Sula (00:00) In this episode, I was joined by Kate Moyle, renowned sex therapist and author of The Science of Sex, who is no stranger to talking about sex, having appeared on the BBC and multiple prominent podcasts, including A Diary of a CEO. And with her, had Lorraine Grover, nurse by background, turned sex therapist with 20 years experience working in this field, who brought with her her toolbox of tricks, which we had a lot of fun exploring. What I loved about this episode was the clear relationship between the social messages we get and our experiences, how we come to think about things, our beliefs about ourselves, our emotions, and how that all impacts on our physiological function and of course our ability to have sex. During the course of this episode, you'll come to understand why reflecting on your relationship with sex and intimacy is important, whether or not you identify with having difficulties in this area. We touched upon the differences between sex and intimacy. why that can feel so embarrassing and why no matter the health issue, sex life shift or change in circumstances, you can hope to have a good sex life no matter your age, gender, sexual orientation, health issues and more. Kate, Lorraine, thank you so much for coming to talk about intimacy and all of the various different facets that come with intimacy. So maybe just to begin, can I ask you Kate first to introduce yourself a bit about you and what you do? Kate (01:27) Yeah, I'm Kate Moyle. I'm a psychosexual therapist and I wrote the book, The Science of Sex and host a podcast called The Sexual Wellness Sessions. But I guess my specialism is sexual dysfunction. That's the kind of thing I think I work with the most and I love to see whether that's individuals or couples. Sula (01:45) Thanks, Kate and Lorraine. Lorraine (01:47) I'm Lorraine Grover, I'm a nurse background of over 40 years and I am a psychosexual therapist. I've been that since 2000 because that combination is a great combination. I've sub-specialised in men with erectile dysfunction and even further with men who are diagnosed with prostate cancer. I do see couples, I see individuals and I'm really passionate about spreading this important subject within healthcare. Sula (02:19) And I'd love to hear a bit about who you both say, like who would be the patients that come to see you. So you, Lorraine, were saying about patients perhaps with erectile dysfunction, maybe that's overlapping with a cancer diagnosis. Lorraine (02:32) Absolutely, yeah. So there are actually International November guidelines. In fact, three UK clinicians, was one of them, Pia reviewed them about sexual wellbeing and prostate cancer. So it's there, it's written, but it's rarely managed. And we really need to get the right people managing it with psychosexual training because we're professional, we've got accountability. And actually it's letting the patients know this is part of their care pathway. So yeah, definitely. Prostate cancer and erectile dysfunction and erectile dysfunction affects men of all ages. It always happens to a guy at some point in their life and we should normalise that to help remove some of the fear and anxiety and stigma around it but through an ill health and it can be a sudden onset due to a cancer diagnosis or a chronic with something like diabetes or inflammatory bowel disease there are lots of diseases that impact. Sula (03:26) Yeah. And I'd love to explore that overlap between ill health and the sorts of things that give rise to people becoming either, you know, having the onset of sexual dysfunction in some way or becoming aware that they've got a problem. But before we do, yeah, Kate, what sort of people are you seeing in the presenting issue? Kate (03:47) Yeah, so I guess my clients are kind of 18 to 80 is I guess how I describe it. I only work with adults and I suppose I do a lot of cross referring with people like pelvic health physiotherapists, doctors, sexual dysfunction is I view it quite like creative problem solving. So I'm kind of understand what started the problem, what's maintaining it, how are we going to change it? I work with sometimes with couples, sometimes with individuals, sometimes with people whose relationships have just ended because of a sexual problem and they want to sort it out before their next relationship. And I think for me, one of the big questions I kind of have for people is like, why now? What was it this week that meant you send that inquiry email? But I'm sure you're gonna say the same thing. Psychosexual therapy is everyday people with everyday problems. It's just the problems happen to be about sex. And so I think we have this kind of mysterious view of psychosexual therapy, but it's not really that mysterious actually when you get into it. Sula (04:48) Yeah, and hopefully, yeah, it would be so great to pull that out more in this episode, you know, what it involves, what kind of things that you're doing, but we'll definitely get to that. I was curious, can I ask like a very broad question? When I was working with a team on this topic of intimacy, I think automatically the word intimacy is often used as a broad safer term than to talk about like sexual dysfunction or sexual intimacy. But then it can be quite ambivalent. So I'd love to hear from both of you, what would you say intimacy is? Kate (05:25) Yeah, I mean, I would detach intimacy from sex. I mean, sex can be a form of intimacy, but it's really important that we say that they are not, they don't mean the same thing. You can have sex without intimacy and intimacy without sex. And so we have to be really careful when we're asking people about intimacy, that we're not saying the only way you can get that is through having sex. Because it may be that someone, for example, has an illness that means that they can't have sex in the way that they used to ever again for some reason. It doesn't mean they can't have intimacy and intimacy is about a relationship kind of going down a level into something deeper or more connecting. But we are so uncomfortable using the word sex, even in medical settings, that intimacy is quite a nice kind of euphemism for the word sex. It kind of suddenly makes everyone feel a little bit more comfortable, but it's confusing quite honestly. Lorraine (06:17) I agree with that. And I think it can be a tick box, you know, oh, intimacy, we've written it down in the notes or we've asked that in a questionnaire, we've dealt with it. But actually you're right. When you talk to a person or a couple or an individual about intimacy, you say, we're not on about sexual intercourse necessarily. It's actually, what does this mean to you? And it's amazing the number of people who've lost intimacy over time before this diagnosis or this event, like you say, brought you here now. It's dwindled. And so actually, it's so rewarding when you use the word intimacy and start to get them to think about what does that mean to you and how can you reintroduce it? It takes away the scariness and the taboo around sex, which often is a barrier. Sula (07:08) Just on that, you know, having recognized that it's dwindled, because the two are separate, like you're saying Kate, intimacy and sex, but for lots of people, intimacy helps sex, right? So when it's dwindled and then there's sexual dysfunction or difficulties with sex, that makes a lot of sense. But what are the markers of that intimacy dwindling? Because maybe that's the first time people are realizing, yeah, that went a long time ago. Lorraine (07:36) Kissing is quite