One of the sex therapy sub-specialties I treat is erectile disorder (previously called erectile dysfunction for you psych and sex nerds) which is defined as difficulty getting or maintaining an erection and/or decrease in erectile rigidity the majority of the times during a sexual encounter. Helping men with this issue is always a good portion of my practice - it’s a very common problem and the TV and magazine commercials sure know it.
Most of these adult men say it’s not a new occurrence, they have had this issue for a long time, and they each have their own valid reasons for seeking help now: a new romantic/sexual partner is on the horizon or their long-term sexual partner is getting fed up or they themselves have simply gotten fed up. Generally speaking, men who struggle with their body’s sexual functioning and come to see me have a similar experience: they’ve tried various ways to “fix it” (including medications prescribed by their doctor) but have only had intermittent relief from the problem. Some haven’t had any relief from medication. They also have emotional pain, fears, and anxieties — about past failed sexual encounters, about future encounters, and about the process of seeing a sex therapist just to name a few. My office is usually their last stop, at least in their minds, and they’re feeling desperate, ashamed, embarrassed, and afraid…while also feeling a sense of immense urgency to get it “fixed” NOW. Welcome to session #1.
Helping a man better understand his body and getting it to do what he wants it to do when he wants it do it is my goal for him as well. But it’s so unfortunate how many men become engrained to believe that their manliness, their ability to be a great lover, is completely dependent on one body part performing on demand. So much hangs in the balance for them. I can’t help but feel for their plight.
So I do an assessment as there can be many contributing factors to ED. We identify what could be causing his erectile issues and then we get to work. He may go see his doctor and get a blood test. He may begin to make lifestyle changes and then we see how that affects his sexual functioning. Sometimes there’s a simple solution: “Have just one beer, but not two, if I want to have penetrative sex that night.” Or “Turns out I had borderline high cholesterol that may have been the cause so I’ll work on my diet.”
Often times, however, the solution is more complex. Things like learning anxiety reduction and self- and body-awareness techniques. Changing his (and possibly his partner’s) definition of sex and “being a man”. Figuring out how his partner can not blame herself, her appearance, or his pornography viewing as the reason for his unpredictable erections. Identifying things his partner can say that will help, not hurt, his sexual confidence should he have another episode of ED in her presence. And he may have to learn how to speak kinder to himself and what it means to be sexually resilient.
So that’s the actual work we do in sex therapy. But inevitably what also happens is we touch upon much larger themes of what it means to be a human being in the 21st century. It’s fascinating how sex does that.
In particular, what I find so curious about sexual functioning issues is how some people hold tightly onto culturally-determined (and, unfortunately, often porn-informed) ideas about sex when real life sex is showing up differently. Those tightly-held ideas can be about what “sex” is, how to “have sex” with someone without actually engaging in a conversation about how that person likes to “have sex”, what you “need” to “have sex”, and what it uniquely means to each person if these shortsighted ideas and goals are not met. There ends up being a difference between what is and what should be and it can create conflict both within the individual and in their relationship. Folks can go to dark emotional and relational places if they or their partner misses the mark sexually and they experience that conflict. I’ve seen people end relationships, buy sketchy products online from unknown origins to “fix” themselves or their partners, harm their partners emotionally, and sacrifice their integrity — all when their idea of sex simply wasn’t showing up in their actual lives. It doesn’t have to be this way and the turmoil is optional.
Unfortunately during my week off from seeing clients between Christmas and New Year’s I got sick with a nasty cold. So instead of all that I had planned to do, the week was a perfect opportunity to both rest and read. I knew immediately which book on my nightstand I would grab: Esther Perel’s latest, “The State of Affairs: Rethinking Infidelity.” It turned out to be a great week after all.
This book is not a how-to-recover-from-infidelity sort of book — those books have been written. Rather, think of this book as a meditation on infidelity, relationships, and sexuality. Esther spends most of the book discussing and exploring the many facets of relationship betrayals and highlights some of the more interesting, and existential, issues that are always present. Her writing style is beautiful and poetic. Just like any good book, this one was a true pleasure to read. I hope you will consider reading it; you don’t need to have experienced an affair to ponder and learn.
In particular, I was so impressed with chapter 11 “Is Sex Ever Just Sex?”. This chapter was about male sexuality and compulsivity. And it was like none I have yet to read in a major book on the subject of human sexuality. Esther put words to what I have been thinking and seeing in my office for a long time. It’s time we start talking about it more. So let’s start with…
“Men want sex and women want love.” Oy. You hear this sad, pathetic, tired, and old heteronormative trope over and over in every corner of our culture. This is absolutely not true! I sit with men every day, I help them learn about their sexuality, and I can tell you with great certainty it’s not just sex that they seek.
