The Gates Foundation research shows that, Africans, like most Americans, don’t wear condoms primarily because they decrease pleasure. Of course many feel that to be true, but from my point of view safety comes first. The Gates Foundation web site states that such innovation would “lead to substantial benefits for global health both in terms of reducing the incidence of unplanned pregnancies and in prevention of infection with HIV.” This of course makes a lot of sense to me.

“Sixty percent of teenagers use condoms and fifty percent of gay men use condoms” (Atlantic, April 2013) and “the proportion of women using contraceptives who relied on condoms decreased from 20% to 16% between 1995 -2008” (Guttmacher study on contraceptive use, 2008). Another surprising statistic from the CDC is that women only use condoms consistently 21 percent of the time. Men were quoted to be using them 24.8 percent of the time.”

I do hope the Gates Foundation is successful in finding a condom that feels better for everyone but in the meantime I hope women and men can embrace the joy of sex responsibly, because the healthier you are the more of it you can have!

Everyone grows up with different social, familial and religious norms.  For those who grew up in environments where sexuality was a taboo subject and discussion about it was shunned, transitioning into a healthy sexual relationship can be difficult. Feelings of guilt may arise, as well as feeling dirty, deviant and improper. Initiating sexual activity may feel inappropriate despite knowing intellectually that there is nothing wrong with having sexual desire.

How can one overcome this hurdle?

The first step is acknowledging the debilitating thoughts and being aware of when they arise. Next, it is vital to develop ways to minimize the presence of the thoughts and their effect on performance.  Since unwanted thoughts only intensify when shooed away, finding replacement thoughts and learning mindfulness can aid in enhancing the sexual experience.  An example would be that during sexual activity, one focuses on what is happening using their five senses.

Changing one’s mindset and cognitive distortions takes time and patience. For some, this work can be done alone and for others help from a therapist may be the answer.  Either way, if one has the willingness to go out of their comfort zone and can use a gentle approach, sexual satisfaction can increase and it can be a true mind/body experience.

 The conversation with me went something like this:

Me: “What happens when your husband tries to enter you with his penis?”

She:  “He feels like he’s hitting a wall and can’t get in.”

Me: “Okay. Do you stop him? Are you scared or nervous?”

She: “Not at all. That’s why it’s so perplexing.”

Me:  “Why does your GYN think there is no physical problem?”

She: “Because she looked in my vagina and everything looked fine.”

Me: “Did she actually try to insert something the size of a penis into your vagina or did she just use a speculum (which is much smaller)?”

She: “Uh… no…. she didn’t put anything larger than a speculum in…but she said…”

Me: “Why don’t you come in? I’ll bet we’ll figure out what the problem is… and frankly, I don’t think it’s in your head.”

We did it again!  We saved this woman from a year of talk therapy which, alone, probably wouldn’t have gotten her anywhere closer to her goal.

I can’t really make this message any clearer. If you can’t achieve penetration (and you want to) either because you are scared, it hurts or it just plain won’t go in, seek out professional help from someone who knows how to handle this. You’ll be so glad you did!

After working with teens in various settings, I think many are aware of the risks involved with their actions; with more information, I think they are capable of making good choices. If I were to create a program for teens, I would highlight the following six areas:

1. Education- Learn about your body. Understand your anatomy. Know what each part is and how it functions in the body.  Learn about safe sex practices. There is a lot you can do to protect yourself from STDs and pregnancy. Sex can and should remain a safe and exciting activity.
2. Exploration- Learn what makes you feel good, and learn how to communicate this with your partner. Good sex is about communication. Everyone loves a mind reader, but few of them really exist.
3. Imagination- Esther Perel, a relationship expert, says that the best way to keep a marriage sexually exciting is to create a safe place for sexual freedom fueled by imagination. The same goes for anyone, including teens.
4. Seek Help- Often women and men with any type of sexual issue don’t seek help. Sex is shrouded in secrecy and when there is any type of difficulty whether it be pain, low desire or difficulty with orgasm, people often don’t seek help. This means that the problem generally gets worse over time and that the person with the difficulty suffers alone.
5. Beware of Myths and Movies- Men and women alike are surrounded by sexual myths perpetuated in movies. 70% of women cannot orgasm from intercourse and yet I speak with women every day who feel they should. Men tend to hold this idea to be true as well. So instead of focusing on trying to orgasm from intercourse, women should figure out what feels good and stop comparing themselves to others. Good sex is present, connected sex. When women feel inadequate, they generally don’t feel present in their bodies or with their partners and the sex will suffer.
6. Move at Your Own Speed- Some people develop early, some develop late, some feel sexual and some don’t.  Those who are sexually active and find sex easy are often the most vocal, leaving those with more fear or concerns feeling left out and bad about themselves. Move at your own speed. Explore things that interest you and don’t feel pressured by those around you.

That’s right, 43% of women suffer from sexual dysfunction. 

