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Archive for the ‘The Good Stuff’ Category

That sounds like a bad riddle, right? Like one I heard on NPR last week: What goes up a hill and down a hill but doesn’t move? The answer to that one is a road. And the answer to what subtracts more than it adds is sex.

Here’s the disturbing—but not, when I think about it, surprising—statistic I ran across this week, courtesy of colleague Sheryl A. Kingsberg, a PhD and chief of the Division of Behavioral Medicine at the University Hospitals Case Medical Center: “When sex is good, it adds 15 to 20 percent additional value to a relationship. When sex is bad or nonexistent, it plays in inordinately powerful role draining the relationship of positive value—about 50 to 70 percent!”

I was so struck by that statistical picture, I’m on the trail of the original research to understand more. But in the meantime, what I know from other studies—and my own experience and conversations with women—suggests that’s about right.

Let me first say that good sex doesn’t automatically make a relationship good. And a good, loving relationship doesn’t automatically mean that the sex will be good. But if I think back to a study done a couple of years ago, “The Components of Optimal Sexuality,” I’m reminded of how many of the characteristics of good sex are also characteristics of good relationships.

I won’t revisit the whole list, because you can read the series of detailed blog posts we did on each of the components. But here are just a few that come to mind in this context:

  • Being present. It’s so easy to take our partners (and, of course, others in our lives) for granted. Truly paying attention to one another—today—is a great gift.
  • Connection. When we feel connected to our partners, intimacy comes naturally (especially when we’re overcoming obstacles together). If you’re feeling “together but alone,” there are steps you can take.
  • Authenticity. At this point in our lives, I find that many of us are more willing than ever to own what we think and feel. Whether we’re in longstanding or new relationships, this helps us to be ourselves—and to be open about what we like and need, in the bedroom and the rest of life.
  • Vulnerability. Having sex is perhaps the ultimate act of making yourselves vulnerable to each other. What a reinforcement of the bond that a couple has with each other!

If those parts of your relationship are important to you, too, you’ve got more reason to understand how to stay healthy and be intentional about nurturing this part of your life.

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Surely this has happened to you: You read one article, and it leads you to another. From that second article, you’re pointed to another. Before you know it, you’ve spent an hour diving into a topic that wasn’t quite on your to-do list.

Today I’m glad I did. The first article was “A Good Sex Life Can Help Older Couples Cope with Illness and Other Difficulties,” in the Washington Post (a long title, but you don’t have to read the whole article to get the point). That led me to the full research in The Journals of Gerontology. And a reference in the full research prompted me to seek out an earlier article by researcher Adena M. Galinsky, published by the National Institute of Health.

That article, published in 2012, is called “Sexual Touching and Difficulties with Sexual Arousal and Orgasm among U.S. Older Adults.” The author defines “sexual touching” as “non-genitally focused sexual behavior,” including “but not limited to, kissing, stroking, massaging, and holding anywhere from one part to the entirety of a partner’s body.”

This, ladies and gentlemen, is foreplay, and what I love about this article is that it presents empirical data of its importance! With more foreplay, both men and women experienced fewer “difficulties with orgasm, sexual pleasure, and sexual arousal” and more physical pleasure in their relationships.

We all have “sexual scripts,” Galinsky says, which we learned growing up and tell us, without our thinking about it, how to be intimate. Depending on where and when you and your partner learned about sex and romance and relationships, your scripts may not include much sexual touching. If that’s the case, it’s time to call “Rewrite!”

Having the time and the cues of desirability, safety, intimacy, and arousal are critical to us in midlife. If we don’t have them and still expect our bodies to respond as though we’re 20, we’re setting ourselves up. And we can fall into the downward spiral I’ve talked about before: We’re uncomfortable or unsatisfied when we have sex, so we’re unmotivated for a repeat performance. Because we’re not having sex, it’s less comfortable next time we try, so we put it off longer. We may begin to wonder if there’s something wrong with us, which is the opposite of feeling sexy. And before we know it, we’ve abandoned a part of ourselves that made us feel loved and lovely and powerful—and our partners quite happy!

You can talk to your partner about a collaborative revision of your “sexual scripts.” You can share this guest post by a “man friend” of MiddlesexMD, or this “Open Letter: How to Really Turn Me On” to start the conversation. And then, you know, one thing can lead to another. In a very good way.

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One of the motivations for my work with women both in my practice and through MiddlesexMD is the difference staying sexy makes for women in their relationships. I’ve heard anecdotes on both sides of the issue: from women who feel the intimacy with their partners drifting away, and from women who’ve reignited their sex lives and feel a burden lifted in their relationships as they and their partners re-engage.