(BTW, I cannot tell you how many times I’ve heard that trope said by a woman in my office. And yet that very [false] belief is getting in her way. This sort of message is so damaging to relationships. I spend a good portion of my week dismantling them and helping my clients take the emotional risks to really interact with each other — and not interact with their faulty perceptions and projections of their partners.)
In reality, men are just as complex sexual creatures as women. Generally speaking, besides the sensual pleasures of sex, I’ve found that men turn to sex to feel emotional vulnerability and relational connection. This is something us women need to learn and learn NOW. “Men want sex” because it’s the one place they can safely experience being vulnerable with another person — and straight men want to experience that with women. Wow! What a humbling compliment, ladies (truly).
Men get so many toxic messages about what it means to “be a man”. “Man up.” “Brush it off.” “What are you, a pussy?” They may hear those statements as children or teens and stop hearing them as adults but those memories and messages remain. Those are all harmful messages about masculinity. Even in adulthood it doesn’t really stop. Other men at the office or on the dating app are seen as competitors, people they have to defeat in order to win the prize.
All these kinds of messages tell men it’s not OK to (1) have feelings, (2) recognize those feelings, (3) give voice (internally or behaviorally) to those feelings, and (4) let alone work to soothe those feelings in a constructive, healing way. So how do a lot of men cope instead? By stuffing their feelings and/or withdrawing. That’s when a man “solves the problem”…of their uncomfortable feelings. Sex can definitely help distract us away from our emotional discomfort and create a mood change. (Enter sexual compulsivity.) Ours is not a culture that makes it easy for men to cultivate caring relationships with other men. No wonder sex is so important to them — it’s where they can finally let their guard down and maybe, just maybe feel a full range of emotions (like maybe vulnerability and connection) with another person.
Another thing I have seen repeatedly that Esther discusses in chapter 11 is the dilemma of the sensitive and caring man. This is the guy who maybe self-identifies as a feminist, maybe was raised by a single mom, maybe had a sister or two who had great influence on him, or maybe it’s the guy who is paying attention, close attention, to all the things women in our culture are saying right now about toxic masculinity and the use of power. This guy wants to honor and respect his female partner (and all women) and be their ally in the fight for greater equality for women…and he has sexual urges and desires. Urges and desires that may not fit nicely into the egalitarian relationship he and his female partner have fostered outside the bedroom. How do those sexual urges square up with that? It’s confusing and perhaps shameful for him.
The fact is, there is an element of sexuality that is aggressive. This is eros, the life force. It’s big and powerful and intense at times. We all have this aspect to our sexuality, men and women alike, and we need to learn about this part of our sexual selves if we are to have healthy sexual relationships based on self-awareness and mutuality.
I’ve worked with quite a few men over the years who have an uneasy or unknown relationship to their own sense of their masculinity and sexuality. They want to be strong and powerful and successful. They want to be admired by other men…and of course women. They want to be caring, sensitive, and skilled lovers. Just as the 21st century woman feels a lot of pressure to “have it all”, most 21st century men feel an equal amount of pressure to be all those things — a superman. Each man has to go through a process of examining these messages to decide what sort of man — what sort of human being — he in fact wants to be in the world. It’s no minor task and the implications are huge. And it has the potential to change his relationships and our world for the better.
Wow, reading this article in the New York Times, The Power of Touch, Especially For Men, was like deja vu from my previous blog.
If you recall in that blog below, I discussed how non-sexual touch can be used to manage sleep issues after the stress of those wildfires that destroyed a good portion of Sonoma County. Now the NYT is discussing how American men need more non-sexual touch, especially amongst each other. Dr. Ofer Zur is, unfortunately, correct: most socially acceptable touch for men is limited to violence and sex. I see so many men in my practice get the majority of their touch needs, A.K.A. skin hunger, met via sex. So for those guys sex has a greater urgency, importance, as well as possible implications. That's a lot to put on sex and your partner! Especially when they're not available for sex.
So this gets me thinking about about a really big question: how can we facilitate changing the culture of men to normalize non-sexual touch? I hope you will ponder this question too.
Now that most of us are out of the immediate danger of these fires that ravaged our beautiful community, I’m hearing from many people that they are struggling with sleep: having trouble falling asleep, having trouble staying asleep, not getting restful sleep, waking at specific times, or even having active dreams, nightmares, and flashbacks.
This is due to what is called hyperarousal.
