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Archive for September, 2011

It’s the third Friday of the month, and you know the script by heart—half-hearted foreplay, missionary position, a quick (or not-so-quick) denouement, and your partner’s already snoring while you’re thinking about tomorrow’s chores.

Routine is inevitable in long-term relationships. Routine can feel secure and orderly, but too much routine in the bedroom just feels boring. When you can anticipate every move, when you stay up late to avoid sex, when you wish your partner would just hurry up and get it over with, it’s time to hit “reset,” and crank up the heat with your honey.

It’s worth putting the effort into a good sexual relationship for all the reasons I mentioned in the last post. You’ll probably be spending your golden years with this person, and sexual intimacy (which includes kissing and cuddling) is at the heart of a healthy relationship outside the bedroom. Regular sex is also good for your health, and it’s good for your mental frame of mind. Besides, if you’re going to have sex, you might as well make it good.

But you can’t just jump in bed with sex toys in hand—lay the groundwork I discussed in the last post. Communicate. Try to understand your partner’s needs. Does he or she feel vulnerable? Uncertain? Inadequate? Bored?

Share fantasies. And keep an open mind. Anything new seems awkward and weird at first, but neither your mother nor your pastor is in the bedroom. This is sacred space for just the two of you.

Once you’ve both agreed to sweeten the honey pot, here are some ideas to heat things up:

  • Create a boudoir. Your bedroom should be a place for sleeping and for sex. It’s not the junk room, not the den, not the family photo gallery. Take out the distractions—including the television. Create a private, comfortable, beautiful space for the two of you to be together.
  • Write love letters. Leave notes for each other throughout the day. Make them more lusty as the day goes on. (We found some postcards you can use if you like.)
  • Fantasize. Talk about sexual things you’ve always wanted to do. Write down three for each of you. Put them in a hat and draw one. The other has to at least try. (Not sure where to start? We found these vows when we were looking for postcards!)
  • Focus on foreplay. Forget about scoring a home run. Get creative with the many ways of getting around the bases, from sexy undressing to intimate touching.
  • Focus on skin. Remember that big sex organ? Use that powerful sense of touch to explore your partner’s erogenous spots. Use textured objects, such as feathers or silk, to create new sensations and to stimulate sensitive nerves.
  • Swap roles. One of you is the “giver,” whose sole task is to pleasure the other. Pay attention to what feels good to your partner, how he or she responds to certain touch in certain places. Then switch roles—you get to be the receiver.
  • Change places. Make love in a different room, a different house, outdoors, in front of a mirror. “[Sex] is about the stimulation of your surroundings,” said Jane Seddon, author of Daily Sex in an interview with Cosmopolitan. “Doing it somewhere out of the norm adds an element of fun and makes you feel a little deviant.”
  • Stay healthy. Stress is a sex-killer, and it isn’t good for your health, either. Eat healthfully. Keep your weight under control. Exercise to maintain flexibility and to keep your joints healthy. You’ll be able to make love and do a whole lot more.

The goal, of course, isn’t to become sexual superstars, but simply to reestablish the connection and intimacy that was undoubtedly there in the beginning of your relationship. With decades of life experience behind you, the best is yet to come.

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Maybe your last child left home, as mine just did this fall. Maybe you (or your partner) retired. Maybe your partner became ill. The catalyst could be one of many life events, or it could simply be the realization of time passing, but at some point you look at your partner and realize that you’ll be spending the rest of your lives alone together.

Do you need to hit the “reset” button?

Life passages tend to elicit examination and reassessment. These bittersweet moments give you an opportunity to readjust and re-evaluate. They give you a second (and third, and fourth…) chance to get things right. You tend to be more receptive to feedback and direction during those times. You tend to be less complacent.

Chances are that after years of distraction—raising a family, building a career—your relationship needs some attention, and that includes the sex. “Sex is always where the grit of a relationship settles,” writes a reader to the UK’s Globe and Mail. In that sense, sex is like the canary in the coal mine—an early warning system that all may not be so copacetic in the relationship.

So, how is your sex life? Robust and satisfying? Routine and uninspiring? Or is it non-existent? If your answer falls into the “boring” or “non-existent” categories, it’s time to reset.

“When sex drops off there’s a lot more at stake than missing out on pleasure,” says Joan Sauers, author of Sex Lives of Australian Women. “A healthy sex life is critical to the survival of a relationship. Without it, our happiness and overall health can suffer.”

