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Before Sex and the City, before Gloria Steinem, before Jane Fonda, there was Helen Gurley Brown. She was the creator of the iconic Cosmo Girl, wearer of organza and décolletage, and advocate of a woman’s right to a career, sex, and life on her own terms.

It may be hard to remember or to appreciate how radical her approach to a woman’s place in the world was as we look back through the lens of rapid change in women’s rights and cultural expectations.

In the old-school world that Helen Gurley Brown faced in the 1950s and 60s, women had only grudgingly been granted the right to vote. She did not come upon the scene with either pedigree or good looks. (She called herself a “former mouseburger… not beautiful or even pretty… not bosomy or brilliant,” although others said she was “obsessed with boobs,” as the Cosmo covers suggest.) Her achievements came because of hard work and skillful politicking and through the unabashed use of feminine subterfuge and seduction.

In this she differentiated herself from the bra-burning feminists who were to come shortly after. She was the anti-feminist. She challenged the traditional role of women in the workplace (as secretaries) and in the bedroom (as wives) just as vigorously as the ERA women, but from a different perspective. In HGB’s world, a woman had to be smart and confident. But it was also useful to be feminine and to know when to deploy those charms, either to get what you want or for the sheer fun of a sexual romp.

While she predated the feminist movement by almost a decade, her book Sex and the Single Girl was the first crack in the dike, the first shot across the bow, signaling the vast social upheaval that would follow. In her book, “Brown challenged [single women] to take the same liberties as young men: to enjoy a long and lusty sexual prelude to marriage and to use the rest of the time to build a successful career,” writes Gail Sheehy in Cosmo.

Although the feminists who followed disagreed, sometimes vociferously, this was HGB’s homegrown revolution, and she practiced what she preached.

Born into poverty and possessed of no great physical endowment, HGB worked like a draft horse at 17 jobs before reaching the seat of power she’d been striving for at the age of 42—editor-in-chief of Cosmopolitan magazine.

For the next 32 years, until she was forced out of her job at 74, HGB created the icon and the culture of the Cosmo girl. And while on the one hand, the Cosmo girl perpetuates the imperative of feminine beauty and bosom, perhaps at the expense of brains; on the other, it celebrates the power and potential of a woman who knows how to use her femininity.

At the time, the Cosmo Girl was fresh and naughty; then, however, as one pundit commented, “she became familiar. And then she became a cliché.” Maybe, in today’s world of silicone cleavage and über-sexiness, she has become a caricature.

But in her work and in her personal life, HGB was a cheerleader for lots of fun, juicy sex. Clearly, sex continued to be important in her last marriage to David Brown as they both grew older. And it is in this capacity that Helen Gurley Brown has something to say to us—mature women who might be wondering what role sex has in our lives and relationships. While we may not want to emulate her, from that perspective we can learn a thing or two.

In memory of Helen Gurley Brown, who died August 13, 2012, at the age of 90, here are a few choice quotes for the older woman:

  • “It’s just ridiculous for a woman over 50 to assume sex has to be over. You may not be as rambunctious as when you were a teenager, but an orgasm is an orgasm, it doesn’t matter how long it takes to get there.”
  • About keeping the romance in marriage: “It helps if you go on romantic trips together. …When you’re in another city and a glamorous hotel that is conducive to sex, you think, ‘Hey, let’s don’t let this go to waste.’”
  • “What you do have to do is work with the raw material you have, namely you, and never let up.”
  • “Being sexy means that you accept all the parts of your body as worthy and lovable … your reproductive organs, your breasts, your alimentary tract.”
  • “A woman who even occasionally enjoys an orgasm from the roots of her hair to the tips of her toes is sexy.… Remember, frigidity isn’t a physical disability. It’s a curable state of mind.”

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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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Sex and religion aren’t often mentioned in the same breath. One is fleshly; the other spiritual, right? Like oil and water.

Yet, both are integral to our person and to our psyche. Both faith and sexuality are deep expressions of who we are. We can’t chuck our sexuality at the door of the church or temple or synagogue; nor can we drop whatever we believe about God at the door of the bedroom.

