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I started MiddlesexMD because I wanted to help women to stay as sexually active as they choose for as long as they choose. I’d heard from too many women in my medical practice who assumed that they were “over” that part of their lives, whether or not they liked the assumption. Discomfort, downright pain, less pleasure, and diminished libido appeared to be barriers they just couldn’t see past.

I thought I was in a unique position to help: I’d practiced obstetrics and gynecology for a couple of decades, had become qualified as a menopause care specialist, and had myself reached what we call “a certain age.” I could explain the medical realities from the perspective of a woman who shared experiences and day-to-day impact.

And I hoped to contribute to breaking the silence about midlife sexual health, since so few of us have talked to our friends, our doctors, and even our partners about what’s changing and what we might want to change.

It’s been rewarding. An unexpected benefit for me—and in some ways for you, too—is all of the people I’ve met who share the vision: of women taking control of their health and wellness, including their sexuality, as they move through midlife.

The MiddlesexMD team first met Rebecca Posten, CEO of PrevaLeaf, at a conference for nurse practitioners in Savannah. We were struck by the similarity in our missions and values. PrevaLeaf’s purpose is to “provide women with gentle and natural products to maintain their intimate wellness.” When Rebecca says she’s all about “helping women stay in control and stay well,” she’s speaking my language.

She and I have other things in common, too: We’ve both had medical training specializing in ob/gyn; we’ve both networked with women entrepreneurs who had practical experience in bringing a vision to life; she shares my interest in spreading the word about women’s health; we both have daughters who know much more than their peers about women’s anatomy and sex.

None of those, though, are the reasons I feel good about offering PrevaLeaf™ products. As a physician, I share PrevaLeaf’s bias toward prevention and wellness, and the intensity of their focus on women’s health. I like how seriously they take natural ingredients; they’re a member of the Natural Products Association and follow their guidelines for ingredients and manufacturing processes.

But the proof is in the products, so I invite you to check them out. PrevaLeaf Oasis is a water-based vaginal moisturizer for daily use. PrevaLeaf Soothe is for those occasions when discomfort calls for some additional relief.

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

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

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

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

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

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

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

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

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

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

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

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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.”

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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?

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

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

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

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

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

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

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

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

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With a long hard winter that took far too long to end, it’s been easy to forget there’s a big world out there. Help is on its way, via a new book: Frommer’s/AARP Places for Passion: The 75 Most Romantic Destinations in the World—and Why Every Couple Needs to Get Away.

The subtitle says it all. The co-authors, Pepper Schwartz and Janet Lever, are PhDs and sex experts. They’ve put a huge amount of thought and research into a book crammed with irresistible ways to foster romance.

They list getaways to suit every taste—cities, natural beauty, beaches, and adventure; on every continent—well, maybe not Antarctica. A random sampling: the Great Barrier Reef, the Loire Valley, the Amalfi Coast, Marrakech, Bali, the Cotswolds. Detailed listings for each destination make planning that much easier.

The hardest part might be deciding where to go. Schwartz and Lever suggest having both partners list the three places they most long to see. With luck, the two lists will share at least one destination.

The authors acknowledge, “Keeping romance—and passion—alive over the long term isn’t impossible, but it isn’t easy, either. It’s complicated: We crave the security that comes with our committed relationship, but we also desire adventure and fresh discovery.” Traveling, including the planning and anticipation beforehand and the shared memories afterward, restores the excitement a relationship had when it was new.

Couples who share a long history are inevitably liable to “hedonic adaption”: getting so used to good things that they don’t feel good anymore. When traveling, couples encounter one surprise after another. Novelty makes the two more interesting to themselves and to each other. The authors write, “Research shows that the very best way for couples to refresh their love for one another is to do something, anything, novel together.”

Uninterrupted time away from day-to-day obligations means a chance to get to know a partner more deeply. Learning new skills, like kayaking or navigating an unfamiliar transit system, enhances mutual respect. According to the authors, a magnificent natural view “can ignite all four of the so-called love hormones: dopamine, which fosters feelings of love; oxytocin, which helps create trust and bonding, serotonin, which increases feelings of pleasure and well being; and norepinephrine, which gives us energy and is part of our sexual arousal.”

Inspired to start dreaming? Some promising websites are Travel.AARP.org, Frommers.com, PeterGreenberg.com, and SmarterTravel.com. AARP membership includes discounts for those 50 and older. Road Scholar (formerly Elderhostel), a nonprofit, offers educational adventures all over (including Antarctica). The Golden Age Passport, for those 62 and up, gives lifetime free admission to all U.S. national parks for only $10. For those 50 and older who would like to try swapping housing with other travelers, there’s also Home Exchange 50 Plus.

But you don’t have to look across the world for new experiences to share. A day trip or a weekend trip can get you there—or even a trip to your bedroom!

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While reflecting on our anniversary, we were reminded of how many women have come before us, paving the way for straightforward conversations about women’s sexuality. This is the fourth in a series (read the firstsecond, and third) launching our sixth year with gratitude!

Helen Gurley grew up in the Ozarks, “ordinary, hillbilly, and poor,” but determined not to stay that way. When she was 10, her father died in an elevator accident. Her mother struggled for years to provide for her two daughters, then moved the family to Los Angeles in hopes of getting help from a relative. Helen Gurley, the valedictorian of her high school class, learned to type. She said she went through 17 secretarial jobs before a boss finally promoted her: to advertising copywriter. She never looked back.

She was a highly successful career woman but chafed at remaining unmarried well into her 30s, so she plotted to snare the movie producer David Brown (later known for The Sting, Jaws, and Driving Miss Daisy). Among her wiles: she put her phone in the fridge so she wouldn’t hear it ring, making her suitor think she was out with some other man. They stayed married for more than 50 years, until he died at the age of 93. She had told the New York Times, “I look after him like a geisha girl.”

When Helen Gurley Brown published Sex and the Single Girl in 1962, she was 40 years old and married; her husband had suggested the subject. She later recalled, “Before I wrote my book, the thought was that sex was for men and women only caved in to please men. But I wrote what I knew to be true—that sex is pleasurable for both women and men.”

The book’s notoriety led to her becoming the editor of Cosmopolitan. Her first cover, in the summer of 1965, featured ample cleavage, pouting pink lips, and heavily made-up eyes. She was aiming for the “grown-up girl, interested in whatever can give you a richer, more exciting, fun-filled, friend-filled, man-loved kind of life!” Her underlings were told, “no glums, no dour feminist anger and no motherhood.” She remained the editor of Cosmopolitan for 32 years. She claimed that her husband wrote the cover lines.

Helen Gurley Brown insisted that she was a feminist but others disagreed. One year after Sex and the Single Girl, Betty Friedan’s Feminine Mystique heralded a new wave of feminism. In 1970 Kate Millett led a sit-in in the Cosmopolitan office. Jennifer Pozner called Cosmopolitan “one of the most body-shaming, insecurity-provoking, long-lasting sexist media products of the last 100 years.”

Helen Gurley Brown died in 2012 at the age of 90. She had suggested that her epitaph say, “She worked very hard.” She claimed never to have taken a day off except for plastic surgery. As Margalit Fox’s obituary slyly put it, “She was 90, though parts of her were considerably younger.”

But Dr. Ruth had a gracious tribute. “What Helen Gurley Brown taught women was how to use their bodies not to give someone else pleasure but to give themselves pleasure, and that is a tremendous contribution for which I thank her on behalf of all the women who are now orgasmic and might never have been without her pioneering efforts.”

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