Begin with reflection. Is infrequent, boring, or non-existent sex perhaps an indication of deeper trouble—entrenched lack of communication, trust, or respect? Is it due to physical changes or limitations that you haven’t risked discussing? In this case, hitting the “reset” button should include some honest soul-searching with your partner and maybe some sessions either with a sex therapist or a marriage counselor. Simply addressing the sexual issues without tackling the underlying problem is like painting over rotten wood. The veneer won’t hold for very long.

However, working to improve your sex life ipso facto improves the relationship as well, because both rely on intimacy, connection, and communication. “Keeping things interesting outside of the bedroom also plays an important part in keeping things exciting in the bedroom,” writes Rhegan Lundborg, sex and relationships expert for the Omaha Examiner. “Doing new and fun things completely outside of the bedroom can be a great way to reconnect emotionally as well as take sole focus off the sex and just spend time enjoying each others company.”

Focus on reconnecting. In a quiet, intimate surrounding, reminisce about the day you met, your first kiss, what attracted you to your partner. Go through a photo album together. Talk about key moments in your relationship—adventures you shared, challenges you got through. Few people in your life know you as well as this person. That’s a rare and precious treasure. Make time to appreciate it.

From memories, move on to fantasies. In a perfect world, what would you like to accomplish or experience together—or separately? What’s still important?

Don’t be stingy with the sugar. Express approval. Say thank you. Notice the small ways your partner is thoughtful.

It takes time and careful tending to reignite a flame. As you rebuild intimacy on other levels, communication about your sexual connection could follow naturally. Or you may have to initiate the conversation when the time is right. Or—you may have to initiate the conversation with professional help.

Start the conversation in a safe, accepting, non-judgmental space. You both are likely to be experiencing changes, whether physical or emotional. You may have fears; you may be vulnerable. And you may also have fantasies—things you’d like to try but never had the guts to ask.

Isn’t it time to hit the “reset” button and get this conversation started?

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We all remember Maslow… don’t we? That noted psychologist who, in 1954, published his famous hierarchy of human needs that we all learned about in high school psychology?

Maslow determined that we all have basic physical and psychological needs that fall into an orderly hierarchy and are necessary to achieve happiness. But, he propositioned, basic survival needs for food and shelter had to be met before we’d benefit from higher levels of need fulfillment, such as the love and belonging or self-esteem.

To test whether Maslow’s theory would hold up under modern scrutiny, two researchers designed a massive Gallup poll of well-being. Almost 61,000 people in 123 countries were quizzed about fulfillment of specific needs and daily feelings of joy and unhappiness as well as on overall life satisfaction. Maslow was correct that people everywhere share the same basic needs, beginning with physical needs and ending with self-actualization (a “fuzzy” term that scientists don’t much like).

However, this survey found that, although Maslow was on target about his list of universal human needs, he was wrong about their orderly nature. People seem to need everything all at once. People can (and do) enjoy the higher-level needs for love and friendship, for example, even if they may be lacking some basic needs. “They’re like vitamins,” said one of the researchers in a recent article in the Atlantic. “We need them all.”

So where do we fit in—midlife women who probably have our basic physical needs met, but who still are actively engaged in life’s endeavors?

While the Gallup researchers were revisiting Maslow, Jaki Scarcello, author of Fifty and Fabulous, was conducting a little survey of her own, interviewing older women between the ages of 45 and 102 around the globe. She wanted to find out what happens when women grow old. How do we evolve?

What she discovered was that many of us do indeed reach Maslow’s highest levels of human development. We become wise, accepting, purposeful—you know, self-actualized—and this at times despite living under difficult challenging circumstances at times.

“I think the Maslow link is that perhaps self-actualization and improved self-esteem are more available to us as we age, which, ironically, may be a time in our lives when our basic needs are once again threatened,” said Jaki.

Jaki calls these the Women of the Harvest.

“Many older women told me they were experiencing a confidence they had never felt before in their lives,” says Jaki, “that they had found their voice, they were daring to do things they had not dared to do before.”

Younger women, on the other hand, tend to look to external sources for validation, to be more invested in appearances, and to be more distressed when basic needs weren’t met.