an important part of it. People will say, I don't get that kiss when he/she goes off to work or it's a peck on the cheek or the forehead. And they've not had a kiss on the lips and they miss it, but they've never spoken about it. So that, I often hear kissing mentioned quite a lot. Kate (07:54) I think there's something about the potential of it as well. So the Gottmans who are really famous relationship researchers, they talk about a six second kiss and they call it a kiss with potential. And I think the kiss on the forehead is a really common example that we hear in our clinics, which is we used to kiss and now I get a kiss on the forehead. It feels like a desexualizing kiss or the way I'd kiss my gran or my kid. And there's something in that where it feels like it's changed dynamic. And it's often when the possibilities for sex don't feel like they're happening again. And when I say sex, I don't mean just intercourse, I mean sexual experiences. So it feels quite platonic. And that is often what people feel that they miss. I feel that often people come to clinic and they're like, it's not that actually we're not having sex anymore, we've lost everything that was in the run up towards it. And now that's gone and we don't know how to even start with sex because we never reach out for each other when we're sat on the sofa. My partner never kind of gives me like a cheeky squeeze when they walk past me and we've lost a sense of any kind of sexual relationship between the two of us. We feel like housemates. And it's that also that kind of not knowing what to do without the possibility. Because when the possibility is there in the faith that when the context is right, that it will happen. When that goes, that's very different to we are having a really kind of crazy couple of weeks or my partner's having chemo. And I know that sex is off the table, that side of our relationship was at the table for now, but I kind of have the faith that it will come back when things change again. And I would say that that's a differentiator. Sula (09:40) It's really interesting as well, because a lot of the people that I work with have chronic illnesses, pelvic health difficulties, might have had a period of chronic UTIs, things like that, which mean that sex is off the table because of these health issues. But over time, that then becomes the new normal, and then it can become very difficult to resurrect. It's interesting, you talked about that dwindle of that going away and people not really quite noticing, and then when you realize sex is difficult now, it's not just the sex itself, but it's also everything that comes with it. And I was interested in what you said earlier, Kate, about why now? Like, what is it that brings people, that helps them recognize now is when I want to come to explore this. Kate (10:28) I'm sure, I mean, especially in your work, because you're a much more healthcare-based than I am. Something could have been going on for so long and we avoid it and then we have the anxiety. And then suddenly, often there's a trigger or something changed. And that's such a crucial point in someone's kind of healthcare process. Lorraine (10:47) And it's also not just the individual, it could be the partner. For example, the man with prostate cancer, I'm always asking about their partner and any sexual difficulties. It's interesting, they usually look at me in surprise because they're in a medical model. The doctor's asked about the patient, only about the patient. So someone suddenly being asked about themselves — and they may be running along with breast cancer or gynaecological cancer and they've had no input themselves. And you know, it's specialised care that we're providing and it's joyous when you actually speak to a couple rather than just the ill person. Sula (11:32) Yeah, that team unit element can be really important as well. Again, in a lot of the people that I work with, I'm working with the person that is impacted, but there's a common sense of feeling like they're letting their partner down. And then it can almost bring up a resistance to put another thing on the table of like, this is another thing that I'm gonna feel ashamed about or embarrassed about to speak and another thing that I have to work on. And I guess just to broaden that out a little bit more, why does sex feel so embarrassing or taboo? Lorraine (12:19) I think we all come in our own skin. I would never have believed I would end up being a sex therapist. My 18 year old self would love my school friends to see me now. And I talk very openly with anybody about it. If I'm in a taxi, we do taxi talks. There was a famous incident in America where we went round a roundabout three times because the driver was listening to what we were saying. And it's just about normalizing it. But I appreciate that for me growing up — I remember asking about what does caress mean? And my mum said to dad something like, stop being silly. I can remember that. That's really powerful for me still. And there are many people who feel like that around the word sex. I like using the word sexual wellbeing. Not dysfunction, it's sexual wellbeing. There are many aspects of it. So our upbringing has a huge part to play, and culture and peer pressure around us. We think we've all got to look fantastic, be able to orgasm on demand. It's got so much pressure. And in healthcare, we're not trained to talk to patients about sex. So we bring our own cultural anxiety into the dialogue. Kate (14:20) I think there's a term I really like, which is that we're kind of all marinated in the society and the culture that we grew up in. And most of us have had experiences where even the fact that people drop their voice when they say sex, you know, they'll be having a conversation and then sex comes out as a whisper. It's even in 2025, I watch people do it. And if it happens in therapy, I say, what's that about? Did you notice that you did that? And we've all kind of grown up with the unsaid as much as the said, you know, messages about what people wear, the type of things that we interpret about someone by how they look. And then we have these perfect glamorized versions of sex on TV. And then we have these interpretations of what good sex and bad sex are. This is stuff we're picking up from a really, really young age. And no one is kind of sitting us down and saying, actually, do you understand what sex would be like and the difference between non-consensual experiences and consensual experiences. And I think we internalize all of those ideas and we then become adults who are allowed to legally have sex at a certain age and we're meant to have a full comprehensive understanding. Nobody has really told us what we're doing, how we're meant to feel, is it the right thing. And so then we're all stuck with this idea that we're meant to be experts, without all of the tools that would make anyone an expert — trial and error, questions, learning, education, finding resources. Lorraine (16:21) It's not a tick box. Not one size fits all. I had an interesting experience myself. I had a tumor in my spinal canal in 2022. I had the surgery and the concern was there may be sexual dysfunction. So I'm thinking to myself, great, I'm glad you've mentioned that. Post surgery, lying in bed flat for four days, the team came around post-op. How are you Lorraine? I said, absolutely marvellous. I'm not paralyzed, I can move my legs, I can feel my clitoris — and they didn't know where to look. It was so interesting. And it was shocking because this was 2022. The