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The FDA’s announcement yesterday that they’ve approved flibanserin is huge for women. This is the first medication approved for treatment of hypoactive sexual desire disorder (HSDD), also called female sexual dysfunction (FSD) and, more recently, female sexual interest/arousal disorder (FSIAD—a new abbreviation!).

The multiple names for the condition we’re treating tell a story all by themselves. It’s been a long road to get sexual arousal issues for women the same attention as has been paid to erectile dysfunction in men, perhaps because the symptoms are less visible. The media coverage of the process, I’m hopeful, has had some educational effect, endorsing FSIAD as a real medical condition with real potential for treatments. I have new reason to be optimistic that this decision will lead to further developments in the field—because it’s been proven that it is possible to get a medical treatment in this arena through the FDA approval process.

This approval is great news for women who suffer from this specific medical diagnosis, for whom I, as a menopause care specialist, have had nothing to offer. It’s great news for their partners, who, along with the women, have some hope and optimism that the desire and passion they once shared may be restored to their relationships. I’ve heard from women in my practice about the double-whammy of their loss of desire: Not only do they miss their sexual selves, they regret the unintentional messages they’ve sent their partners.

I’m hopeful that hearing about this development will encourage more women to be frank with their health care providers. At least half of women will have sexual difficulty at some point, but far fewer of them will bring it up to their doctors. If they know there’s a possible treatment, perhaps women will have more motivation to ask. I haven’t seen a study, but I’d be willing to bet that more men asked doctors about erectile dysfunction when they’d heard Viagra was available.

Together with my patients facing the FSIAD diagnosis, I can have a conversation about the potential benefits and side effects of this medication. We can make a plan of action. The women I serve aren’t expecting miracles; any possibility of even a modest improvement will be life-changing for them.

As a doctor, I’ll now have something to say after “no, it’s not all in your head” and “I’m sorry.” I can’t wait.

Even though I’m a medical doctor, I’m not accustomed to watching the Food and Drug Administration’s actions as closely as I have the past few months. If you’ve followed this blog, you know that last October, I traveled to Washington DC for a public hearing and then a workshop of women’s health experts. The FDA sponsored the events to hear about women’s sexual health and to examine how they might respond.

And then in June, an advisory committee to the FDA recommended the approval of flibanserin, a medical treatment to address hypoactive sexual desire disorder (HSDD). The FDA is poised to announce its decision next week.

It’s been a long road. I first wrote about flibanserin back in 2010, when the company that had developed fibanserin shelved it, saying that it didn’t have sufficient “potential to make it to market.” There’s been controversy about the HSDD diagnosis, although it was first medically characterized in 1977 in the Journal of Sex and Marital Therapy and is listed in the International Classification of Diseases.

More important to me than those scientific listings are specific women I’ve seen in my practice. They’ve had satisfying sex lives. They love their partners. They want to want intimacy. They don’t have psychological problems, relationship issues, social hang-ups, or a medical problem—beyond HSDD. Brain scans show different activity and structure in women with HSDD, proving the biological component.

As their doctor, I want to offer them options to reclaim the life they want, which includes intimacy. It’s up to each woman to decide which of the options she’s like to try, and then to determine whether each option is working for her.

Beyond the approval of this one pharmaceutical product, the FDA’s action is, I hope, a signal for a bright future. When I was there in October, I heard that the agency “recognizes that this [female sexual dysfunction, or FSD] is a condition that can greatly impact the quality of life,” and that “the FDA is committed to supporting the development of drug therapies for FSD.”

As a physician, I’m committed to the least invasive, simplest solution for each woman. But when that simplest solution doesn’t work, I’m deeply grateful for well-tested, thoroughly researched pharmaceutical options that help women restore the fullness of their lives.

Almost as soon as we posted the piece on how to bring up difficult topics, a reader asked “But how do I get my husband to listen?”

It’s an excellent question, and we put it to our friend Ann McKnight, a social worker and psychotherapist. Her answer might surprise you. If you feel like you’re not being heard, you might want to look at yourself first. “You have to ask yourself, ‘Is this really about me getting my way?’ If it is, you’re virtually guaranteed the conversation won’t go anywhere,” she says. “Most of the time, we engender defensiveness in the other person because of the way we say things.”

That defensiveness shuts down the opportunity for real communication, and the conversation ends before you’ve gotten to the issue, even if you’re still talking. That defensiveness is rooted in fear—fear of being judged, criticized, blamed, shamed, cut off. Just as fear interferes with our willingness to bring up difficult issues, it interferes with the other person’s willingness and even ability to really listen. Fear is the ultimate intimacy blocker.

Your genuine desire to understand what’s going on with the other person is critical to that person’s listening skills. Arriving and hanging onto that desire while you’re talking about a touchy subject isn’t easy, but it is possible.

Here are three things Ann says you can do to improve the chances that your beloved will be able to hear what you’re saying.

Be curious. That thing your loved one is doing? He or she is probably doing it for a good reason. “The conversation needs to be ‘There are clearly some things about this behavior that are working for you, so let’s talk about those.’ After you connect about those reasons, then you have a more interested audience. Repeat the reasons back in a nonjudgmental way, and then ask if the person is willing to hear what’s not working for you. If you can get to that place, then you have an opportunity for an open dialogue.”