So I was especially interested to see a study announced this month that puts some numbers to those observations. The study was led by Adena M. Galinsky and Linda J. Waite through the University of Chicago’s Center on Demography and Economics of Aging. I’m waiting the full text of the study, but an article in The Washington Post provides some interesting highlights.

A healthy sex life helps couples dealing with physical illness. Illnesses, especially chronic ones, can stress a marriage at any age. The study results showed that couples with more sexual intimacy viewed their marriages more positively in spite of illness.

Assessments of relationship quality are tied to frequency of sex. To put it plainly, couples who had sex more often were more likely to say they had a good relationship. In other studies, good marriages have been shown to prolong life—and certainly quality of life.

At any age, we can “expand [our] idea of what sex is,” according to Amelia Karraker, postdoctoral fellow at the Population Studies Center at the University of Michigan. I look forward to studying this part of the study in detail, because many of us grew up thinking sex equals vaginal intercourse. When that becomes uncomfortable or less pleasurable, too many of us think we’re done with sex.

This study’s data encourage us to keep sex as a part of our lives for just as long as we’d like to. When sex changes for us, we only need to learn about what’s different and how we can compensate (and engage our partners along the way). When we abandon that part of ourselves, we accept an unnecessary loss—to ourselves and our relationships.

“Wellbeing in older age incorporates both psychological and physical wellbeing as well as sexual wellbeing, which can occur at the intersection of those two,” Karraker said. Or, to put it another way: Sex is part of our physical and emotional health. Our whole lives.

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As a menopause care provider, I have lots of conversations with women about sex. I’ve heard confirmation that our motivations to have sex change with our situations. What motivates us when we’re young and single is very different from what motivates us when we’re older and in longstanding relationships, or older and single.

So when we suffer from lack of desire—are we missing the sort of drive we had when we were teenagers? Or is it possible we just haven’t found a new motivation for sex? The more we learn from women, the more it seems that for us sex doesn’t always begin with lust, but instead starts in our hearts and minds. We engage in our heads first, decide to have sex, and then with enough mental and emotional stimulation, our genitals respond. The older we grow, the more this is true. Age and maturity bring a new game into the bedroom.

For us, having sex is less an urge than a decision, one we can make and then act upon. When we decide to say yes instead of no, decide to schedule sex instead of waiting (perhaps for a very long time…) for our body to spontaneously light on fire, decide to engage with media or methods that will put us in the mood rather than wait for romantic moments to happen along, we’re using our heads to keep sex in our relationships.

Deciding to be intimate unlocks the pleasure. And the more sex we decide to have, the more sex we will feel like having. That’s the secret to regular bonding.

Why just decide to do it? This much we know:

  • Sex leads to a longer life.
  • Sex, like all exercise, helps protect us against heart attack and possibly stroke.
  • Hormones released during sex may decrease the risk of breast cancer and prostate cancer.
  • Sex bolsters the immune system.
  • Sex before bed helps us get to sleep.
  • Sex burns calories.
  • Sex can help relieve chronic pain, including migraines.
  • An active sex life is closely correlated with overall quality of life.
  • Good sex can protect us against depression, reduces stress, and increases self-esteem.
  • Sex with your partner stimulates feelings of affection, intimacy, and closeness.

That last point is what I hear most often in my practice: Women want to keep or already miss the intimacy with their partners that mutually satisfying sex communicates. While they also miss the feelings of power and wellbeing that sex gives them, it’s the loss of connection that impels them to take action.

And you can take action, too. We don’t need to wait around for “desire” to lead to thoroughly satisfying sex. We can use our heads.

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I don’t always catch AARP The Magazine, I suspect because I’m still adjusting to thinking of myself as part of their demographic. But the most recent issue contained an article I’m glad I saw: “You’re Old, I’m Not,” a report on an AARP survey on “Aging in America.”

Among the findings are a few you’ll accept as common wisdom: People in their 40s define “old” as younger (63) than people in their 70s (75). As we grow older, we find that the process is “easier than I thought,” that we’re not held back from doing what we want to do. Older people appreciate old-folks humor more than younger folks do.

One section of the results, though, sparked my interest in a different way. There’s a difference by gender in agreement with this statement: “I know I’ll enjoy sex no matter how old I am.” Seventy-one percent of men agreed; only 51 percent of women did. Gender mattered much more than age: There’s only a 7-point difference between people in their 40s (66 percent) and people in their 70s, 59 percent of whom still expect to enjoy sex.

