Recently I presented at the TransLife Professional Symposium here in Sonoma County, a conference for professionals who provide services to transgender individuals. There were physicians, psychotherapists, educators, and lawyers in attendance and the workshops represented the various medical, psychological, educational, and legal needs of the trans population. I presented on how to talk to your trans clients from a sex-positive perspective. It was an honor to be part of such a progressive conference.
Our society has come a long way in a relatively short amount of time to support, validate, and make legal the diverse trans experience. We (I think?) have a greater understanding of gender identity versus sexual orientation. We (I think?) understand the importance and in many cases necessity of hormone therapy and gender confirmation surgeries. We (I think?) understand that if one is transgender, not respecting this can lead to mental health issues including trauma, substance abuse, anxiety, depression, and suicide and all of those have public health implications. All of this (I hope?) feels greatly affirming to trans people. But where my profession still has a growth edge is in talking to transgender folks about their sex lives. It’s yet another taboo subject under the bigger taboo umbrella of “Talking About Sex In Therapy”.
A good portion of your sexuality involves your feelings about your own body both in general and regarding specific body parts. For example, cis-gendered folks have told me “this body part is too big” or “that body part is not big enough”. These are feelings of inadequacy, insecurity, and shame and also involves fears of judgement and rejection by others based on those body parts and their perceived deficits.
For a trans-identified person, this aspect of their sexuality is often made more complicated. In addition to the feelings I stated above (and others), sexual organs and erogenous zones can be full of emotional turmoil for additional reasons: perhaps those body parts represent a rejection — not by others but by themselves “this is not me”. Perhaps those body parts symbolize a disconnect from the body they were born with versus the body they want and need to feel authentic and whole. Or perhaps a certain body part represents sadness or anger because they do not have the resources to change it to what they envision and need. For many trans individuals, their bodies do not feel like home. Add to that the fact that those very parts are often where body-based sexual pleasure is obtained and sex is now made more confusing and emotionally messy.
Most people tell me that when they can receive sexual pleasure from their partner(s) they feel loved, accepted, and seen. Sounds amazing, right? But when a trans person has understandably conflicted and unresolved feelings about their own body, using that very body to engage in sexual activity can feel risky, scary, and downright unsafe - not necessarily because of their partner (although that’s true too), but because of themselves. Perhaps you can now see why it’s common for a trans individual to feel intensely uncomfortable with their own sexuality.
Trans folks have unique challenges when it comes to having sex, too, and my profession needs to support them in better understanding their sexual selves. Helping trans folks better integrate their sexuality — not just their gender identity — into themselves and their sense of place in the world, and learning how to be a sexual being with their body, is another important aspect of the transitioning process.
'Whole Again': A Vet Maimed By An I.E.D. Receives Transplanted Penis
This provocative news article is getting a lot of attention today because of these two words: "penis transplant." Certainly gets one's imagination going, doesn't it?
Headline aside, every war brings home new medical and psychological wounds that our veterans must live with every day and our health care system must learn to treat effectively. While many veterans of Iraq and Afghanistan are coming home alive, they are also not coming home intact. Whether a veteran is suffering from medical or psychological scars (or often both), many of them hope to resume their sexual relationships with their partner once home. Or if they're single, they hope to find a partner and build a life together. Sexual functioning represents "normalcy" to many but it also is about connection, one's sense of self, their ideas about their future, and as the article states, a wholeness. Genito-pelvic injuries have far-reaching consequences. We need to remove the shock, stigma, and shame surrounding them and treat these brave individuals with the respect and dignity they so greatly deserve. I'm happy to see this article illustrates the beautiful humanness in it all.
The common belief is that Valentine’s Day is the day to celebrate love, especially romantic love. In reaction many people get anxious, or feel insecure or angry, or become critical of the day. “Singles appreciation day”, “a Hallmark holiday”, and “It’s just about obligation” are things we have all heard. I want to offer you a different perspective on how to observe this day that has nothing to do with your romantic relationship status and everything to do with yourself.
Think of all the traditional gifts we give those we love on Valentine’s Day: beautiful flowers, sweet treats, a delicious meal, a soft teddy bear. All of these gifts involve the senses. The tokens exchanged on Valentine’s Day are not about love but are instead about sensuality.
Valentine’s Day can be a day to celebrate indulgence and sensuality - two things us Americans don’t seem to do well. You may be thinking “You’re right we have a problem with overindulgences! We overeat, drink to excess, over spend, and binge watch.” But I would actually argue that those activities aren’t about overindulging, at least not the way many of my clients tell me they do them; they’re examples of consuming a luxury without mindfulness.
I’ll paraphrase a French philosopher: the excess of pleasure without savoring is debauchery. Unfortunately this is what many of us do: we don’t savor a sensual experience. To savor something means we slow down, notice all the many facets and nuances of it, experience it fully, and appreciate it. If you’ve ever been to Italy, you understand what I’m talking about. Italians know how to savor - a glass of wine, a carefully-prepared meal, a beautiful piece of art, music, or fashion. We could learn something from them in this regard. Americans deprive ourselves of sensual pleasures over and over which creates a sense of scarcity about the very thing we are denying ourselves. So we end up devouring it because we think it’s scarce…only to then feel guilt and shame about devouring it. When given the opportunity to indulge our senses after a period of self-denial, we can easily go overboard.
Old habits die hard and our culture’s history of denying the self for virtuous reasons that lead to attaining one’s moral and spiritual goals is still there under the surface. I know: I often bump up against these hidden beliefs with my clients. To fully enjoy a sensual experience is a scary prospect to some because of the intensity of their self-denial behaviors and their anxiety about pleasure. Some folks swing back and forth between self-denial and overindulging, creating an emotional seesaw. I believe it’s this seesaw, not the pleasurable sensations themselves, that cause an individual’s pain and suffering. No wonder we have such mixed messages about the pleasures of Valentine’s Day and end up making the day about love instead. Love, even in all its enormity and complexity, seems more manageable than individually savoring sensual pleasures.
When I talk to my clients about the need to build a better appreciation for sensuality in their daily lives, I can tell they don’t really understand what I mean. Many people confuse sensuality with sexuality so let me explain. Sensuality is the use of one’s senses to notice and experience pleasure whereas sexuality involves sexual feelings. For example, receiving a massage is a sensual experience — the dimmed lighting, the warm hands on our body, the smell of the massage oil — without it necessarily involving sexual feelings.
Today is a day you have permission to slow down and savor sensuality so I hope you will go home tonight and enjoy the fuck out of those flowers, that chocolate, or your dinner. Notice everything you can about it. You might find that you not only experience a deep sense of pleasure and relaxation but that you also feel really fulfilled doing so. You might even learn a thing or two about yourself. And none of this has anything to do with your romantic relationship status.
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.
I am a licensed Marriage and Family Therapist and AASECT Certified Sex Therapist located in Sonoma county, California.