This serenity and self-acceptance applies to our sexual selves as well. “And so our sexuality is still important to us, but it does not suffer as much interference from self-deprecating mind chatter and from external reactions,” she said.

So, despite the physical and emotional changes of aging, we may be more confident in our own sexuality and look to others less for approval and validation.

“If it seems that the sparkle in a Woman of the Harvest deepens with age, perhaps it’s because her fire is fed in part by the internalization of sexual energy. This beauty is truly no longer skin deep. Instead, it radiates from some knowing place inside a woman who has ceased to need the outer world to know herself,” writes Jaki in Fifty and Fabulous.

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By the time women reach midlife, we’ve experienced all kinds of things in our relationships, some good, some bad. It’s great to think back on the positive experiences once in a while, maybe even relive them from time to time.

For the negative experiences, that’s not such a good idea.

And the more serious the situation, the harder it is to not think about it. Maybe you’ve had to deal with an infidelity or some other kind of betrayal by your partner. If so, its lingering effects may very well be interfering with your ability to fully embrace your partner in a healthy–and even in a literal–way.

If you’re harboring resentment or anger over some past wrong, you need to address it. As psychotherapist and our relationship coach Mary Jo Rapini says on her blog, “When your relationship struggles with resentment, it can feel like you are sleeping with the enemy. The resentment is felt deeply by one of the partners, and although it is rarely discussed openly, the tension can be felt by anyone close to the couple.”

So how do you let go of it? Well, it’s forgiveness. Dr. Fred Luskin, a psychologist affiliated with Stanford University, has made the study of forgiveness his life’s work; he’s written several books on it. The first, Forgive for Good, is based on the successful workshops he conducts using a step-by-step process to teach people how to forgive.

His second book, Forgive for Love, was written specifically for husbands and wives, and came about, he explains, because so many of his workshop participants were women trying to forgive current or ex-husbands.

Dr. Luskin has done studies that show harboring feelings of resentment and anger is not good for us physically or emotionally. It means we’re in a constant state of stress and negativity. In lectures he often quotes Nelson Mandela: “Harboring resentment is liking drinking poison to kill your enemy.” In other words, it’s doing a lot more harm to you than it is to the person who hurt you.

His methods of letting go of anger are similar to stress management and include mind-over-matter techniques like visualization and focusing on positive thoughts rather than negative ones.

Mary Jo, too, advises readers who are angry to “make a peace with your past. Tell whoever hurt you how you feel about what happened.” She also says that “letting go of your ego and learning to forgive your partner for their flaws and weaknesses—as well as forgiving yourself for holding on to that anger—are two of the biggest obstacles to overcome when working through resentment.”

Learning to forgive may not be easy, but it’s worth a try. In fact, it can be a life-changing experience. Because it’s never too late to take action. And you’ll feel much better when you do.

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Vaginal estrogen is the most effective treatment for vaginal atrophy and its symptoms: dryness, itching, irritation, pain with intercourse. There are three low-dose, localized (without systemic absorption) estrogen options: the vaginal ring (Estring), vaginal tablets (Vagifem), and vaginal creams (Premarin and Estrace). I prefer the ring and tablets, because the cream is messy to use and the absorption is somewhat more variable. Studies confirm is no significant or noted changes in circulating blood estradiol levels with the ring and tablet; the creams are more variable and therefore more likely to have transient elevations in estradiol levels. I have many breast cancer patients who use these methods.

Women who are candidates for vaginal estrogen often also consider over-the-counter lubricants and moisturizers. Lubricants make sex more comfortable in the moment, but don’t improve or prevent the progression of the atrophy. Vaginal moisturizers give more lasting comfort. Used independent of sex on a continuous basis, usually two times a week, they can help restore moisture to the tissues. The moisturizers can also help restore a more healthy pH, promote elimination of dead cells, and increase moisture in the tissues.

If there are multiple menopausal symptoms, which may include vaginal dryness, systemic estrogen (like Vivelle) might be considered, weighing all health factors in the decision.

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In 1968, she was Barbarella, the fresh-faced ingénue in shockingly sexy outfits. Then she was Hanoi Jane protesting against the Vietnam War. She was the prostitute in the movie Klute, for which she won an Oscar for Best Actress. She became our Fitness Queen in 1982 literally inventing the workout video. The “Jane Fonda Workout” is still the bestselling video of all time (17 million).