word sexual dysfunction had been mentioned once, nothing post. And this was a spinal unit. I was shocked. Sula (17:18) Yeah, that adds to the internalised sense of shame or taboo as well, right? When it is mentioned, there's deathly silence. Lorraine (17:32) And even I thought, should I have really said that? I am the patient. Because I was the patient and I wasn't the healthcare professional. So even I was thinking that. Kate (17:41) And most people have that experience of, as and when and if sex comes up, that they're made to feel that it was wrong that they asked. And in healthcare settings, we see that a lot. And particularly things like cancer care and people feel guilty for asking about sex. Something I've heard a lot is, I got through all of my treatment. I felt so lucky to be one of the people that got through it and I'm starting to live again and sex had never been mentioned throughout. And then I didn't feel like I could take any more of my doctor's time because I'm alive and I'm here and I'm healthy. And that felt like it was too much to ask, but actually it was the thing I really wanted to ask. And if it hasn't been brought up by a healthcare professional, it doesn't give the patient permission to bring it up at any point, even if the healthcare professional brings it up and it's never discussed again. For patients, it's an indicator that it can be brought up, it can be introduced. And we see that not just in cancer care but across the board. We talk about contraception, we talk about fertility, but we don't talk about sex and pleasure. Sula (18:46) Yeah, the central thing. Thinking about that lack of permission to talk about it and the guilt that can come up of taking time because it's not this central thing, you know. What impact does that have on how people relate to sex? It shows that there's a sense of it's not so important. It's a nice to have. It's not a necessary to have. Lorraine (19:14) Yeah, you're right. I've got a very simple diagram that I show patients about sexual arousal circuitry. I use the analogy of cook and pasta. So someone's coming to see me, say a post radical prostatectomy patient, and I'll say, I'm really pleased that you're here. Actually, it's an important part of your care. So it validates it with them. And then I show them about desire, arousal, orgasm. And I say, we impacted on this arousal circuitry by giving you the care that you've required, but it's an important part of us now looking after you. I think the shame and having the dialogue can be inhibited at the beginning because they're still not sure — should I really be talking about sexual intimacy here? I used to provide a service in the NHS and patients got 20 minutes. It wasn't a huge amount, but I could signpost them to safe places and we had the discussion. And I think it's stopped a lot within the NHS at the moment because you're hearing people saying, I haven't got time. Well, we have to make the time. We can do a two or three minute flag-it-up. We can say, we can talk about that at another appointment. Or we can just keep silent. We will never get that discussion going. Sula (20:35) Yeah, like you say Lorraine, even just asking the question gives a kind of permission, doesn't it? Even if there legitimately isn't the scope to explore that in lots of detail, it gives permission for someone to say, this is something that I have permission to be bothered about. Kate (20:51) Where it takes away a question mark around, okay, but I'm struggling with sex and it's not being mentioned. Is that typical for someone with the condition that I have? Is it typical for this treatment plan? Because if it's not mentioned immediately, I think I'm atypical. And that this can't be happening for other people because if it was happening enough, it would be mentioned. Sula (21:13) Yeah. Also, I wanted to explore that sense of these assumptions that we have about sex, that we should just know what to do and that everyone's having good sex, you know? And this comes up a lot for my younger clients that are impacted by health issues. Somebody put it to me in a really impactful way which was something along the lines of — this is just something that nobody has to think about. Everyone can just do it. And I have to think about it. Lorraine (21:45) Yeah, a lot of people say that. Kate (21:49) Yeah. Like sex is a thing you don't really think about until you have a problem with it. I would say that puts most people that come into our clinic. They say, never thought I'd be here. Didn't even know psychosexual therapy existed until I had a problem. Or I never thought I'd have to talk about this. And it's an assumption that comes with the idea that everyone's got this all worked out and that it just works for everybody. And again, that's the shame bit. Because it's that, well, I don't see anyone talking about this not working publicly, which means it's probably me. And then I don't see it being addressed anywhere. So it's probably me. It didn't get brought up as a side effect of healthcare. So it's probably me. It's not working with my partner, but everyone else seems to be having great sex or looks like they're having great sex. So it's probably me or us. And again, that feeling gets reinforced all the time. The sex we're having doesn't look like it does on Netflix, so it's probably us, probably me. Lorraine (22:53) I think women in healthcare as well, you know, you have a baby or you have a gynaecological issue, but you'll be fine in six weeks, you know, post your health visitor appointment. And you don't want to feel like that but you're sort of made to feel like it and everyone else is having sex so I better be. And it's quite interesting where you sometimes just unravel. I like using the analogy of an onion. You take the skin off and you get the layers and sometimes people who think I'm having great sex — are not — and they may have missed out themselves on real pleasure enjoying sex. That's the beauty of psychosexual therapy: we can modify things. Sula (23:39) What is the impact of some of these thoughts about sex and the increased sense of pressure on sex? How does that actually impact on the physiology of sex? Kate (23:50) Yeah. A perfect example is if people think that they should be having sex because that's an indicator of relationship health, how healthy they are, that it's a thing that they have to do. And for example, overlapping with health, they have a condition which makes penetrative sex painful. So we have conditions like vaginismus, vulvodynia, pelvic inflammatory disease, people who've had gynaecological cancers, birth trauma. There are huge lists — recurring infections, UTIs. If they think that they should have to continue having sex because that's the done thing and sex in that particular way, and they are doing it even though it is causing painful symptoms or even though it is reinforcing pain, even though their body is telling them this is not something that we should be doing, that can cause hugely difficult cycles of anxiety, impact on relationships, impact on someone's health, self-esteem, reinforcing pain, can make infections and conditions worse. And it's going to relate psychologically, socially, biologically. It's why we talk about the biopsychosocial model all the time in our work. You can't untangle it all because if someone is having painful sex and then they're feeling anxious about it, they're going to tense up in response to attempts at penetration because they're going to be anxious. They don't want to tell their partner it hurts. So they