The International Society for the Study of Women’s Sexual Health (ISSWSH) is a multidisciplinary academic, scientific and clinical organization devoted to women’s sexual health.  ISSWSH is committed to further development of the field of female sexuality.  This organization advocates for a collaborative approach with assessment, diagnosis and treatment of women who are suffering from sexual health problems.

ISSWSH has created an online petition to be submitted to the US government as treatments options are being considered for approval.

“If you agree with the following statements, please sign the Women’s Initiative Sexual Health (WISH) petition:

• My WISH is that my sexual health be viewed as an integral part of my overall health and well being, not a “lifestyle” choice.
• My WISH is that women who suffer from sexual dysfunction be respectfully evaluated for the best course of treatment, whether medical or psychological, not dismissed.
• My WISH is that, provided a therapy is safe and effective, government agencies strongly consider approval of a treatment option for women just as they have for men.”

Our WISH is that your voice is heard. Your signature at https://www.yourvoiceyourwish.com/ will be shared, on behalf of the International Society for the Study of Women’s Sexual Health, as we continue to work for the further development of the field of female sexuality and advocate for solutions to address this important, and often disregarded, issue for women.

The biggest problem with the WHI study was with the timing of starting HRT in women.  The data suggests that the women who started HRT after 10 years from their last period suffered from an increased risk of cancer, DVT, and stroke.  It appears that starting HRT within the first 10 years of menopause greatly decreases these risks.  The study states that… “starting HRT early after menopause and taking it for 10 years following menopause had significantly reduced risk of mortality, heart failure, or heart attack, without any apparent increase of cancer, venous thromboembolisms (DVT) or stroke.”

I do believe the benefits of HRT will gain more traction in the medical world in the next decade.  At this time, HRT is only recommended for women suffering from severe vasomotor symptoms associated with menopause; hot flashes, night sweats, insomnia, etc.  There are studies being done now that are not only showing benefits for cardiovascular health but also bone and brain health.  This is an exciting time for women’s health and I definitely look forward to the advances in this field and keeping you up to date!

As a therapist, I wanted to know more. What was really going on in her marriage? Was she adequately addressing their issues? Why  was she confiding in this friend as opposed to her husband? Why was she  concerned about this friendship? Was she afraid it would lead to more? Was she afraid it would impact her marriage? Did she want it to unconsciously or consciously affect her marriage?

Every individual is different and every marriage is different but in general, emotional intimacy outside of the primary monogamous relationship with a person of the opposite sex can have an impact. It can certainly threaten and alter the intimacy that exists or is struggling to exist between two people.

The danger with emotional intimacy outside of a monogamous relationship is obvious. It is threatening to the primary relationship. Some people are interested in open relationships. That is something else. But if two people think they are having a monogamous intimate relationship and one part of the couple has deep emotional intimacy outside of that dyad it can definitely be a threat to the primary relationship. And if one person is expressing concern about the outside relationship it needs to be taken seriously. A perceived threat, in this regard, is a threat. Often the person involved in the emotional affair is defensive and may say, “it is not serious or it’s just a friendship or it just exists at work.” Whatever the case may be..intimacy can only thrive when both partners experience a sense of safety and trust.

Creating ongoing intimacy between two people over time is a constant challenge and requires work. When it is working, as relationship expert, Sue Jonhson states, it is like watching two people dance the tango. They are in sync physically and emotionally and any challenges or surprises are maneuvered together. When one person in a couple steps out of that dance, dissonance, confusion and hurt can ensue.

I became interested in dopamine because we have found  that it can greatly improve a woman’s sexual functioning. It helps men too! It is frequently prescribed for both men and women, to  off-set the negative sexual side effects of SSRI’s (Selective Serotoninin Reuptake Inhibitor).  The fact that we have seen this drug help in these ways,  made me curious about other ways to increase dopamine in the brain.  Marijuana can also improve dopamine yet it has a some negative side effects. “Tetrahydrocannabinol, the active ingredient in marijuana, stimulates release of dopamine in the mesolimbic area of the brain, the same neurochemical process that reinforces dependence on other addictive drugs.” This is from an article in Pediatrics, published in 2004. So though occasional use of marijuana may be helpful in inducing an orgasm, for a multitude of reasons it Is not a good solution to orgasm problems. And in fact, though some patients report that it helps occasionally with sexual functioning, “Scientists have demonstrated that the emotional stress caused by withdrawal from marijuana is linked to corticotropin-releasing factor, the same brain chemical that has been linked to anxiety and stress during opiate, alcohol, and cocaine withdrawal.” As well as, “ Some of the significant neuropharmacologic, cognitive, behavioral, and somatic consequences of acute and long-term marijuana use are well known and include negative effects on short-term memory, concentration, attention span, motivation, and problem solving, which clearly interfere with learning; adverse effects on coordination, judgment, reaction time, and tracking ability….and negative health effects with repeated use similar to effects seen with smoking tobacco.” This is from the Pediatrics article mentioned above by Joffe and Yancy.