No, that’s not a sex therapy term (sounds fun though, right?); it’s a clinical psychology term for a set of symptoms. Those symptoms include an overactivated nervous system and hypervigilance: being constantly tense, “on guard” and ready to take action if a threat returns. And let’s face it: everyone in our community was experiencing hypervigilance for several days during the fires.
So, back to sleep. In order to fall asleep, one must slow their thoughts and body down and have some sense of feeling safe. Basically let go of their hypervigilance temporarily. That’s hard for many to do, whether you lost your home and are now sleeping somewhere new and unfamiliar, or you temporarily evacuated and are back home, or never evacuated at all. Again that’s because of needing a sense of safety and calmness in order to fall asleep and the fires disrupted that on a profound level. Even for people who still have their homes, their homes maybe were not safe to them just a little while ago. As Sonoma County’s only Certified Sex Therapist, I want to offer some suggestions to help you get safe, restful sleep again.
First of all, most Americans are touch-deprived, especially American men. We just don’t touch each other enough affectionately. We fear that touch will send the wrong message, make someone uncomfortable, or lead to sex when maybe our touch is trying to communicate something else entirely like comfort, nurturance, safety, trust, closeness, and connection. This is a wonderful time to practice non-sexual touch. As a sex therapist I know one of the most calming and connecting things is touch.
Restful sleep generally returns for most people after a trauma with time, calmness, routine, and quiet. It takes conscious, deliberate effort to achieve though. So if you’re struggling with sleep, ask your partner if tonight when you get into bed you can hold each other for 30 minutes. Invite your kids to snuggle on the couch with you when you watch a movie. Pet your dog or cat slowly and gently. Do these daily. This type of touch will truly bring healing and calm to your overstimulated nervous system.
Other touch-centered ways to help get your sleep back on track include:
1. Some sessions with a professional cuddler. Seriously. Especially if you’re single and have no one to cuddle. It’s been proven that holding another human being lowers stress levels and increases oxytocin, the calming and bonding chemical in our bodies.
2. Get a massage. Not the deep tissue/sports massage but the long slow strokes kind you find in Swedish massage. Hot stones would be lovely too, as their warmth and light pressure would relax tight muscles.
3. Order a weighted blanket online. The slight pressure you feel under one helps calm you. Use it before bed or anytime you feel anxious.
Some people find only temporary relief when they do one of these things and get frustrated that the positive effects don’t last. But I take a different view: hooray it worked! Your body has experienced an entirely different state than the one it’s been in for the last 2 weeks. What a great, promising start. You’re already on your way to feeling better. Now that your body has experienced that calm, it will be easier to remember it the next time you touch/hold/cuddle/get a relaxing massage/lay under your weighted blanket.
And as always, if restful sleep doesn't return for you in the next few weeks, please consider making an appointment with a licensed therapist who can do a thorough assessment for trauma.
Nighty night, Sonoma County.
If you've been watching the television news of Sonoma County's horrific fires, you may have noticed that the news teams are NOT at the evacuation centers interviewing evacuees. In fact, the evacuation centers have outright said "NO MEDIA ALLOWED." Interesting, right? Certainly different than in the past. Wondering why that is? Because as a profession, we're not sure if talking about a trauma in an unstructured way immediately after it happens helps -- we think it may make some people worse.
Here's an excellent article from The Guardian, a UK paper, that explains more.
So if you're: hosting survivors in your home; plan to; know someone who has been evacuated; know someone who has suffered immense loss in the last 72 hours; know someone who might suffer immense loss in the next few days; or you fit any of these categories yourself, please read this. There are some useful tips on what you can do instead that truly are helpful.
Earlier this year I learned about and was fascinated by "the attention economy". Basically, the theory states that a human being's attention is now considered a resource and a commodity and various things (software applications, device/electronic companies, advertisers, other content creators) are all competing for our attention. Makes sense in this 21st century world, right? But why am I, a Certified Sex Therapist, writing about it? Because attention economics has direct applicability to human sexuality.
Many of my clients have some sort of complaint about their sex life. Whether it's a sexual functioning problem (like ED or inability to orgasm or problems with arousal) or a satisfaction issue ("I don't feel my partner and I are connecting during sex" or "Our sex life has become routine"), a lot of the problem is related to attention and focus. During sex, there are SO MANY THINGS competing for our attention: your feet might be cold, or your partner's breath might be unsavory, or the garbage truck out on the street might be making a racket, or you notice your worries about whether your body will do what you want it to do, or you worry if your partner is enjoying themselves. This doesn't sound that different from modern life where my iPhone game, TV, Netflix, latest YouTube video, texts from my friends, and even Facebook are all calling out to me, vying for my attention.