Whatever you might think of Jane, she’s always been at the cutting edge, always willing to forge new paths, and she’s always relevant.

Now Jane is at it again, tackling stereotypes and pummeling barriers with her latest book, Prime Time, an uncensored examination of “love, health, sex, fitness, friendship, and spirit.” This time she’s taking on the stereotypes of aging. With a freshly remade face (about which she is unabashed) and characteristically toned body, she looks many years younger than 73. Yes, you read that right. Seventy-three. In a quintessentially Jane statement, she attributes her appearance to 30 percent good genes, 30 percent lifestyle, 10 percent plastic surgery, and 30 percent good sex.

As you might expect, Jane doesn’t pull any punches about the sex. She has sex, and she likes it. Her frank, 50-page chapter on sex in Prime Time (“The Changing Landscape of Sex When You’re Over the Hill”) is a refreshing peek behind a curtain that is ignored at best and considered unmentionable at worst.

Perhaps the first important revelation is that she is doing what she can to continue enjoying sex with her longtime boyfriend, music producer Richard Perry. She was on hormone replacement therapy until she was diagnosed with breast cancer in 2010. Until recently, she also took testosterone, which “makes a huge difference if you want to remain sexual and your libido has dropped,” she says. She stopped taking it recently when she developed a stubborn case of acne.

In her book, she discusses masturbation, sex toys, and resuming sex after a hiatus. After divorcing Ted Turner, she was alone for six years before meeting Perry. “If you have been celibate for a long time and then begin a new love affair, be aware that your vagina is likely to need some attention,” she said in a recent interview.

Jane’s done her homework, and her advice is solid. But her most important contribution is to broach a subject that is socially taboo. When a celebrity and role model talks about having sex at 73, it becomes okay for other people to talk about.

That was a conscious decision on her part. “I wanted to go into such detail about sex because it can be very important in later life,” she said. “There are all kinds of changes that no one ever tells us how to handle. One of the things I kept hearing from the sex doctors was that very few people come to them with their problems… So I thought it would be helpful to go into detail about that.”

She also reveals another little-known secret of aging in Prime Time—that it can be the best time of your life. People over 50 tend to be less hostile, less stressed, and more capable of maintaining intimate relationships. And the sex can be better, too. According to Jane, all this adds up to happiness.

Thanks, Jane.

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There really are no special considerations specific to your diabetes. While I can’t confidently diagnose the cause of your pain with intercourse, I can’t think of a diagnosis or treatment option that would be eliminated because of your diabetes.

If you or your physician are considering systemic estrogen/progesterone, cardiovascular disease risks are taken into consideration. On the other hand, if localized (vaginal) estrogen could be part of the solution, cardiovascular disease risks are really not pertinent: The estrogen isn’t absorbed systemically to any significant extent. (Don’t interpret this to mean diabetics shouldn’t be on hormone therapy. May of our new studies suggest that starting hormone therapy at a younger age–closer to menopause–may actually be cardio-protective.)

I’m so glad you’re taking the initiative to investigate your health and your options!

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Why Buy the Cow

Remember back in the day, when good girls didn’t “hook up”? They “saved themselves” for marriage, and there were names for those who didn’t. If, God forbid, an unmarried girl happened to disgrace herself, she was whisked out of sight for a few months and returned chastened but unburdened.

Remember when the only career options for educated women were nurse, teacher, or maybe social worker, and they were expected to quit when they became pregnant (after getting married, of course)? No one wanted a pregnant nurse or teacher on the job. Presumably, their patients and students would know for sure that they were “doing it.”

Pre-Sexual Revolution, girls withheld sex and boys paid for it—with a diamond ring and the big “I do.” The price of sex was high because it was a woman’s most valuable asset. Since she couldn’t easily orchestrate her own financial security, she could, at least, demand a high price for sex.

This, according to Roy Baumeister, social psychologist at Florida State University, is the economics of sex, and he maintains it isn’t a thing of the past. According to Baumeister, in repressive cultures today, when women have limited access to education and economic resources, sex tends to be less casual and more rigidly controlled—and more “expensive” for men to get. “It’s a bit like OPEC: You restrict the supply and you’re going to drive up the price,” said Baumeister in an interview with Salon.com.

