sex education in pleasure. Sex for pleasure, not sex for procreation. It doesn’t talk about babies at all!
Jason: That sounds very relevant to what we’ve been talking about. And also the fact that it’s never too late in life, or in a relationship, to pick up some of these insights.
Carol: And to rewrite your script. It can always be done… but as a team effort.