Shame and Medicine Exeter
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Shame in the Psychosexual Therapy Room

Shame and sex are synonymous with each other. This entwined relationship has led me, as a psychosexual therapist, to explore shame for my PhD research. Through my research, I have recognised that anxiety in sexual difficulties is only one part of the story, and that shame plays a far bigger role.

Shame is rarely taught in psychotherapy training. Freud, the famous psychanalyst, and Bowlby who developed attachment theory, alluded to shame in their work but generally shame was overlooked in favour of guilt and anxiety. It is likely that it this omission of shame from two significant theorists in the field of psychotherapy, has influenced shames absence in trainees’ education. The implications of this are that shame is often not recognised in the therapy room, either by the therapist or the clients themselves.

This is certainly the case in psychosexual therapy in which trainee sex therapists are taught the importance of anxiety as a cause of most sexual difficulties. In my own training, I have little recollection of shame being discussed and it certainly was not presented as a possible cause of problems such a rapid ejaculation of erectile difficulties.

However, my own research into shame has enabled me to recognise that shame is key to most presentations in the therapy room. It is present in the first consultation, the shame of having to give such intimate details about yourself to a stranger. It is shame that motivates people to seek out sex therapy, either because of perceived sexual failure or a shameful desire. It can also be shame that make clients end the therapeutic process abruptly, as they move into a safer place of withdrawal. Shame is present through the whole psychotherapy journey.

It is easy for shame to be unacknowledged in the therapeutic context. Clients will rarely present stating they have an issue with shame, despite shame and sex being so aligned. Instead, people will be distressed about the level of anxiety they feel about sex. So, we find ourselves as therapists in a scenario where the client is telling us they feel anxious, and our training also tells us that anxiety is the cause of this persons sexual problem. Why would we look anywhere else for a possible explanation?

Here I will present a common presentation in psychosexual therapy and demonstrate shames significance in sexual difficulties.

Dan tells me he has not had a sexual relationship for 5 years because he is anxious about having partnered sex. He has rapid ejaculation which he states he experienced the first time he had penetrative sex with a partner aged 19. He recalls that experience as one of the worst events of this life. He ejaculated before he was inside his partner and describes a feeling so intense, he thought he was going to be destroyed by it. He felt a kick to the gut and wanted to disappear and not exist. He was left terrified that his partner would tell people of his sexual failure (as he describes it). This event is what I call uncontained shame. Others have described this as acute shame. This experience of shame usually comes as a shock or something we have not been able to predict. We can feel frozen or in panic, feeling like this state will never end.

Dan is now feeling anxious about getting into a relationship as this could potentially lead to him having the same intolerable uncontained shame experience. This avoidance is what I describe as a shame containment strategy. In order to avoid the potential for uncontained shame, we develop various strategies that can be conscious or unconscious to us. In Dan’s case, he is avoiding anything that could lead to uncontained shame being experienced again.

In this sexual scenario Dan is anxious. However, he is not feeling sexual anxiety, which was what sex therapists have been taught. Rather he is feeling what Wurmser describes as “shame anxiety”. In other words, he is anxious about the shame he is going to feel in an intimate and vulnerable moment with another person. As shame is relational, Dan is anxious about being seen as useless and worthless in the eyes of another. This potential is certainly anxiety provoking. To help Dan move away from sexual avoidance it is the shame that needs to be gently addressed.

Over 10 years of clinical practice and my PhD research has led me to conclude that shame is the most important factor in psychosexual difficulties and whilst anxiety has an important part to play, shame is considerably more significant.


Lisa Etherson – Doctoral Researcher, Teeside University

17th May 2023

Photo by Efe Kurnaz on Unsplash

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