On the other hand, in cultures with greater gender equality, in which women have more opportunity, sex tends to be casual and frequent. People have more sexual partners and start experimenting at younger ages. Women have less incentive to withhold sex—to make it expensive—because they have access to the same resources that men do. Women don’t need to trade sex for a home and financial security.

So, how does this apply to us—women who, presumably, completed our sexual bargaining long ago?

Well, many of us are in the uncomfortable position of re-entering the “marketplace” at a time when the value of our “goods” has gone the way of real estate in California. Demographics, life expectancy, and the ease (relative to women) with which men can attract younger women all conspire to drive down the value of what we have to offer just when more of us are finding ourselves single again.

“When you have a surplus of women relative to men, then there’s a lot of premarital and extra-marital sexual activity,” says Baumeister, “and women can’t demand too much in terms of commitment and fidelity in exchange for sex.” In a supply-and-demand environment, according to Baumeister, we’re in the position of bringing coals to Newcastle.

So, what’s a gender-equal, midlife, liberated woman to do?

  • Maintain perspective. While a theory about the economics of sex makes for an interesting presentation at a conference, and while it even may contain elements of truth, a whole lot of life falls outside those academic theories. We write our own scripts, and we certainly don’t have to feel devalued because we fall heavily on the supply side of the sexual equation. Most of us aren’t interested in peddling sex, anyway.
  • Celebrate equality. Despite all the cultural complexities it brings, gender equality has been a huge game-changer for women (and for men.) Economic empowerment has given us choices far beyond the kitchen sink and maybe has redefined marriage as a less-coerced commitment between equal partners. A lot of women paid dearly to achieve this cultural evolution.
  • Celebrate maturity. Who wants to be 25 again? At this point in life, we certainly should be more emotionally developed, wise, experienced, and self-actualized than our twenty-something self. That’s an accomplishment worth celebrating. So even if we’d really like a steady sexual partner, we’re probably not sitting around waiting for the phone to ring. And we probably have a full life happening in the meantime.
  • Believe in love. Even the jaded Baumeister admits that his theory of sex-as-economics can’t account for love. “You can have sexual norms and still have plenty of love, and you can have plenty of love when sex is very permissive,” said Baumeister. “I think this is a little independent of love.”

That’s why we witness (as I did recently) octogenarians getting married in their twilight years. That’s why my friend, Sue, a retired professional with an active social life, refuses to give up on her search for her soulmate, even though she knows all about the demographics. She sometimes gets discouraged, but she’s not desperate. She’s identified what she wants, and she’s on a determined search to find it. In this case, it’s all about love.

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Play Date

We have had a great time listening to and talking with Mary Jo Rapini, our pal+resource for helping us put our minds to our sexuality. We asked her about the advice we hear a lot: Making an appointment for sex. And, she is all for it.

“But it’s not a business appointment you’re making,” she says. “Don’t be confused. What you are making ought to be more of a play date.

“We have to bring pleasure and playfulness back into the bedroom, and back into our experience of sex, especially as we get older. And the nice thing about being older, is — we have more time. No more awkward speed-sex after the kids have gone to bed. If we can make the time for a round of golf, we can certainly make the time to be together, for a half an hour or an hour or three hours, to play, to have fun, to touch and cuddle, and to have great sex.

“When couples come to me for counseling, I send them through their first assignments. It’s very relaxing, by the way, to have homework to do that is broken down into these discreet assignments. It helps people stay focused on one principle at a time, and that helps us relearn more thoroughly, so I wouldn’t skip those first assignments if you are trying this at home, on your own, without a counselor to coach you along.

“Next, I tell them they have to make time for each other, two to three times each week. An hour-long session. Write the appointments on their calendar. They can come up with a cute code-word for it, but it’s got to be on the main calendar they use throughout their week to stay on track. On the morning of a day with a scheduled appointment, they should remind one another that the appointment is coming, and if they can work it out, keep the reminders going throughout the day. Those reminders ought to be playful. They can include lunchbox notes, tantalizing vows, or texts or emails or phone calls. Flowers or candy. Whatever. Just make it obvious that you are thinking about one another, and looking forward to your time together.

“For your first few weeks of hour-long dates, forget intercourse. Use the time to eat fruit and cheese together, with tea or wine, or try a bubble bath, or dancing to music. The important thing is to block the time to spend with your best friend/lover. The time goes fast, so use it to really connect.