Given my line of work, I take that difference by gender as something as a battle cry. I certainly don’t want women to be like menvive la différence! But I take it as a personal, professional, and generational challenge to see more women look forward to enjoying sex!

I doubt that AARP was able to delve into the thinking behind people’s responses to that question. My guesses about why women are less optimistic than men are based on my years as a menopause care provider, not on AARP’s data. But here are my theories:

First, we’re young at understanding menopause. The average age for menopause is now 50; until 1900, few women lived past that age. We’re living longer now, and have much more experience with menopause, but we have no deep cultural expectation of conversation about it.

And that leads to the second factor: In the absence of good information, the worst-case scenario tends to take over our imaginations. Have you noticed that talk about child birth and root canals nearly always leads to the sharing of horror stories—the labor that lasted four days, the excruciatingly painful dental experience? Even though those stories are the exception, not the rule? I’ve seen the same thing happen with women talking about menopause, and the women who hear those stories are more willing to accept limitations and less empowered to take control of their own sex lives!

There’s one more factor, too: We as women start to receive messages that sex and older don’t compute. For some reason, “sexy woman” conjures a young woman in our media and culture—and, for some reason, we’re susceptible to that suggestion!

I don’t know when AARP will conduct this survey again. But when they do, my hope is that women agree just as often as men that “I’ll enjoy sex no matter how old I am.” Because we can, when we take the time to understand what’s happening as our bodies change. And we want to, when we recognize what sex means to our health, our well-being, and our relationships—and all the ways those intertwine.

And, okay. Because we women can be a little bit competitive, too.

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Women are not men. No surprise, right? In many parts of our lives, we know that.

When it comes to sex, though, many of our expectations—and those of the experts who advise us—are still based on expecting that men and women are more alike than not. And women are not men.

There’s an important implication from the model for women’s sexuality I’ve shared before, the one developed by Rosemary Basson, of the University of British Columbia. Women are not men: While men quite predictably experience desire and then arousal, women don’t. Sometimes, actually, women don’t experience desire until midway into lovemaking.

No big deal, you’re thinking? I wish.

Unfortunately, the messages we’ve internalized affect the way we behave and what we believe about ourselves. I’ve talked about hypoactive sexual desire disorder (HSDD) before, and it’s something I regularly talk about with women in my practice. There are hormonal changes, reactions to prescriptions, and other factors that can lead to HSDD, which is real and deserves attention from researchers and pharmaceutical companies.

But sometimes what we wish we could fix with a pill is actually the fact that we’re women, not men. If we, as women, expect to respond sexually as men respond, we’re more likely to misread our reality as “lack of libido.”

Which leads to the other reason I think understanding Rosemary’s model is a big deal. I talk to women who are at some point in a vicious cycle: They don’t experience interest as they used to; some physical changes have made intimacy uncomfortable or even painful; they begin to avoid sex; the physical changes continue; and intimacy becomes even more uncomfortable. How do we reverse this sequence? Or avoid the slide into it?

We can start with the reasons—beyond the hormones that drove us at 27—that we might want to be sexually intimate with a partner: to please him, to experience closeness, to cement our relationship, as an apology, a thank-you—or because we want to feel our own liveliness, sensuality, and power!

And then we can trust that desire will come into the picture, if we’re having the kind of sex that arouses us. Michael Castle wrote about this in Psychology Today: “Sex that fuels desire is leisurely, playful, sensual….  based on whole-body massage that includes the genitals but is not limited to them.”

Castle says women often complain that men are “too rushed, and too focused on the breasts, genitals, and a quick plunge into intercourse.” That kind of lovemaking doesn’t allow space for women to experience desire. He points out, too, that leisurely, sensual sex is also recommended by sex therapists to men dealing with premature ejaculation or erectile dysfunction. Happily, the kind of sex that fuels women’s desire is also good for their partners.

Women are not men. We can recognize, internalize, and celebrate our difference. We can be sure we’ve communicated with our partners what we like when we make love. We can let go of any expectations except our own. We are women.

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My last blog post, about thinking about sex as we think about exercise to encourage us to keep our sexuality alive, reminded me of another article I saw a while back.

In “Men Don’t Think about Sex Every Seven Seconds,” Dr. Laura Berman set out to debunk the urban legend alluded to in the headline. She cited a study done at Ohio State University, which concluded that men think about sex, on average, 19 times a day; women think about sex about 10 times a day.