Make sure you’re staying connected. “That means the other person is experiencing that I am in a place that’s open to hearing them. It doesn’t mean I have to agree. Only that I care if they are feeling judged and I care about their thoughts,” says Ann.

If the other person hears judgment or criticism or blame—even if you don’t think you’re conveying any of that—the connection will be lost. Increase your chances of maintaining the connection by, at the outset of the conversation, saying something like: “I have something to share with you and I’m not coming from a place of criticism [or blame or whatever], so if you could raise your hand when you’re feeling that, then I can reassure you in the moment or I can say, ‘You’re right. I am being critical.’”

Let go of the outcome. Finally, go into the conversation with absolutely no attachment to the outcome, and keep an open mind the entire time. Once you hear what it is about the other person’s behavior that is working for them, says Ann, “your attachment to ‘You need to stop this right now’ changes and you think, ‘Maybe, given what works for other person, there’s a different way to solve this.’”

Throughout the conversation, keep demonstrating to the other person that the conversation is not just about you getting your way. “You keep throwing them a lifeline by asking ‘What is it like for you to hear what I just said?’ That shows the person that you actually care about their response to what you’re saying.”

Throw that lifeline enough times and your partner just might start throwing it back to you. That’s not just a way to resolve a difficult issue—it’s also the way to increased intimacy.

“I just cannot talk to him about this!” I’ve heard that declaration from patients and friends alike over the years. Sometimes the “this” is something related to sex, but sometimes it’s related to issues that have festered—everything from “he doesn’t spend time with my side of the family” to “I always have to be the ‘bad cop’ to his ‘good cop’ with the kids.”

The topic itself doesn’t matter much because all topics come down to the same things: “Do you care about me? Can I trust you?” says Ann McKnight, an experienced social worker and psychotherapist in my community. “We want to tell ourselves it’s just about this one issue, whatever that is, but this issue is often sitting on top of other hurt that hasn’t been addressed.”

Intimacy is all about connection and trust. Deepening intimacy involves making yourself vulnerable. Being real. What makes it so difficult to talk about things that really matter? Ann says reasons vary. We might do it because we think we are being considerate of the other person. (“He’s under so much stress right now. The last thing he needs is another problem.”) We might not feel confident in our ability to navigate through the conversation. Or we might worry that the conversation will result in so much anger that the relationship will never recover. And the longer we don’t talk about the topic, the harder it becomes. The resulting resentment can erode even the best relationships.

But it’s actually the very things we try to avoid, like sensitive topics, that increase intimacy. Ann asks, “What would happen if we saw these conversations and the pain and anger that come up in them as an opportunity to learn something that might result in growing closer to each other?” While there are no guarantees, Ann has seen this happen over and over in her practice.

After you decide you want to bring up the issue (and you’re sure that you’re not expecting the conversation to lead to a change in behavior for the other person) then you’re ready for the conversation. You might start by saying something like, “Our relationship is so very important to me that I’m willing to risk feeling uncomfortable right now to work on strengthening it.  I’d love to know more about what ____[issue] is like for you.  Would you be willing to talk with me about this?  When would be a good time?” In some cases, you might want a therapist to act as facilitator.

While such conversations are painful, they are also necessary. How can your partner respond if you haven’t shared what’s going on? “If we are not bringing ourselves forward to be known and seen and cared about, it’s easy to tell ourselves we are not lovable to others,” Ann says. “But when we take that risk with people who hang in there, the rewards can be huge. It can be freeing and it can help people shift out of places that seem impossible to get out of.”

In an ideal world, we’d all love our bodies exactly as they are. We’d love our little muffin tops for the reminder of all the ice cream sundaes we’ve shared with a best friend, our marshmallow tummies for the children we carried, and our pancake boobs for making bras (practically) pointless.

But we don’t live in an ideal world, and the way we perceive our bodies affects how we feel about having sex. We probably all have personal experience with this, and research backs it up.

Fortunately, there’s a way around poor body image and it’s called exercise. Before you groan and stop reading, just let me say that this post is about more than exercise’s effect on that muffin top. It’s about exercise’s effect on a whole lot of things.

Research shows that exercise improves body image, desire, and (our male readers will be happy to know) erectile functioning. It also leads to an increase in overall sexual satisfaction, according to research, the findings of which were published in the Electronic Journal of Human Sexuality.

And here’s the best part of that research: the exercise doesn’t even have to be strenuous. “Overall sexual satisfaction was significantly associated with all modes of exercise/physical activity (i.e., sport, aerobics, recreation, and strength training).”

Improving your satisfaction with your sex life might be as simple as taking a walk or a leisurely bike ride or going canoeing—the more frequently, the better. So the benefit of exercising isn’t just that it tones our bodies. It’s that we feel better about ourselves and our sex lives, maybe long before the effect shows up on our middle-aged middles.