The good news is that there are many healthy ways to increase dopamine such as exercise and getting enough sleep. Dopamine itself is not produced in foods, however the precursor essential amino acid required for the production of dopamine can be found in foods. Meats, dairy, soy, nuts and seeds all have this precursor amino acid.  So including those foods in your diet is a good place to start. It has been found that more dopamine can lead to clearer thinking and better mood as well and that is obviously a good thing!

*.” (“Neurobiology of the structure of personality: dopamine, facilitation of incentive motivation, and extroversion.” By Depue and Collins in Behav Brain Sci in 1999.)

According to NAMS (North American Menopause Society) an estimated 25%-50% of postmenopausal women suffer from VVA, which equates to about 32 million women in the US.  Data suggests that only 7% of these women are being treated, a very sad statistic.  There is no need for women to suffer.

VVA can have significant negative effects in quality of life, on partner relationships as well as with a woman’s self-image and self-esteem.  Over time, all of these negative effects add up and can spell disaster for a woman’s sex life.

Luckily, there are plenty of treatment options available these days.  There are estrogen based creams, gels and vaginal rings formulated to restore balance in vaginal tissue locally.  There are also plenty of options for systemic estrogen replacement therapy (ERT); patches, vaginal rings, and sprays that can help treat other symptoms of menopause including hot flashes, night sweats, insomnia etc.

Unfortunately, not all OB/GYNs take the time to discuss sexual health, especially if the patient doesn’t bring up the subject first.  I am always amazed at the stories I hear from our patients.  A practitioner may notice atrophy but since the patient didn’t complain of any symptoms the atrophy may be left untreated until their next appointment which may be in 3 years (based on the new Pap smear guidelines)!  So, I encourage women everywhere to speak to your OB/GYNs or other practitioners about your sexual health.  Effective and simple treatments are available.  You may feel embarrassed at the time but that feeling is only temporary.  Your vagina is worth it.

Dining and Differentiation

What’s the secret to keeping  passion alive?    There’s no one best answer, and every couple is different.   But many therapists, myself included, talk about something called “differentiation” as a key factor.   Differentation means being able to take care of yourself, as a separate person, while you’re in intimate dialog with your mate.

A popular book on the subject of differentiation is David Schnarch’s Passionate Marriage. Schnarch has probably done more than any modern sex therapist to promote the idea of differentiation as a core value in a romantic partnership.

Differentiation is hard. Especially if one hasn’t seen it demonstrated in one’s family of origin.   One of the benefits of a good enough marriage or any other deep partnership is that it provides a holding place in which differentiation can occur.   In which each partner can “become more truly oneself.”

Differentiation is not easy to describe, as an idea and as a feeling.    Many couples tell me,   “It sounds nice, but I don’t get what it’s supposed to feel like”

In such situations, I offer an analogy:

Let’s say you really want to go out for sushi, and your husband really wants pizza.   You could (1) go along with his wish.   (2) insist he go along with yours     (3) decide to go to separate restaurants.    All pretty conventional approaches.

None of them, though, are going to help you feel what it’s like to be more differentiated.

But let’s say that instead you decide to (4) stand on the street bickering about it, getting more and more hungry and upset, and wondering if this relationship is really going to work.

Now that’s a good start!   You’re suffering together.    You’re both being real clear about what you want, and advocating for your own needs.

Now let’s say you’re so exhausted that you say to each other, “let’s see if we can find a place that would work for us both.”   You walk down the street looking at restaurants.  You find an Indian place that looks promising, but you discover that one or both of you don’t really like Indian food.

The next night you go out again, thinking, “there’s got to be SOMETHING that we both like – and damn-it, we’re going to find it together!”

Now you’re really on your way!    And when at long last, after many weeks of searching, you find a kind of food you both like, and a restaurant that serves it, you are so happy and feel so accomplished, that it becomes “your restaurant.”  You find recipes for all their dishes and start learning to make them at home.

Those recipes are YOURS as a couple.   You worked hard for them.    They belong to no one but the two of you.    They are your story – of keeping faith with yourself, and with each other.

If you’d never met each other, you’d never have found them.   The relationship (this is important) took you someplace that neither of you ever intended to go.    The relationship expanded you, and changed you.   But it only did so BECAUSE you and your mate both insisted on what you really wanted. The answer wasn’t clear at first – but you found it.

You’ve differentiated from your respective families as well.   No one in either of your families ever knew anything about that kind of cuisine.     Your families think your new dining habits are a little strange.    But they don’t understand about this particular journey you’ve been on together.

Only the two of you understand.  You’ve become a more differentiated couple.    Now you’re more confident that you can each take care of your own wants and needs in the relationship, and make it work.

And you know that the next time you stand together on the street bickering about whatever the next thing is . . .

You’ll figure it out.

http://www.stephensnydermd.com/whats-the-secret-to-making-romantic-love-last