think, I'm just going to carry on. And we hear this stuff all the time. And their partner might not know because they think that they're the problem. So they shouldn't tell their partner. They don't want to disappoint their partner. They don't want to upset their partner. And there's a social bit. They then don't feel understood by their partner because how can their partner not know? And it's all this stuff that's happening underneath and it becomes cyclical incredibly quickly. Lorraine (25:41) I use visual aids. I have a vulva, an emoji for penis, and the brain. And I'll have them on the desk and I'll say to people, the brain is the biggest sex organ. For our erogenous zones to respond and our genitalia to wetten, for our lips to engorge, we need to feel relaxed. And if we're not relaxing, we're anxious, that won't happen and we need to connect. Whether we've got two vulvas, two penises, you know, we have to be relaxed and communicate about that. And it's wonderful when you can actually just use simple things to get people to click with something that no one's ever talked to them about because of all the shame and taboo and what's expected of them. So I use them a lot and humour is sometimes used in that dialogue in the room and allows that conversation to happen. Self-pleasuring — I think we don't talk enough about whether it's masturbation. I always say to patients, what do you call it? Self-pleasuring? And I'll use the word they feel comfortable with. And I even get them to say, what do you call your vulva? Or it might be your vagina or your penis. Let's talk about this, because communication is important to get people to relax. It's way back, isn't it, before any genitalia. It's what we're saying about intimacy — that whole beginning of what's in our brain that triggers these thoughts for us to become aroused and relaxed. It's so important. Kate (27:27) And people might never have thought about having sex or their sex life in any other way. We talk about penis and vagina sex — it's very heteronormative. Clearly, lots of our patients and clients are not in heterosexual relationships. But if you ask most people how they would define sex, they would say intercourse. And so we need to check what they mean so that we're never assuming what they mean and they're never assuming that that's what we mean. It may be sometimes you say to people, okay, but what about when you have other forms of sex and they're like, oh, but that doesn't count. Or my partner doesn't think that counts. And you think, what doesn't count about a mutually pleasurable, enjoyable, connecting experience? How else would you define sex? But that's a really big moment for people. And sometimes I'll be working with people and they're not able to have penetrative sex, for example, for a medical reason, but they have a great sex life otherwise. And I will say that and I'll be like, how amazing for the two of you, you've worked around this, you've got a great sex life, you're both orgasmic, you're really enjoying each other. So it's just one bit that's not working. And it's honestly like mind boggling to them that they have a really good sex life because they're so focused on the one thing that isn't possible. And it can be such a breakthrough moment with people. Sula (28:47) Until that point they've thought, well, that doesn't count. Kate (28:50) They're like, we have no sex life. And what does that mean about us? But they do, it just doesn't look how they think it should. Lorraine (28:56) I think public display of affection is quite an interesting thing, isn't it? An expression of intimacy. I love it if I see someone holding hands. But you don't see it that often. It's like there's a sense of — I shouldn't be showing this affection to other people. And it's a real connection that people have. Such simple things sometimes that we forget are a part of intimacy. Sula (29:20) And so speaking about the circuitry between brain and sexual organs, what a lot of people that I work with have a difficulty with is that their body no longer feels safe, right? Because of illness or maybe it's because sexual problems have come up, but predominantly my client base is people who have had illness for some while and often illness that overlaps with areas associated with the genitals. It's not always directly, but for example, the bowels feel super close to the genitals because it's just all down there and the cramping of the pelvic floor and all that kind of stuff. But of course, if people have urinary tract infections, that feels super close for a lot of people to having sex and that area just now feels far from something that can even experience pleasure. So what sorts of things might you do to help people feel safer and kind of tackle those difficulties? Lorraine (30:18) Well, I think communication with a partner because if, for example, a lady with frequent UTIs may not want penetrative sex, they're not going to relax if they think their partner is going to start touching their area. So actually being able to communicate — I may feel sensual, I want some intimacy, but I don't want anything penetrative. Even talking about that sets a boundary. And I think that's really important. And sometimes I'll say to patients about your orgasms, if that's what you want to achieve, are they vaginal, are they clitoral? How do you respond to that? Because some people might be happy with clitoral touch and play, but don't want anything penetrative in the vagina. So it's finding out a bit more — is there anything that they would be happy with? Kissing of breasts or neck and moving away from the vaginal and vulval area, maybe something they've never talked about with their partner. So it's become this shut off. It's a bit like the magician's box where you put blades in and cut things off. It's bringing it back in, in a way that's acceptable for that person, which will be different for everybody. But you need to open up the dialogue with communication and that's really important if you're in a relationship. Sula (31:46) Yeah, so it's almost that kind of all or nothing attitude towards sex means that that conversation in the first place can be off the table. And then, you know, having that kind of awareness allows some more open dialogue and exploring things that can make it feel a bit safer. Kate (32:04) Well, it means that often if a particular part of sex, let's say penetrative sex, if that feels like the problem, for example, for people who really struggle with UTIs — we know peeing after sex is an essential because if bacteria can get into the urethra, that can cause it. But also if people have recurrent UTIs, they often get really easily irritated. Even if they're doing everything right, there's recurring irritation. If you are anticipating that's going to happen and you're thinking, okay, well, I really actually want to be with my partner, but all I'm thinking about is that tomorrow morning this is going to be agony. Within 24 hours I will have a UTI because this happens to me every time. You are not going to be relaxed and comfortable enjoying what your partner's doing. And you start — I often describe it like an oversensitive smoke alarm. That starts the minute your partner reaches over on the sofa and puts their hand on yours. It's not the minute that you pick up a potential cue from them that they might be interested in sex. So all of that immediately becomes something which starts to make you anxious rather than aroused. And your brain will always, always prioritize anxiety over arousal. And so if you can