Perhaps you already do those walks or bike rides. If so, good for you! Want better orgasms? Consider adding weights or aerobic exercise to your routine; the research also showed that strength training had “the strongest relationship to overall satisfaction with quality of orgasm.” And many studies show a correlation between aerobic exercise and quality of orgasm.

See? No need to be deterred by the word “exercise.” Just think of it as adding a little more activity that will lead to getting a little more action.

Ah, summer! The sun is warm, the days are long and languid, and it has three holidays. It’s a season tailor made for spending time with the one you love, focusing on each other, and building intimacy.

While there’s nothing wrong with going to all those old familiar places, like the summer-only deck of your favorite restaurant, your time might be better spent mixing it up a little. That’s because familiarity and desire don’t always coexist happily. Couples often have to fan those flames, and the right kind of date night can help.

This summer, try applying Hollywood’s 80/20 formula: 80 percent familiar (girl meets boy) and 20 percent novel (girl happens to be a mermaid).

Choose something that the two of you have done and enjoyed in the past, but add a little (or big) twist. We’ll get you started.

  • If you like the theater, go see a contemporary performance art. Better yet: Take an improv class together. What you learn there will be useful in all of life, not just your relationship, and at the very least, you will share a few laughs.
  • If you like movies, go to a drive-in. Better yet: Make your own movie short using the camera on your smartphone. You don’t have to be a budding Martin Scorsese. Do a send up of a scene that you like from your favorite movie or TV show.
  • If you like to shop, go to thrift stores. Better yet: Spend a morning going to garage sales. You’d be surprised at what you learn about your beloved—and maybe even by what you remember about yourself.
  • If you like to play games on your smartphone (Candy Crush, anyone?), go retro by playing three-dimensional Scrabble or backgammon. Better yet: Pair the game with a bottle of wine and some cheese and turn it into a picnic.
  • If you like living a little on the edge—speeding, breaking rules, disobeying authority, in general—go parking, or go commando. Better yet: go skydiving. Commando.

Whatever it is you like to do as a couple, give it some spin, a kick in the keister. If nothing else comes to mind, try Phil and Claire’s trick. The Modern Family couple occasionally adds zing to their date night by pretending to be “Clive” and “Juliana,” two people who leave their responsibilities behind for a night of passion with “a stranger.” It may be the most ingenious solution of all to the love/desire dilemma.

Will some of this make you uncomfortable? We certainly hope so! Novelty—doing something you haven’t done before—involves risk, which leads to excitement, and can rekindle desire. It’s already July. How will you spend the rest of the summer?

Relationships at midlife are complicated. Expectations and needs of aging parents, boomerang children, extended family and friends—they can completely exhaust us. Especially if we have grown accustomed to putting others’ needs before our own, we can end up being busy, lonely and depleted. Exhaustion and loneliness can make us vulnerable to the allure of relationships that hold a little more excitement. The tough reality is that we can be tempted into relationships that are not safe.

When we were younger, safe sex used to mean sex that was “protected”: from unwanted pregnancy or sexually transmitted diseases. But now we know that those issues are just the first level of “safety” in sexual relationships. It’s one of the reasons that we at MiddlesexMD, in our recipe for sexual health, include emotional intimacy. The fundamental requirement for emotional intimacy is to be safe, emotionally and physically. If your relationships pose a threat to your sense of security, sex will not be intimate.

Lots of research has gone into what makes for intimacy. One of the most famous early researchers was Abraham Maslow (1908-1970) who studied psychologically healthy people. He developed a model that is called the “Hierarchy of Needs” to describe psychological development. Key to understanding how the model works is the idea that if the “first order” needs are not met, it is difficult if not impossible to work on attaining higher levels. Often portrayed as a pyramid, the hierarchy starts at the bottom with these first three levels:

  1. Biological and Physiological – air, food, drink, shelter, warmth, sex, sleep
  2. Safety – protection from elements, security, order, law, stability, freedom from fear
  3. Love and belongingness – friendship, intimacy, affection and love, from work group, family, friends, romantic relationships

Notice that in Maslow’s model, sex is listed as a first-level need. Intimacy, on the other hand, is at the third level, part of love and belonging. And between those two is safety! So Maslow’s model tells us that to have real intimacy, we need safe sexual relationships. In recent years, the tidiness of Maslow’s model (really? one need first and then another?) has been challenged, but the central truth—that a sense of security is a prerequisite for the vulnerability that’s part of real intimacy—still holds.

Our suggestions–or anyone else’s–for developing intimacy aren’t helpful if the relationship is not safe. And no generic answers are appropriate. There is help available, and some resources are listed here.

It’s difficult and complicated territory. Women often feel culpable—that they’ve “asked for trouble,” or we assume that men are just more aggressive. If you feel threatened and can’t talk about it with your partner, that’s a warning sign. In a 1975 interview in People (right after the publication of her landmark book Against Our Will: Men, Women and Rape) Susan Brownmiller was asked, “Are most women not wary enough?” Her response was “Not nearly enough. They should learn to say no at the door…. A lot of women make mistakes out of loneliness.”

You don’t have to be lonely. And you don’t have to be unsafe. You deserve better.

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