So I was interested to read about a recent survey conducted by psychologist Darrel Ray, who compared the behavior and feeling of nonbelievers (agnostics and atheists) to those of believers (mostly of Christian persuasions). In a nutshell, he found that both groups behave similarly. Both became sexually active at about the same age, have similar levels of sexual activity, do the same things in the bedroom. They even pursue affairs at similar levels. The significant difference was that the believers tended to feel more guilty. This was particularly pronounced in more fundamental denominations: Mormons, Jehovah’s Witnesses, Seventh Day Adventists, Pentecostals, and Baptists. But mainline Protestants and Catholics experienced higher levels of guilt, too, than atheists or agnostics. Not crippling, but noticeable.

Leaving aside for a moment serious questions about Dr. Ray’s motive and methodology (he calls religion a disease and himself a “recovering religionist”), his report raises some interesting questions. Do people who believe in God feel guilty about sex? Are certain acts, masturbation or oral sex, for example, more troubling or guilt-provoking? If so, why would this be? Does guilt derive from actual church teaching or from cultural conditioning or from something misunderstood or misapplied in childhood?

Even the religious institutions themselves struggle to honestly incorporate sex in a faith context. Yes, sex, in the context of a loving, uncoerced relationship, is a beautiful, God-given gift. Just read the Biblical Songs of Songs. However, as it’s practiced on the ground, the message isn’t all that clear, and even some church leaders admit as much.

“In the context of Catholic teaching, I would think it safe to say that the connection [between faith and sexuality] is contorted, controverted, and often confusing,” says Dr. Michael Higgins, vice-president of Mission and Catholic identity at Sacred Heart University in Fairfield, Connecticut.

“If we could only transcend the ‘forbidden fruit’ mindset, perhaps religion could evolve into a much healthier sexual ethic,” said Rabbi Howard Voss-Altman, of the Reformed Jewish tradition.

Dr. Sheema Khan, a practicing Muslim, said that “…sexuality forms part and parcel of [Muslim] spirituality. There are even prayers prior to sexual intercourse, and… foreplay is encouraged (as part of religious teachings).” But she also condemned the Muslim preoccupation with the “purity of women,” which could result in the ritual killing of a woman suspected of having sex outside of marriage.

So it would seem that if we aren’t sure how to feel about sex or some sexual behaviors, or if some indefinite guilt is associated with sex, we aren’t alone. Our religious institutions are grappling with the same issues.

But isn’t this the nature of life—to honestly articulate and wrestle with our inconsistencies? And in the end, to become more mature and integrated?

I remember the advice a wise old pastor gave my mother when she was trying to reconcile church teaching with the expression of sex in her marriage. “I don’t think that anything a loving couple does in the bedroom to give each other pleasure can possibly be sinful,” said this man of God.

Amen to that.

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We had a flurry of questions about foreplay — or dealing with the lack of it — awhile back, which led to a number of conversations within the MiddlesexMD team, but also between team members and their partners. This guest post — from a man! — was spurred by one of those conversations. We think it’s important — and reassuring — to hear that men do like foreplay. If this is a topic you’d like to raise with your partner, perhaps sharing this post is a way to do it. –Dr. Barb

“And the women crazy ’bout me ’cause I take my time.”
–Taj Mahal, “Little Red Hen”

I was 12 years old when I first heard about what goes on during foreplay. A mouthy teenage boy from across the street told me about it as he smoked a morning cigarette on his front porch. I really didn’t want to hear it, and when I did I couldn’t understand why anyone — man or woman — would want to do such things to each other. I was barely able to fathom what foreplay led to, and this just made the whole thing even more bizarre, at least to a kid living in the Midwest in the late 1950s.