work out ways to kind of calm that reaction and allow what does feel good and does feel enjoyable for you because you have taken away the source of the anxiety or you've changed the relationship with that, that can be really transformative for people. But it's also about having to kind of approach the source of the thing which makes you anxious. Whereas most of us, our most natural response to something that makes us anxious is to avoid it. That's the best way of kind of shutting off that feeling. And that back bit of your brain, the limbic system, isn't sophisticated enough to understand that your partner isn't actually a threat to you. All it is is pain protection. It's not thinking, okay, but I'm in an intimate relationship with this person who I trust. It's just protection first. And then we have to bring the front brain online — as the phrase we use — to work out the rest of it. Safety: your brain's primary job is to keep you safe. It doesn't mind about your happiness in those moments. It is about safety. And we have to then learn how we manage that in whatever way that looks like for us, which is why so much of our work is about desensitizing and helping people feel in control and reestablish safety with themselves and then with their partners. Sula (34:39) That's a really interesting thing, because Lorraine, you mentioned increasing that safety through communication. But I'm curious about some of the ways that people might increase a sense of safety within themselves. Have you got anything in your toolbox as well? Lorraine (34:55) I do because I think the safety — women have never touched themselves often, they've never even looked at their vulva. And so sometimes I'll say to people, well, get a mirror, have a look at your vulva. I definitely get women looking at sex toys — well, everyone looking at sex toys, actually. I always say they don't talk, they don't make a cup of tea, they don't caress. People get a bit frightened and say, you know, my partner might feel useless if I'm using them. Or a woman who might be getting frequent UTIs but needs to explore their genitalia in a way they're happy to — that might be just looking at their vulva and touching it with a finger. Lubrication is really important, super important. The wetter the better for everyone. The least ingredients, the better because you can potentially get thrush. Silicon lube stays wetter longer. There are lots of tips we can give around lubrication. And if someone does ever want to reintroduce penetration, using vaginal trainers, which are essentially like dilators, can be really helpful. I hear horror stories where women are given a bag of hard plastic dilators — they're about having radiotherapy, you know, or in the urology department — and no advice is given. But the great thing about them is you can take control yourself by trying them. And this is a set that I really like. They're silicone. They're very soft. They've got a loop. You can actually just put it near the end and just see what that feels like. Also using clitoral toys — 80% of women orgasm clitorally compared to vaginal penetration. And that's something about taking control yourself of your sexual self to share it with somebody else that is liberating. Kate (39:30) And I think one of the most important things you said there was learned experiences. A lot of our work is about helping people to relearn. And one of the really important things is we might be relearning or learning something new because it might not be possible for it to be how it was before. Prostate cancer is a perfect example, gynaecological cancer is a perfect example. And we hear this phrase all the time — back to how it used to be. It's not possible for everyone, but that isn't a bad thing. What could be different about it? It could actually be better for some people because they might not have had great sex lives before. But psychoeducation is massive, massive in our work. Sula (40:15) Yeah, it's kind of like we're socialised to this almost unidimensional idea of sex being like good or bad — and good equals penetration, bad equals not doing it. And then actually when people are presenting with these difficulties, they're learning this whole nuance of all the different ways that one might gain sexual satisfaction. Kate (40:43) It's just not one thing. It's not like a monolith. It's not that we just get sex and then it stays exactly the same. It changes from the sex we have in our twenties to our thirties, forties, fifties, sixties, seventies, eighties, nineties. If people have children, if people have recurrent miscarriages, infertility, cancer, ill health, hormonal contraceptives can change our experience with sex, trauma, a bad breakup, being cheated on — the list is unending. All these things that we think don't interrupt sex. And it's just that we're all given this idea that sex is a fixed entity. It's not, it's something we have to adapt all the time. It's so psychological as well as physical, but sometimes one might be ahead of the other. Physically our body might say we can't, and sometimes psychologically we're so anxious because we don't have an understanding of what's happening for us physically. We talk about the function of the dysfunction as a phrase we often hear. Lorraine (42:34) And the intimacy, I would say it's like the glue in a relationship. People do think it's almost like they're swinging from the chandeliers. They're expected to perform and no, it's not the case at all. I think certainly in prostate cancer or erectile dysfunction, it can be a little bit like — I usually use a light bulb analogy. There's a light bulb missing. The electricity's there, but the light bulb's missing because actually at the moment your ill health has impacted on the nerves. So we can bypass that. And actually they don't then feel like, I'm the problem. It's been induced by something else and they can think, okay, I'll think about the change. And I will say, you know, yes, it will be different. It's as if you broke a leg, but now we've got to recover from it. So I like using recovery and discovery a lot. I can't stand the word rehabilitation. Sula (43:32) It's not very sexy. Lorraine (43:33) It's not. Which is why I then trained as a sex therapist. I was giving out the tablets that then became Viagra. Patients were talking about their sex life to me. I was really embarrassed because I'd been a casualty sister and we didn't talk sex. And then I thought we should be addressing this in healthcare. I knew there was a missing piece of the link. And I heard a sex therapist speak — a wonderful lady, Tricia Barnes. And it was like this light bulb moment for me. She encouraged me to train as a sex therapist. Bringing the physiological and the psychological together and explaining it is so rewarding because all of what we've just been talking about is encompassed in that consultation — and it starts with communication and intimacy. Sula (44:37) You're in a unique position there, Lorraine, as a nurse, bringing together that biomedical element of care and the psychosocial kind of elements. How do you manage that? Because I guess maybe you have some clients that come to you like, I just want the drugs or I just want the particular medical thing. Kate (44:42) It's like gold standard. Lorraine (45:02) I love that. Oh my God. I always love a so-called difficult patient. They're not difficult. They're just never been asked the right questions. And I love it. Particularly if a man comes along and they do want the prescription for a tablet, I'll say, let's talk a