I find that many of my clients have never actually talked about, let alone paid attention to, where they put their attention and focus. Not just during sex, but also in life. For many, attention is a passive process. And over time this passivity becomes a habit and unconscious. A perfect breeding ground for sexual problems to occur in the bedroom!
So one of the things we talk about in my office and I teach my clients who come in with an attention-related sexual problem is how to pay attention to certain things while tuning out or ignoring other things. The shift from passive to active (or intentional attention) can be difficult initially but most folks generally seem to figure it out. It's a joy to observe.
John Gottman, famous marriage researcher, identified two types of problems in long-term relationships: solvable problems and perpetual problems. Solvable problems are exactly that: problems a couple can solve when they come up. For example, it can be whose family do we spend Thanksgiving with this year, or how should we spend the tax refund, or how do we help our child do better in school. The couple can work together to decide on a solution. Perpetual problems are those problems that always reappear whenever that particular subject or issue arises. They can be whose family do we spend Thanksgiving with this year, or how should we spend the tax refund, or how do we help our child do better in school. (See what I did there?)
Gottman's research shows that 69% of marital problems are perpetual problems. Let that sink in a minute. What a bummer. For many couples who come to my office this is a tough reality to accept especially when the perpetual problem is sex. Hopelessness is a common reaction.
But it doesn't have to be this way. With patience, perpetual problems can teach us more about ourselves and help us grow...that is, if we're willing to stretch ourselves psychologically, relationally, and sexually.
Here's a blog from The Gottman Institute that's a primer on how to cope with your relationship's perpetual problems.
It's not just women who fake orgasm. Men can, and do, fake it too, trust me. (Can't imagine how? Message me.)
I was reminded of the phenomena of faking orgasm recently and the impact it can have. Mainly, when a person fakes an orgasm they're making the decision to lie to their sexual partner: they are pretending that they are experiencing pleasure when they in fact are not. Why would someone fake an orgasm? Sometimes a person fakes it for the sake of their partner's ego. A previous blog post of mine from June 30, 2017 expanded upon how a man's sense of himself can depend on the sexual response he evokes in his partner and how he wants to be seen as a skilled lover. Sometimes a person fakes it because they are disinterested in sex either just that night or all the time and faking it gets the act to end quickly.
If faking orgasm is part of a relationship, then that relationship is one not based in honesty and integrity and the next time the partners have sex, the faker often feels their partner now expects a similar performance. It's a terrible cycle to find yourself in and also just plain unsexy.
What's the solution? Sexual integrity. What do I mean by this? That your outsides accurately reflect your insides. So if inside you're feeling not into a sexual encounter, instead of faking an orgasm to get it over quickly have your external behavior accurately reflect this feeling of not being into it. You might say "Honey, I know you're really into this but I just am not tonight. Can we rain check this to another time when I'm more motivated?" Or you can say "Sweetie, I wasn't initially in the mood so I thought by doing stuff I'd get in the mood but it's just not happening for me tonight. Can we focus on your sexual pleasure instead?" Or you can say "I need to be honest with you because up until now I haven't. I have low sexual desire; always have. I haven't been able to tell you this because I really liked you in the beginning and I was afraid you'd break up with me over it. I love you and want us to be together. Let's talk about how we can manage our desire differences."
Practicing sexual honesty and integrity can be challenging. It means taking risks, being your real self, being vulnerable, not taking things personally, listening non-defensively, and a host of other skills grownups need to have for a fulfilling sex life.
What do you consider private and what do you consider secret?
After there has been a relationship betrayal of some kind (for example an extramarital affair, or sexual behavior not shared with the partner, or pornography viewing done in the absence of a partner), this question inevitably comes up. It's one of the most important questions we talk about in my office and yet one of the most scary for couples. Why? Because initially after the discovery of the betrayal, one or both partners want complete transparency: unlimited access to the cell phone, passwords to email and other online accounts, and heck, even ankle monitors! This is a direct result of the trauma felt by the betrayed partner and observed by the betraying partner (not to mention the guilt the betraying partner now feels): something was happening to/in their relationship without their knowledge or consent and now their world has turned upside down. What they thought was clear is now murky. Scary indeed -- to both partners. But complete transparency is impossible (believe me, I've seen and heard many clever strategies by the betraying partner to avoid so-called "complete transparency") and the betrayed partner usually end up saying something like "I don't want to be in the role of the cop", meaning they don't want to monitor their partner's activities 24-7. As their couples and sex therapist, I don't want this either. This can have profound implications down the road and it's my job to think about these things. The betrayed partner wants to trust. And if the betrayer is really committed to the relationship (and not doing the betrayal as a way out the door), they generally want to be trusted again too.