That’s a far cry from every seven seconds, which works out to somewhere over 8,000 times per day, if my math is right and assuming eight hours of sleep.

Now, that research was done with college-age men and women, and I’m willing to cross-reference the National Surveys of Sexual Attitudes and Lifestyles (NATSAL), recently completed in Britain, to guess that by midlife, the rate is reduced by as much as 60 percent. For women like me, that means thinking about sex three or four times a day.

I don’t know how that strikes you—as too much or too little! Laura made another comment in her article that resonates with what I’ve seen in my practice: Researchers “found that incidence of sexual thoughts were most highly governed by one’s own sexual belief system. …People who had anxiety, shame, or guilt around their sexuality were less likely to have sexual thoughts, while people who were comfortable and secure in their sexuality were more likely to have sexual thoughts.”

That’s especially important to us as midlife women. We get lots of messages that conflict with the reality that we are still vital, complete, sensual, sexual creatures. As we watch our bodies change—through childbearing, decades, illness, losing and gaining (and losing and gaining) weight, new wrinkles—we ourselves sometimes question whether we are still sexual, attractive to ourselves as well as to our partners.

Dissatisfaction with our bodies is hardly exclusive to us midlife women, sadly. But when it affects what we decide to do or not to do, it begins to matter more to us. You’ve no doubt seen articles about staying active, because the more active you remain as you grow older, the more active you’re able to remain. You keep muscle tone, bone mass, and balance only as you exert yourself.

The same is true of our sexual selves. Physically, being sexually engaged increases circulation to vaginal tissues, which naturally thin and become more fragile as we lose estrogen. It’s equally important that we’re attuned to the mental part of the equation.

Remember Stuart Smalley on Saturday Night Live? The nerdy guy with the affirmations? “I’m good enough, I’m smart enough, and doggone it, people like me.” What if we midlife women had affirmations for ourselves? Could we use them to both reclaim our bodies and nurture our sexual selves?

I’ll have to give that some thought. Possibly up to ten times a day.

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There are many benefits to being sexually active: It releases estrogen and increases oxytocin, serotonin, endorphins, and immunoglobulin A. This chemical and hormonal stew makes us both feel and be healthier. Having sex makes us feel powerful, giving, and connected, all of which feed our relationships with our partners.

I came across a recent study that affirms another benefit I often talk to women about: Sex is good exercise.

The study was conducted by Antony D. Karelis, who teaches exercise science at the University of Quebec at Montreal. Participants in the study wore armbands while having sex, and also jogged on treadmills to produce comparative data. The results? On the “metabolic equivalent of task” scale, on which sitting still ranks a 1-MET, sex ranked 6-MET for men and 5.6-MET for women. That puts it, according to Gretchen Reynolds, author of “Sex as Exercise: What are the Benefits?” as roughly equivalent to playing doubles tennis or walking uphill. To do your own comparisons, it’s categorized as “moderate exercise.”

Good to know, right? And I think we midlife women can use this knowledge to our advantage. Part of my counsel to women experiencing diminishing libido is to be intentional about remaining sexually active. There are two parts to my rationale: First, as our hormones diminish, we’ve got that “use it or lose it” thing going on that I’ve talked about before. Second, having sex begets having sex. That is, we women will want to have sex more often when we—wait for it—have sex.

There’s a line from the study conclusions that made me smile: “Both men and women reported that sexual activity was… highly enjoyable and more appreciated than the 30-minute exercise session on the treadmill.” I’m so glad to hear that!

So I start to wonder: How can we apply to our sex lives the same thinking that gets us religiously to yoga or Pilates several times a week? Neither we nor our partners want us to be thinking about sex as one more chore on the to-do list or an obligation on our calendars. But can we consider it a gift to ourselves and our health, as we do our morning walk or Zumba class? Will that give us the extra incentive to make the time and the commitment?

I’m hoping so.

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For every reader of a study, there’s a different headline. That’s my conclusion after reading The Lancet’s publishing of the findings from the British National Surveys of Sexual Attitudes and Lifestyles (NATSAL).

I’d been intrigued by an article in The Guardian that suggested Britons are having less sex because of the struggling economy and too much technology. I think either is credible. I agree with Kaye Wellings, of the London School of Hygiene and Tropical Medicine, when she says that “there’s a strong relationship between unemployment and low sexual function [which] is to do with low self-esteem, depression.” And common sense tells me that it’s hard to be aroused by a partner with an iPhone in his hand.