“And I tell them they need to prepare their body for this appointment. Men, take a shower. Everybody likes a clean body. Women, take time with your own body, bathing, using lotion, dressing in something that makes you feel good, running your hands over your body. Women take longer to get ready for sex the older we get. Just a little more time for arousal. Both partners, use your imagination to think about the time ahead and replay the sexual talks you have been having.

“When you are ready to include more sexual play, get ready in advance of your “dates” by having your lubes and touch toys, massage candles and tasty things ready for your evening together. Clean sheets when you do plan to make love on your bed.

“That is, pamper yourselves. Make this a special time. Build toward it. Make it important, because it really is important. Make it memorable, and the desire will build with every encounter. In short, make it as good for your imagination as it is for your body, and you can’t go wrong.”

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First Things First

If you follow us on Facebook or on Twitter, you’ve likely seen us posting stuff by and about Mary Jo Rapini, a psychotherapist who specializes in intimacy, sex and relationships. You may have “met” her already in her work with print and television media. She is often consulted as an expert in keeping relationships hot for a long, long time.

Well, Mary Jo has become our friend. She is helping us understand how we can help midlife women get their heads in the game, if you pardon the sports analogy. As they say, the best sex organ we have is our brains. When our sexuality gets away from us, the help of a specialist like Mary Jo can be the best first step to bring it back.

We will sit down with Mary Jo regularly, with our questions, and with yours, too. We caught up with her a little while ago, and put this question to her: If a midlife woman came to you looking for help to reinvigorate or retrieve her sex life, where would you typically begin?

“I will first make her aware that her sexuality is hers to claim,” says Mary Jo. “I want her to understand that her sexuality is one of the gifts every woman is born with. To hand that gift over to someone else to take care of is not only unfair to the person she has given that power to, it’s unfair to her too. When she understands that her sexuality and her pleasure is up to her, not up to her partner, the doors open, and we can move along.

“That’s usually a pretty big piece of the work right there, but I try to move quickly from that point to exploration. Once a woman knows she is in charge of her own pleasure, the next logical step is to find out what pleases her. And it’s surprising, but many, many women don’t know what pleases them because they haven’t spent much time exploring their bodies at all. Either they were trained not to or told that nice girls don’t do that, or whatever. But they haven’t been in touch with their own skin.

“So I try to get a woman to give herself permission to explore her body, explore her sexuality. If women only understood how much their partners really respond to being told what feels good. It’s impossible to do if you don’t know your own body. That’s one good reason to explore. Another is that the more options we have in sexual expression, the less trouble we have with our sexuality as we age. As we lose the ability to perform in sexual expression A, we still have expressions C, D, and E, you know? This is the pragamatic side of exploration and sexual play: Finding more options.

“But to start a woman off, I tell her that her first job is touch. I give her homework: ten minutes a day, sometimes in a nice warm bath, she is to touch her body. With her hands, with a feather, with fur, with scratchy things, with silky things. As many different textures and pressures and places she can find. And she is just to note: What feels good where? What is exciting? She is to do this by herself.

“Even women who have been pretty comfortable with sex, pretty expressive, can be surprised by this exercise, because our sense of touch changes, and what we like today may be very different from what we like in a couple of years. It’s fair to say most of us like different things every two to three years.

“The next week invites a partner into the picture, but we are not leading to sex yet. We are still just touching, but touching one another with different textures and pressures and parts of our bodies.

“Then comes talking, clothes on, outside the bedroom, for 10 minutes a day. Talking about what feels good and what doesn’t. Removing the expectation of sex from this work really helps to keep the couple focused on the importance of touch and cuddle, affection and care for each other’s pleasure. We can be a little too goal-oriented in our sexuality, and forget that half the fun is in the play and the arousal.

“I have some of my favorite toys for this work. A nice feather tickler is especially good for a woman to use, because when she uses it with her eyes closed, the textures can surprise her. So can a mitt made of fur. I like good tasting products that are good for keeping this exploration going, like tasty massage oils and creams and powders. Men, especially, respond to flavored products. I don’t really know why, but it works.

“These first meetings and assignments are there to demystify sex a bit, and maybe reset the target, making it all about feeling good. That helps a single woman who has no sexual partner, and it helps couples who have been happy together for years. Frankly these assignments are good for all of us to do every now and then just to stay in tune with our skin.”

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