I learned too many things about sex from other, usually older, boys. My parents stayed away from the subject, figuring, I guess, that I’d learn from other boys. So, much of what I learned was from their raging-hormone perspectives. The focus was always on them and their pleasures, their “conquests,” imaginary or not. I can’t remember hearing guys talk about sex (much less intimacy) from the girl’s point of view — sex was more, as we say now, all about them. I saw this attitude flourish in college in the late 60s, when guys practically competed for sexual supremacy, which you couldn’t achieve with just one partner. “Wham, bam, thank you, ma’am” relationships were fine and dandy. Numbers mattered.

Which brings me back to foreplay. It’s hard to say that it’s a lost art if it was never discovered in the first place. Or maybe, like so many things in relationships, it’s been allowed to languish, to become an afterthought in a hurry-up world, especially as we grow older. There are all kinds of reasons why foreplay might get shortchanged or forgotten. And it’s not as if it can just be wished back into existence. Mutually exciting foreplay depends on couples being willing to take an unhurried approach to their lovemaking, to find out what makes each person feel sexually energized and ready for more. In our haste to get to home base, we men tend to want to bypass first, second, and third. Women, seeing our haste, assume that that’s just the way it is — that men prefer sex with no prologue.

I’ve learned that if you miss the prologue, the play’s not nearly as good; you can’t drive a woman wild by rushing into the final act. But you can heighten her lust for you, and yours for her, if you learn to let the present moment linger for a while and enjoy it to its fullest. You’ll both know when it’s time to move on, and you’ll both be ready for it.

I think that words are a key part of foreplay. Words that precede any touch. Words that express your appreciation of her, your attraction to her. Words that ask her what she’d like you to do. Words that continue during foreplay and beyond, not a lot of them but occasional affirmations, expressions of desire, words that keep you connected both physically and, well, orally.

Everybody is happier and more satisfied when foreplay is part of the experience. It’s something that makes both men and women want to have more of where that came from. Who can argue against such self-perpetuating pleasure?

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We’ve talked about how crucial mindfulness–being mentally and emotionally present in the moment–is to enjoying great sex, sex that is “better than good,” as reported in a study recently published in The Canadian Journal of Human Sexuality.

I like to think of “connection,“ the study’s second ingredient of optimal sex, as “mindfulness times two.” Connection is what happens when both partners are present together: in bed, in the moment, in each other. As one study participant describes it: “Inside my body I’m the other person’s body and we’re just all one together at that moment.”

This sense of merging, of “two becoming one,” was regularly cited as part of the experience of great sex, which has to involve “at least one moment,” as one woman said, “where I can’t tell where I stop and they start.”

I believe that this kind of intense sexual alignment is something that becomes more accessible to us as we get older. Part of our maturity is greater acceptance of self and others, which leaves us more open to making a deep physical and spiritual connection with another person. To experience the joy of merging, of temporarily letting go of the sense of any boundary between the self and the other, a person has to know herself well–and feel safe and respected by her partner.

Which brings me to two great impediments to sexual connection: unsafe relationships and sexual trauma. If you have reasons for not feeling completely safe with a particular partner, or if you have a history that leads you to feel unsafe whenever you are in a sexual situation, you’ll need to address these issues before you can experience intense connections in intimate relationships. There are resources that can help.

But for two self-aware people who respect and desire each other and who are capable of being completely present with each other in the moment, a deeply satisfying sexual connection can happen even without penetration or orgasm. The study’s authors report that great sex is often more about the level of energy between partners than about the actual physical act itself. (Check out our website’s alternatives to intercourse for imaginative techniques for increasing sexual energy and connection.)

Have you experienced these moments of sexual oneness? What were the circumstances? We’d love to hear your stories!

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It’s official. Boehringer Engelheim, the German pharmaceutical company, has shelved its plans to develop flibanserin. They’ve decided to focus on other drugs that “have better potential to make it to market.”

The pill’s been called “pink Viagra” because it was hoped it would do for women what other drugs have done for men with erectile dysfunction. I know flibanserin has been controversial. The drug was rejected by both an advisory panel and FDA staff, and much of the discussion about the project cancellation has focused on the negatives.