So eventually we circle around to this question -- defining what each partner thinks is private vs. secret. It can be a tough conversation because each partner is asserting themselves and there probably isn't going to be 100% agreement on everything. Nor should the partners expect there to be and they need the inner resources to handle that. More importantly, this question and conversation acknowledges that there are some things you just won't know about your partner. It's a necessary conversation. And having it helps each partner grow more into themselves and their relationship.
This is from a Q&A pamphlet from a gynecologist’s office about what a patient can expect during a pap smear. Oy, it makes my skin crawl. Here’s why:
While I understand every ethical doctors’ motives are to help their patients and this pamphlet has been created to do just that, this is horribly offensive to someone who is sex-positive. I don't doubt that some women do feel uncomfortable during this procedure and doctors try to ease their discomfort. Yet this paragraph demonstrates that doctors are expecting their patients to be embarrassed and uncomfortable during the exam and test. That's a dynamic the doctors are setting up even before the patient walks into the exam room -- and it tells me they've been trained to respond to it. But I ask: what is there to be embarrassed about? By getting a pap smear test, a woman (or a trans man) is doing something powerful: they are taking control of their health and getting tested for a potentially life-threatening disease (cervical cancer if you didn’t know). This is something to be proud of! It is empowerment and agency at its best. Doctors help us take better care of ourselves. Where’s the pamphlet from them that celebrates this notable act of courage?
And the part about what the patient can do to make it more pleasant is insulting and bordering on abusive ("distract yourself/don't be in your body and we'll finish soon"), not to mention patriarchal. The real question to ask is: what can providers do to make it more pleasant for the patient? They have the power and expertise in the doctor-patient relationship and the onus falls on them to ensure that the patient’s experience be a good one to the best of their ability. They can start by not indirectly shaming women and trans men for simply having certain body parts.
This pamphlet represents institutionalized shaming on a much deeper level. And as a mental health professional, here’s what I know about shame: it keeps us small and compliant. Is that what doctors, and the medical field for that matter, want in their patients? Eeek, I sure hope not. I challenge every medical professional who is reading this to look more critically at their office’s written materials and see what can be
made more sex-positive, respectful, and sensitive of the patient's experience. And I hope everyone who is due for their pap soon to go in asking their providers to support them in their bravery.
I concur with a lot in this article and research. I, too, notice in many of my straight male clients that they care very much if their female partners orgasm. This article and the associated research tell us there's a lot wrapped up in that experience for men when a woman comes:
- the man has an enhanced sense of his masculinity and confidence
- he thinks he's perceived as a skilled lover and therefore she might want to have sex with him again
To quote from the article: "Unfortunately, when a man’s view of self depends upon the response he evokes in his partner, it may put tremendous pressure on the partner, and ignores the fact that healthy, pleasurable, mutual sexuality involves much more than just the man’s skill." YES! And that dynamic is exactly what we talk about and work on changing in my office.
And this last paragraph is a great one, worthy of some reflection:
"We can help change the script, and help men to reduce the degree to which they pressure their partners, in order to fill that aching fragile fear of being less of a man. But we can only help if we recognize that men didn’t choose to be this way. Understanding that “giving” orgasms is one way men build up their masculinity helps us to better empathize with men. It challenges us to consider the ways we “emasculate” men such that they must sometimes be so desperate to rebuild it."
Thanks, David Ley and Sari Van Anders.
As I prepare for a presentation I'll be giving later this summer at a local retirement community on Sexuality and Intimacy While Aging, I am reminded of how much I enjoy working with older adults. This can be people 60, 70, or 80+ years old wanting to improve their sexual relationships. Once we get the obvious age difference addressed (theirs vs. mine) and set aside, I find these clients to be authentic, energetic, eager, wonderfully humorous, and hopeful about their sexual futures (all good things to bring to the bedroom, I might add). It doesn't come without its challenges, though, and as the saying goes, aging isn't for wimps. Sexuality in later life can be one of the best parts of a couple's relationship, a safe harbor where they can fully feel and share their aliveness and love for each other in the face of uncertainty. It is a joy for me to work with these clients.
Now here's a humorous and endearing video that may stretch your understanding about sex and aging!
Hi friends and readers, I'm leaping into the 20th century (ha!) and officially starting a blog on my website. I used to post my observations on Facebook, which you can find over there, but starting now I'll be posting them here. Check back often and thanks for reading!
I am a licensed Marriage and Family Therapist and AASECT Certified Sex Therapist located in Sonoma county, California.