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“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.

When Size Matters

A recent report in The Journal of Sexual Medicine caught my eye. “Vibrators and Other Sex Toys Are Commonly Recommended to Patients, but Does Size Matter? Dimensions of Commonly Sold Products” is the title. First, I was happy to see that the authors are furthering the discussion about health care providers telling patients about “vibrators and other sex toys” (and, full disclosure, my article in OBG Management is footnoted as among the voices encouraging physicians to consider what they offer women through their practices).

Beyond that encouragement, the researchers compiled dimensions of vibrators and dildos, noting that not every source provides accurate or complete information. The conclusions they reached were that while the size of products varied, the dimensions, overall, “approximated mean penile dimensions.” They further suggested that further familiarity with the product category among clinicians, which is never a bad idea.

Since I’ve been recommending vibrators to women (and men) for some time, I’ve got some practical observations to share, for both patients and clinicians.

First, don’t do anything that hurts. Really.

The corollary to that is that you get to decide what hurts and what feels good. There are no “shoulds.” That’s true even if someone has a chart of dimensions and predictions.

I find that women like vibrators that can be inserted into the vagina for three reasons:

  • They like the feeling of fullness (and for them a dildo is also effective)
  • They like direct stimulation of the G-spot (which, as we’ve said before, has a mystique all its own)
  • While they don’t specifically think of the G-spot, they like the internal stimulation

Their favorite toys are as varied as the women themselves, and dimensions are only one part of that equation. Materials, pulse patterns, and vibration strength also count. Sexual partners and history can have an influence, as can progression of menopause, which can mean narrowing and shortening of the vagina. Over time, women may want a shorter, narrower vibrator, quite possibly with a stronger motor for more intense sensations.

But, again: Using a vibrator should feel good. If a vibrator is too large to comfortably insert, don’t insert it—or wait until you’re more fully aroused before you try again. And regardless of “insertable length,” don’t feel like there’s anyone but you who decides how deep to go.

And if insertion doesn’t sound good or feel good, remember there are a number of vibrators designed to stimulate the clitoris, which is where the nerve endings are concentrated that 70 percent of us need for orgasm.

So if your health care provider is still studying up, don’t be discouraged. Women have more than 100 years of experience using their own judgment with vibrators and pleasure, and you can do the same.

Last week, an advisory committee to the Food and Drug Administration made history. Or, as the Even The Score folks have been hashtagging, Herstory.

They recommended that the FDA approve flibanserin, which is a pharmaceutical product intended to address hypoactive sexual desire disorder (HSDD). There were a number of concerns voiced, and some cautions will likely be recommended, including caution with interactions with alcohol and while driving.

Sally Greenberg, National Consumers League executive director, was quoted in The Washington Post as saying, “I think this is a huge moment for women’s sexual health, in the way that the pill was for women’s sexual health and ability to control their own destiny.” The Wall Street Journal article on the FDA panel said “… the panel’s vote marks a turning point in women’s health.”

I’m celebrating. This particular drug will not be the silver bullet for all women with HSDD, but I’m hopeful that we have turned the corner that the Wall Street Journal reporter envisioned. HSDD has been recognized as a legitimate health problem, and this panel of the FDA has accepted evidence that brain chemistry is a factor (as it is with depression and other mood disorders).

As a medical practitioner, I know that every woman is different, and no treatment will be perfect for everyone. Each woman has her own medical history, her own values, her own desires, her own trade-offs, her own attitudes toward medical treatments—and, for that matter, toward sex. Having options to choose among helps each woman to navigate challenges as she prefers.

The FDA is expected to take action on flibanserin in August. I’m hopeful that after that, I’ll have an option to offer women who have lost desire. And I’m hopeful that having seen this hurdle overcome, other researchers will add to our armorarium so we have even more choices to offer.

This week Thursday, there’s a dry-sounding meeting that is a big event on an issue of enormous interest to a relatively small number of us. I’m talking about the joint meeting of the Bone, Reproductive and Urologic Drugs Advisory Committee and the Drug Safety and Risk Management Advisory Committee of the FDA. Snoozing yet?

This meeting will hear presentations about Flibanserin, a drug developed to address loss of sexual desire, which is a real issue for some women. I’ve been following the prospects for Flibanserin (and other pharmaceuticals) for some time, as you may know if you’ve followed this blog. There’s been controversy—in medical, regulatory, and sociological circles. Some said the original studies were inconclusive. Some said the side effects were too significant. Others said that loss of desire isn’t an issue at all—that, variously, couples therapy, a romantic dinner, or more chocolate was the answer.

As a physician, I have conversations with women about their sex lives every day. Some women are clear about relationships that are no longer satisfying. Some have emotional issues—some from past sexual trauma, others from life’s over-abundance of stress—that affect their attitudes toward intimacy. Some have physical symptoms of discomfort or pain or loss of sensation that we can address.

But there are some who have simply lost desire. They love their partners, they have no physical symptoms or obstacles to overcome, they have no complications in their lives that would explain away the change. The overwhelming emotion they share with me is sadness. They are experiencing a loss. And my overwhelming response is frustration. Because as many options—over the counter and by prescription—as I have for vaginal dryness and pain and loss of sensation and even depression, I have no options for treating loss of desire.

Here are the things I hope the members of the advisory committees are keeping in mind when they hear the presentations this Thursday:

  • Loss of desire—for insurance code purposes, Hypoactive Sexual Desire Disorder (HSDD)—is real. Women and their doctors are smart enough to figure out when there’s another issue of physical or emotional health. And one in 10 women has HSDD.
  • Women are as deserving as men of treatment for conditions that affect their quality of life. There are 26 drugs for male sexual dysfunctions; surely a healthy and satisfying sex life can be as important to women as to men.
  • Women and their doctors are capable of deciding for themselves what trade-offs they’d like to make with their health. We’re already doing it with hormone therapy; for some of us, the benefits to our overall health and quality of life outweigh potential risks or side effects.
  • No blanket rules are required. Whatever treatments are available will be choices, subject to the insight of health care providers and individual patients’ health histories, values, and priorities. We’re hungry for options.

And I recognize that this week’s meeting is only one step down what has already been a long road. The advisory committees will make recommendations, but they won’t make a decision. That’s the work of another day. The pharmaceutical industry has to retain interest and commitment actually to bring drugs to market. Health care providers need to educate themselves and their patients about the options and the trade-offs.

So it’s a long road, still. Please, let’s just take one step. With open minds and fingers crossed.

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