I don’t argue with concerns about Boehringer Ingelheim’s research or focus on marketing instead of fact-finding. But I do know that some of my patients who struggle with a loss of desire are desperate for more options that offer hope. They’re well-informed about their condition and their choices, and they’re fully capable of making decisions about the trade-offs between side effects and a return to a more complete sexuality.

The broader issue for me is the lack of focus on pharmaceutical options for women. Pfizer, makers of Viagra, canceled research into a female counterpart in 2004. Boehringer Ingelheim appears to be saying that it’s just too hard to follow through on a drug for women. What are the barriers? Are they cultural? Is male sexual satisfaction easier to talk about? To measure? To “monetize”?

As a physician, I want the most possible options to explore with my patients. Sometimes mindfulness, information, localized hormones, and tools like vaginal dilators and clitoral pumps are enough to change a woman’s life. Sometimes they’re not. I’m optimistic about ongoing research about testosterone for women’s sexual health, but I’d like to know that pharmaceutical companies see the issues we face as clearly and as important as I do.

Have you found a drug treatment that’s helped? Are you with me in thinking more options to consider is a good thing? Or would you rather pharmaceutical companies keep their focus elsewhere? Lots of voices will help them set their agendas.

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There are many “natural” reasons women our age begin to lose interest in sex. Hormonal changes, diminished energy, lowered self-esteem as we mourn the loss of our youthful bodies — a complicated mix of physical, psychological, and social influences conspire to make us feel less sexy and less sexual.

When patients ask me about “natural” ways to increase levels of arousal and desire, my prescription almost always includes a combination of mindfulness and exercise. Awareness techniques like meditation help us focus on the moment and block out the stress and distractions of our everyday lives. Exercise increases blood flow, releases endorphins, tones our muscles and our perceptions of ourselves as strong and attractive.

I wasn’t surprised then, to read in a recent issue of the Journal of Sexual Medicine that yoga, a practice that combines both of these libido-enhancing elements, “improves several aspects of sexual functioning, including desire, arousal, orgasm, and overall satisfaction” — particularly among women over age 45.

This study, which surveyed healthy, sexually active women before and after a 12-week program of daily yoga practice, found significant improvements in all of the areas measured: desire, arousal, lubrication, orgasm, pain, and overall satisfaction. Nearly 75 percent of the women who participated in the study “said that they were more satisfied with their sexual life following the yoga training.”

Other research has found that yoga increases body awareness and can be used to direct blood flow to the pelvis to enhance arousal and lubrication. The mindfulness that yoga teaches and requires helps a woman be more aware of her body and its needs. “When you’re present, you know what you need to feel fulfilled by your partner,” explains one expert. “You can then translate and communicate this deeper understanding to your partner during sex.“

And of course the increased flexibility and improved muscle tone that come with regular yoga practice help a woman feel more confident and attractive — in bed and out.

If you’re looking for a natural way to tone up your libido, find a yoga class. And let us know how it works for you!

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Maybe I was naïve. We ran into some issues with the launch of MiddlesexMD.com earlier this year: We couldn’t advertise on a popular social networking site. An article we submitted was rejected because of subject matter. We were “ineligible” for a medical site designation.

And I took all that in stride, with some disappointment, as an entrepreneur, and some concern, as a physician trying to get the word out to women that sex is good for you and still possible and pleasurable, well beyond menopause. But I’m a parent, too, and I understand that there’s adult content that can’t just go everywhere.

But in the last week I saw a couple of articles (one in the New York Times, one on Salon) about Zestra and the walls its makers were hitting in trying to advertise. If you’ve missed the story, a commercial for Zestra Essential Arousal Oils was turned down by TV networks, cable stations, radio stations, and web sites. When it was accepted at all, it was slated to run in the middle of the night. Rachel Braun Scherl, the president of the company that makes Zestra, says, “When it comes to talking about the realities of women’s lives, you always have some woman running in the field…. There’s a double standard when it comes to society’s comfort level with female sexual health and enjoyment.”