bit further. And it's that lovely light bulb moment when they start to realize why they thought they needed it, but they never thought about the things that led up to it. It's so beautiful. And yeah, I'm a great fan of the tablets. They were revolutionary when they came out, because we only had injections and vacuums, which I'm still a fan of, and I love an injection, because it raises the dead. But you're right, people have these perceptions of what they feel they need. And younger people, even more so — you can get stuff over the counter now. It's a quick fix. It's like putting an elastoplast on something. If we can actually get more people to be accepting — I think it's the word therapy that puts people off. There's nothing wrong with my brain. Therapy means there's something wrong. And you say, no, it's just part of care, an aspect of healthcare that we should be addressing. Yeah, I do love it when you see that light bulb moment for them. Sula (46:29) It's really interesting that therapy equals there's something wrong with me and how that can preclude people from getting access to care that would actually be really useful for them. There's already this defence of — this means it's something wrong with me. It means also then I've got loads of pressure to figure something out rather than just get the ease of a pill. Kate (46:53) Yeah, I often say, if people come in, they're like, saw my doctor and unfortunately now I'm here. And I always say, I'm fully aware. No one's thrilled to be in a first session of psychosexual therapy. It's my job to help you feel like it's not the worst place in the world to be. But no one skips into a first session of psychosexual therapy. No one's thrilled to be there. No one's really excited about it. And that's fine. That's absolutely fine because in the social context of how we talk and think about sex, that's where most people will be. And I always say to people, how are you feeling about being here? When people say, I'm actually quite excited, I'm like, really? That's more uncommon than people saying, I'm actually so scared. I'm really nervous. I don't know what this means that I'm here. But there's something in when people kind of come in and they've hoped going to their doctor will reveal some medical explanation for why they are struggling with sex. And it's harder to be told medically everything appears fine. Because then the responsibility falls back on them to solve it. Whereas being given a prescription or a gel or a cream or even a name, in some way the medicalization can for people be helpful, but also it can feel like a sentence. They can't do anything about it now. It's a fixed entity. There's so much nuance in all of it. But for people who hoped to go to the doctor and be given a clear answer and a clear solution, psychosexual therapy can feel like the harder work. Lorraine (48:44) I just like the term recovery and discovery. It's great. Because you're recovering from whatever has caused the issue, whether it's cancer or not. Or people might be told awful things. I've had all sorts said to me in that clinical room — it's incredible. We're so lucky, I feel, to be able to share some of the most distressing things people can tell us. But we can hold them in a safe environment to help them. So recovery and then the discovery is about, well, you know, it takes a lot before I would hang a hat up on any man not getting an erection. Because you need to be able to empower people to say, this isn't your fault. Sometimes I will say, actually, it's not to do with the sexual organ. It's some other things that have been going on. Let's see if we can identify that together. It's a shared thing that we're going to do. Because there are these expectations and people are scared coming in the room. They don't know how it's going to go, what language will be used. And it's lovely if someone says, that was just so much better than I thought it was going to be. Kate (50:23) Shows like Sex Education put sex therapy kind of on the map in a way that my inbox has never been busier than when that series came out. But also everyone at work was talking about sex. People were like, did you watch Sex Education? What about that? And it was the permission it gave everyone. A bit like when 50 Shades of Grey came out and there were people sat on the tube reading it publicly and everyone was talking about it. There are these quite kind of cultural moments that happen in mass media that are really helpful when done well. And that was one of them because suddenly everyone had a reference point for what psychosexual therapy might look like or what a sex therapist was or that it even existed. Lorraine (51:26) And that's just mirroring what patients do. Because I've had all that said to me, you've had it said to you — you think you're the only one, just like a patient with a sexual problem might think it's just me. And then you realize, well, so have a hundred other women or men. I had it yesterday actually with a cream. There's a cream, it doesn't work very well. A patient didn't know that. He and his wife tried it. They came as a couple and they said, we tried the cream. And I said, it's rubbish, isn't it? And the lady smiled from ear to ear and she went, well, it is. And I said, I've got permission to use it, said, go for it. It's rubbish, but the expectation was it should work. And they felt like absolute failures. And when I just validated that — they've taken the blame off themselves. She thought she was useless. She wasn't turning them on. And I thought, wow. That discovering and demystifying things is so important. Kate (52:43) We have that with PDE5 inhibitors — so Viagra, Cialis, et cetera. They are not an aphrodisiac. And people often take them for the first time and they sit and wait. And they don't do anything sexual. They just sit and they wait. And they are inhibitors. They inhibit a reaction which has to be excited in order to be inhibited. And people are given it and they're not told how it works. They don't have it explained. And then, well now I'm really doomed because I was struggling already and now the one thing that I've been told by the whole world, you know, the little blue pill isn't working either. Just even saying, okay, but did you actually try anything sexual? Did you get aroused? Did you start touching yourself? No. But we think we have an association that they're aphrodisiacs and that they'll just automatically charge us up and turn us on. And when we know how to use things properly — like anything in Lorraine's toolbox, dilators, lube, medications, touch, sex toys — we can really change things for people. But they have to know how. Sula (53:53) I'm curious Lorraine, have you got some other things in your toolbox? Lorraine (53:56) I've got my sexy knickers for stomas. You can get some really lovely lingerie. Supermarkets are doing online adaptable clothing now. And we have injections — I spoke about injections raising the dead and it's the fear around them, isn't it? And it's a tiny needle, very fine. It's a bit like an insulin needle and when you inject, you insert it into the penis, away from the head towards the base at the side, you go in, push, out and within five to ten minutes you can get an erection. Whereas tablets can take about half an hour to an hour. So actually some men may find an injection works better for them for their sexual and their partner's wants and needs. And certainly if someone's had pelvic surgery, colorectal, prostate — using an injection bypasses the nerve signal that's required to