But when I read the full research report, there were other things that spoke to me.

This is the third time the full research has been done, using comparable methods so that trends can be examined over 60 years. And this is the first time that the eligible age range went beyond 44 years—all the way up to 74!

And that’s a very good thing, ladies, because we haven’t stopped having sex just because we’ve passed our mid-40s.

In fact, that one change to the study’s design led to two of their most notable conclusions:

  • That sexual lifestyles have changed substantially in the last 60 years (which sounds elementary, my dear Watson, but they can tell us exactly how!)
  • And that “research into the sexual health and wellbeing of men and women in later life—who now have increasing expectations of sexual fulfillment—and make up a growing segment of the population—is a neglected area.”

Well, yes! And I’m grateful to see conclusions like those from well-respected research projects!

A couple more things struck me as I read through the details, because they resonate with my experience as a menopause care provider. The frequency of sexual encounters does decrease as both men and women grow older; among women 65 to 74, intercourse is happening about a third as often as among women 25 to 34. There is, though, still a variety of sexual experiences among the older women, including oral and anal sex.

I note that men over 55 are more likely to have a partner of the opposite sex than are women at the same age, and yet men of that age are three times more likely to self-stimulate than women are. Now, I know that sexual behavior depends on many things, including social norms and attitudes.

But I also know that women are uniquely “use-it-or-lose-it” creatures. When we’re without partners, we can’t assume that our sexuality is stowed away to be taken out again at some later date. I encourage women to think about self-stimulation, because orgasm is good for us physically and mentally, and it helps us maintain patent vaginal tissues.

Given the numbers, I know it can’t happen for everyone, but I’ve seen enough women find a second love to think it’s worthwhile to maintain our sexual health. Not because a woman needs a man (that whole fish without a bicycle thing), but because sometimes the right woman and man find each other. And it’s a whole lot easier to maintain your sexual health and capacity than it is to reclaim it.

Because data show—British researchers proved it—that “sexual health is a key component of well-being,” even for those of us over 44, and even for those of us currently without partners.

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The more I work with women in my practice, the more I recognize that the science of human sexuality is young. For most of the last century, we assumed that men and women approach sex in roughly the same way.

Crazy. But there it is: The science is young.

Older models (Masters & Johnson, Kaplan) theorized that sex for people happens in a few neat, linear stages, beginning with desire, proceeding next to arousal, then orgasm, and finally satisfaction.

But it doesn’t always work that way, particularly for women, and especially for women over 40.

More recent researchers who focus on women’s sexuality, confirm that really, women do not experience sex in this simple, linear way. We sometimes skip phases. Our reasons to have sex are many and often complex.

We can be perfectly satisfied with sex that does not include orgasm, and we can reach orgasm without desire. We are flexible that way.

I continue to refer women to work done by Rosemary Basson, MB, FRCP, of the University of British Columbia. Basson formalized a new model of female sexuality that is now widely accepted.

She offers two key insights. First: Female sexual desire is generally more responsive than spontaneous. That is, we are more likely to respond to sexual stimuli — thoughts, sights, smells, and sounds — than we are to spark an interest in sex out of thin air (Men, on the other hand, specialize in this).

Another key insight: Emotional intimacy matters to women. That doesn’t sound like a news flash, but in the realm of the biological sciences, it’s news, trust me.

So Basson drew a new model – not a linear series of steps, but a circle that includes both sexual stimuli—the thoughts that trigger a woman to take an interest in sex, and emotional intimacy—the emotional payoffs of the experience that lead her to want to come back for more.

Rosemary Basson's model of female sexual response

Rosemary Basson’s model of female sexual response

I love Basson’s model and use it every day in my practice to help my patients understand how sex really works for us.

We need to understand that it’s okay and it’s normal that we don’t always start with desire. And as we enter menopause, and our hormone levels drop, spontaneous thoughts about sex and responsiveness to opportunities for sex diminish for most of us. That’s natural and normal too.

If you don’t like the situation, and you want to feel more sexual, more responsive, Basson’s model gives us the hint: We need to stimulate our minds. The more sexual stimuli we receive, the more sexual we feel.

So, this is worth thinking about today, a worthy discussion to have with your partner: What makes you feel sexy? A juicy romance novel? A James Bond movie? Erotic art? Pretty underpinnings? A romantic dinner?  Having your partner empty the dishwasher?  Spend some time thinking about that. Maybe make a list. And then provide for these things. Sexy is as sexy does.

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