As evidence, Rachel points to the advertising for Viagra and Cialis. And that’s when I start to think I may have been naïve. I remember the first time Bob Dole came on my television, during prime time, when my daughters were in middle school and still watching TV with me. It was a little awkward, maybe, to explain to them what “erectile dysfunction” was, exactly. Now they’re old enough to snicker with me (in a compassionate way—I am a doctor) when we hear “in the event of an erection lasting more than four hours, seek medical attention.”

So this gets me thinking. Why can we be so public about an aid to a man’s sexual satisfaction, but not aids to a woman’s? Is it because Viagra and Cialis are prescription products for a condition that’s been named a medical problem? In the case of erectile dysfunction, have we successfully separated the erection from sexuality? Because women’s arousal and satisfaction are more complex (remember why we love Rosemary?), is it too difficult to make that same separation? Or is there really still a double standard, with men’s sexual satisfaction ranking higher then women’s?

I’ll keep thinking. And, I’m sure, gathering anecdotal evidence on both sides of my questions. I’d love for you to join the conversation.

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She’s 54 years old. She’s spent most of her adult life in a long-term monogamous relationship. She’s just been diagnosed with genital herpes.

This happens more often than you might think.

Even I — who should know better! — have been guilty of age bias when it comes to testing for sexually transmitted infections (STIs, also called STDs, for sexually transmitted diseases).

In my former practice, when a 20-year-old came in presenting with symptoms (discharge, discomfort, irritation) that might indicate an STI, I would automatically screen her. When a 50- or 60-year-old came to me with the same symptoms, I was more likely to ask before I tested: “Is this a possibility?” If she said “no,” I tended to trust that. I was trusting my patients. They were trusting their partners.

Times have changed.

Over the past decade, STI rates among people 45 and older more than doubled. In April, the Centers for Disease Control and Prevention reported that senior citizens accounted for 24 percent of total AIDS cases, up from 17 percent in 2001.

Researchers point to climbing divorce rates at mid-life, the rise of online dating services, the increasing number of men availing themselves of treatment for erectile disfunction. And all of these are contributing factors, I’m sure. But in my experience, the most likely cause of the up-tick in STIs among women past their child-bearing years is lack of awareness and prevention.

If you know that pregnancy is not a possibility, why use a condom?

Unfortunately, the risk of contracting STIs — including syphilis, gonorrhea, genital herpes, HPV, hepatitis B, and HIV — does not end at menopause. In fact, sexually active postmenopausal women may be more vulnerable than younger women; the thinning, more delicate genital tissue that comes with age is also more prone to small cuts or tears that provide pathways for infection.

And — it’s not fair, but there it is — with almost every STI, exposed men are less likely to experience symptoms, simply because they don’t have the equivalent of a cervix and a vagina and the skin of a vulva. The kind, older gentleman who gave my 54-year-old patient genital herpes might honestly not have known he was infected.

These days, when a 50-or-60-ish woman shows up in my office with symptoms that point to a possible STI, I go ahead and screen. I’ll say, “I understand this is not a likely outcome, but I want to make sure I’m checking all possibilities.”

Worry about STI can be a real drag on sexual enjoyment. We’ll talk about what you can do to insure that contracting an STI is not a possibility for you in my next post: “When Was the Last Time You Used a Condom?”

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In menopause, in the absence of estrogen, the vagina narrows and becomes more thin and fragile. Even when you are lubricated enough, the tissues have likely lost elasticity and can’t comfortably stretch with intercourse. Some light bleeding represents the “trauma” to those tissues and usually comes from near the opening of the vagina or the vaginal tissues themselves.

Using a vaginal moisturizer (like Yes, Replens, or KY Luiqibeads) would almost certainly help. It may also beneficial to use dilators to try to get back more caliber or capacity (dilators literally stretch the tissues gradually). You might also talk to your health care provider about vaginal estrogen, also known as localized estrogen, which may be of benefit to you in restoring elasticity.

Don’t give up! You can be comfortable again.

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