get the erection. And you can make an injection sexy, you know. If you're in a clinical setting, I talk about when to bring it in, talk to partners about it, don't inject in a bathroom and suddenly appear. There's a role to be played within it and involve your partner. Vacuum devices are similar. You attach the pump to the cylinder, put it over the penis and pump. It's a bit like a physio — if you broke your leg you'd have physio. So whilst recovering from surgery or on hormones and you lose the desire for sex, the anatomy needs to be kept functional. So it's not just about sex. Vacuum devices have been around centuries but they have this bad press. It's about how you bring that into lovemaking. Stomas, for example — patients don't fall in love with a stoma. They fall in love with the person, the music they like, the food they like. Sometimes it's actually empowering the patient to say, let's rethink where you see your sexual self. So vacuums and injections I use a lot and the psychosexual edition really can enhance the use and keep people using things. Sula (57:49) You know, there was something both of you were talking about — this element of, if I have to use this, there's something wrong with me — or just this sense of, I want something to fix this, the problem's kind of outsourced and then it doesn't mean there's something wrong with me. So what is that element of helping people amend that sense of faulty, I think you used the word failure, identity? How do you guys go about doing that? Kate (58:15) A lot of things is actually just talking about it and — okay well there's all this stuff going on, how do you feel about it, where did that message come from, how did you shape that idea? And that is massive. But I'll use lubricant as the perfect example. It is a really simple cost-effective way of transforming comfort, reducing pain and making sex more pleasurable or masturbation more pleasurable. People still think that using it is wrong. If you had a problem with your ankle, you would go and see a physio or a doctor. You might have to do some exercises. You might wear an ankle support. You'd probably change your exercise routine and you wouldn't think about it twice. But lubricant is so easy and basic. We feel shame about it and it's such an easy thing to do and it can transform a sex life for basically under ten pounds. But we think because we have this historical idea that I'm not turned on enough or you didn't turn me on enough, and that is the only reason I would need it. Menopause, perimenopause, breastfeeding reduces estrogen. We have vaginal atrophy, stress, where you are in your menstrual cycle, if you've had a medical treatment — anything can affect it. Anxiety, not being in the right headspace. Had you been given the appropriate information at the right time, you wouldn't now be dealing with a whole host of anxiety about feeling bad about yourself, feeling your body doesn't work, that you're letting your partner down. All of that is, I don't believe, necessary. But it's all the stuff that we've been given. Which is why we all get very excited about talking about this stuff. Because if we can get to people before — these conversations are preventative. Lorraine (01:00:27) Very early on in any pathway, whether it's ill health or not, to have that dialogue. I mean, it's a bit like sex education at school — you know when that should happen. But certainly in healthcare, I say to the surgeons and the oncologists — early on, we need to be talking about this. It should be a standalone part of care because it's not a five-minute conversation. It's got to be a private, safe environment. It's confidential. Patients feel comfortable to talk. But if we acknowledge it with lip service — a minute at the end saying, it can affect your sex life, we can talk about that at some point — okay, it flags it up, but it's not really managing it. It has to be seen as a priority, as part of human sexuality. The WHO has validated World Sex Day. Sexual justice is a human right. I don't know why we've got this barrier. Thankfully there are more of us training as sex therapists and encouraging people to have this dialogue. It's so important. Sula (01:01:39) On that, you were mentioning there Lorraine about bringing it up, healthcare professionals bringing it up so that it gives that permission. Are there any other things that either of you would suggest to healthcare professionals that could de-stigmatize and perhaps give people a better chance of accessing support that they might need? Lorraine (01:01:57) I am a fan of questionnaires and scores that can help. You've got the International Index of Erectile Function, a man could be given that. If you're doing any procedure that you know will impact on sexual wellbeing, the Female Sexual Function Index is very useful. I use the Erection Hardness Score, which is a score from one to four, because if I was to say that a gentleman gets a 50% erection, we really don't know what that means. If I say he's grade three but drops to a one, we know that on occasion three or four it's not bad, but it drops to a one. He can't have penetrative sex and that's what he and his partner wants. So we've got a language and we can audit it and we can write it in letters and notes. In some way it gives that credibility to discussing it. I think it's a cop-out if people say we haven't got time. They could be sent before an appointment. I ask about sexual orientation with all of my patients, because how can we give bespoke care if we don't know their sexual identity? It's interesting, the number of men who will tell me they're gay but they don't tell the surgeon. And I'm still having it happen now. It's so permission-giving if you have inclusive words in any of your documentation in a healthcare setting to get the conversation going. Kate (01:04:01) And to use language like partner — don't assume based on someone's presenting gender that they are heterosexual. But I think if you as a healthcare professional don't feel comfortable or don't feel like you have the time, have a resources pack in your office. There's a great organisation called Sex, Intimacy. They have an amazing booklet. Have them and give it to your clients and your patients and just say, look, we haven't got time to cover this today, but this is a great resource. I'd like to give it to you to go away and have a look at in your own time, if you'd like to. And if there's anything in there, we can always pick that up. Just signposting. Because we chose to do our jobs, we chose to specialise in this area, and that's not for everybody understandably. But you can have a whole pack of flyers or a list of websites or podcasts, saying right, this is the local psychosexual service for this area or this hospital. And that is an easy thing to do. Sula (01:05:03) I think there's a reason that healthcare professionals don't signpost other than of course we know busyness — and that's a real issue within the healthcare system. But I do think there are kind of concerns or reasons why healthcare professionals don't signpost as much for things like this. Kate (01:05:24) Lack of knowing what's there, actually. We know that training is quite minimal on even medical training for this stuff because it's a specialism. I don't think it's the fault of individual people. I think it's just that sex and intimacy are treated as secondary parts of life. Whereas we have, and yes, the luxury of looking at it holistically. I take a full medical history with my patients. And yes, I work in the private sector, which means that a limited amount of people can get to me. I'm the first to say that. But we have a luxury of looking at the whole thing and having the time and availability to do that. And that is a part of it. Lorraine (01:06:16) In secondary care, I think back to my NHS clinic, I used to run the erectile dysfunction clinic at St. George's in the 90s. I had the additional bonus of having a set of notes and I knew the underlying risk factors. And I only had 20 minutes, but I could signpost and I did have the notes and I could document. So I think we have to adapt and accept and we need to just do it, and empower and encourage others to do so. I think there's a lot of bias as well — on age. People think older people shouldn't have input. Absolutely incorrect. Sexual identity — a lot of people say, oh I don't know what words to use, I don't want to offend. Well, if you don't say anything, you are offending. And actually, if you're not sure how somebody identifies, just ask them. They can tell you. I sometimes do that and I'm a trained sex therapist of many years. It's almost like we've got to be able to fix the problem. No, we don't. We need to open up the dialogue and direct to help from other resources if we need to. I've got quite a few 80 year old gentlemen having amazing sex where they actually have had their life transformed. Death, divorce, confidence, ill health — suddenly people present and, you know, using injections, it can transform things. Sula (01:08:22) Yeah, the assumptions of healthcare practitioners, which I guess is hard to spot if you've got these assumptions that you don't know aren't quite right, as the practitioner. But I guess a broader one often that has a massive impact on this as well is that sex would fall under the remit of kind of softer psychological elements, which isn't part of the healthcare practitioner's job. So I spoke at a conference, the ICS, and there was a symposium. There were two medics that had spoken before me on the same concept of supporting patients who are catheter users. The second medic sat down and then I got up and the slides came on about supporting the holistic wellbeing journey, and the room started emptying, right? And I was like, yes, this tends to be the response that I get from medical professionals when I come as a health psychologist talking about holistic wellbeing because you think it's not your remit. It's a nice to have, it's not a necessary to have, I don't have time. But if we do acknowledge that that is part of your role, and yes, you don't need to have the fix, but just the awareness and the ability to give permission — that makes such a big difference. Kate (01:09:45) I would say that as the conference organizers, if you have an idea that's going to happen, put Sula first. Because people aren't going to leave at the start. Lorraine (01:09:56) I did a great thing once at a meeting where I wore my vibrator necklace — it just looks like a simple gold necklace. It was in Belfast at a meeting for erectile medics years ago. And I turned it on and I just said, here I am. I've got a necklace on today. Or is it a necklace? And when I turned it on, you could hear the whole audience go — it was amazing. And then people were saying afterwards at the dinner, did you see people's faces? Like nurses looking at their colleagues, the consultants they were there with, the shock on their face. And to me that just highlighted all those people in that room and their response over something that was just highlighting to them that we judge people. We all do it all the time. So helping to destigmatize is a really good thing to do and normalise the discussion. I've got a slide now where I've got a sex therapist or sexologist as part of the MDT. And it may be that with the holistic model that we've got, permission giving, most people can address it, get the conversation going. There are things you can do, but if you do need further advice, there should definitely be a sexologist as part of the MDT. The accountability and professional accountability is so important. Sula (01:11:57) Yeah, that's a really good point, having someone there and valued as part of that team. Thank you guys. So I'm gonna round up with one last question, which hopefully rounds up the rich discussion that we've had. But if someone's listening now and feels frustrated that sex feels difficult for them, or that their sex life has changed because of health or illness or other reasons, what would you want them to know? I'll go to you first, Kate. Kate (01:12:25) The first thing I would say is don't think that there's nothing that you can do, that this is not unsolvable in a complete, total way. It's not a kind of death sentence for your sex life. I talk a lot about sex education for adults across the lifetime. There are so many good resources now. So the first thing is, when you feel ready, go and start looking. Look up the College of Sexual and Relationship Therapists, look up the ESSM — which is the European Society of Sexual Medicine — and just start gentle. Also, phrases like spice up your sex life kind of fill people with horror because they think they're going to have to change everything and try something so out of their comfort zone. It can be as simple as listening to a TED talk about sex, sitting down with a podcast episode and doing it in a completely de-sexualized way. You don't have to do something sexualized in order to educate yourself. But hearing different voices, different perspectives. Psychosexual therapy is not regulated currently. So checking the qualifications of the person that you're listening to, particularly if it relates to healthcare as well. But it's just start small and start finding ways to educate yourself that can start to make you think about things differently. Knowing that there are possible things available to you, however small they might feel, is starting to kind of turn the corner on it. And there are so many great psychosexual therapists, sex educators, organisations, books, TED Talks and podcasts now offering so much of the information in a way that's accessible for you as and when you want it. Sula (01:14:32) Thank you, Kate. I'd like to recommend Kate's book as well — Science of Sex is one of those. And also our mutual friend Karen Gurney, she's got such a great TED Talk that has really helped so many of my clients with that initial assumption we've been talking about, what sex should be. So yeah, it's a great free resource. Yeah, Lorraine, what do you think? Kate (01:14:45) It's so good. Lorraine (01:14:57) Well, Karen Gurney's books are always on my reading list. Always, always. Communication — please, please, please communicate with your healthcare professional. There's nothing wrong in you seeking advice and help. There are lots of safe websites to go to. Even if you look up particular names that get mentioned, we've usually all got something that's available online to read. It doesn't cost you anything. Change is possible. And even the disease area, if it is with healthcare — if you look at organisations, certainly Prostate Cancer UK, I've been involved in some work with them, with Macmillan — there are disease areas where there are organisations that have got some great advice. But if you don't ask, you'll never find it often. So please take that plunge and just think it's all part of you and your identity and help is available. Sula (01:16:00) Thank you both so much. It's been such a brilliant conversation and I know so many people will benefit from this. So thank you so much for your time.