Erectile Disorder and Sex Therapy

Many people do not realize that Erectile Disorder (ED), the inability to achieve or sustain an erection sufficient for intercourse, is extremely common. Today, 1 in every 10 men in the United States experiences ED, and by the year 2025 the prevalence of ED is expected to increase ultimately affecting an estimated 322 million men. ED affects every aspect of a man’s life–their physical health, mental health, and relational health. It affects not only the person with the condition, but their partners.

When men come in for individual sex therapy with the goal of improving their sexual functioning, I ask those currently in committed relationships if they would be open to inviting their partners, wives, or husbands to couples sex therapy. Why? Because when you are unable to get or keep your erection, a partner may not know how to react, how to be helpful, and may feel like they are doing something wrong. It can impact that person’s sexual self identity if they perceive the inability to sexually connect to be a reflection of their desirability. Why, they think, are they no longer into me? 

Erectile Disorder 

People with ED may be unable to get an erection sometimes, be able to get an erection but not keep it long enough for satisfactory sexual intercourse, or never be able to get an erection. To satisfy the diagnosis of Erectile Disorder in the DSM 5, one must have been having these challenges for at least six months and during at least 75 percent of their past sexual scenarios. ED can be diagnosed in conversation with a sex therapist or your medical provider who will ask about your health history and those experiences where you lost or couldn’t attain an erection. 

While a less frequent occurrence in younger men, a study in The Journal of Sexual Medicine found that ED affects about 26 percent of men under the age of 40. Another study highlighting ED in young men found that 8 percent of men between the ages of 20 and 29, and 11 percent of males ages 30 to 39 have some form of ED. 

The increasing prevalence of ED in young men is an important phenomenon. Particularly because the psychological burden of Erectile Disorder in young men can sometimes be greater as they are in a time in their lives when society expects them to be more sexually virile and, in many cultures, more active. ED has drastically impacted the dating lives of the younger men I see in my clinical practice. They often have avoided dating apps for fear they will be expected to initiate sexual activity after several dates with the same person and unable to perform. Some young men are turned on by texting with a potential partner for casual sex or hookup, but end up self-pleasuring with sexually explicit media or porn rather then asking the person to meet up and risking the embarrassment and misunderstanding that can follow an episode of ED.

Causes of Erectile Disorder 

The most common cause of ED is vascular disease. 64 percent of difficulty getting and maintaining an erection are associated with heart attack and 57 percent with bypass surgery. Up to 75 percent of men with diabetes, 40 percent of men with renal failure, and 30 percent of men with COPD have some experience with Erectile Disorder. Psychological causes of ED are wide ranging. They include stress, depression, anxiety, feelings of guilt, low body image, issues in a man’s relationship, or sleep disorders. 

As more young people are affected by Erectile Disorder, there is an increased risk that their doctor assumes that their ED is the result of a psychogenic cause without conducting a proper examination. Their doctor may offer the young man a prescription of a PDE5 inhibitor like Tadalafil (generic for Cialis) or Sildenafil (generic Viagra), or refer them to a sex therapist. However, similar to ED in middle-aged or older men, ED in young men can be the consequence of the combination of organic, psychological, and relational factors–all of which must be addressed in appropriate clinical treatment. 

In particular, Erectile Disorder in young men–even more than in older men–is considered a harbinger of Cardiovascular Disease (CVD). As a sex therapist, I go through a complete biopsychosocial sexual history to help my clients figure out if their ED is an early warning signal of CVD so that they might work with their medical doctors and find critical preventative interventions if necessary.

Co-occurring Sexual Disorders

Most people don’t realize that there are a number of sexual disorders that co-occur in men who experience ED (most commonly different forms of ejaculatory dysfunction). One co-occurring sexual disorder is premature ejaculation, or what we sex therapists call uncontrolled ejaculation. A recent study found that 76.3 percent of its participants who report premature ejaculation also had an Erectile Disorder diagnosis. Premature ejaculation is relatively common, experienced by about 30 percent of men. Premature ejaculation can cause men shame and anxiety that their erections subside. Anxiety is one of the psychological experiences that causes loss of blood flow, and if there’s one thing a penis needs to keep erect, it is blood flow. Some of my male clients who come in because of their ED have never spoken about their premature ejaculation issue due to the embarrassment of not being able to control how long they last. 

Another co-occurring sexual disorder, though uncommon, is delayed ejaculation–or difficulty achieving orgasm despite adequate sexual stimulation. These are the men who can have penetrative sex for 30 minutes to an hour without climaxing. While American late night comics might make jokes about how fulfilled these men (and their partners) must be, the opposite is usually the case. Couples who come in with this problem often express disappointment that they can’t get pregnant the “normal” way. A delayed ejaculation client’s partner might feel they’re not truly loved or desired by a partner who can’t seem to ejaculate inside them. A female partner may avoid penetration because of the pain that long sessions of thrusting cause her vaginal opening. Over time, a man might begin to lose his erection in anticipation of the disappointment he and his partner will feel when he cannot climax.

These co-occurring conditions are often missed by general therapists. Their diagnosis requires a thorough assessment process including a deep dive sexual history interview and referral to a sexual health doctor, both of which are important in addressing a man’s overall sexual health.

Psychological Contributors to Erectile Disorder 

Psychological impotence, or erectile disorder caused by psychological symptoms, is even more common than other forms of ED. It is estimated that up to 20 percent of men in the United States have experienced ED as the result of a negative mental health state. A survey of men living in the UK found that more than 50 percent of men in their 30s experience ED. About half of those who struggle with ED cite stress as the reason they cannot get or keep an erection. 

One of the most common negative emotions that causes ED is performance anxiety, and rates of performance anxiety seem to be rising among young men. Up to 25 percent of men experience sexual performance anxiety. Sexual performance anxiety can be caused by a number of things including body image issues, low self-esteem, mental health issues like depression and anxiety, stress, previous sexual trauma, and feeling emotionally disconnected from your partner. The shame my clients feel around their sexual dysfunction worsen their performance anxiety and prevent them from talking about and addressing the issue. 

Men may wait many months before seeking out sex therapy because they feel like they should be able to take care of this problem on their own. Men who are survivors of trauma, whether it’s sexual trauma or some other kind of trauma, may not connect their current ED problem with their past trauma on their own. I let clients know it takes tremendous courage to reach out for help and begin the healing journey of reclaiming their sexual pleasure and functioning.

Increased recreational use of erectile dysfunction medication

Phosphodiesterase type 5 (PDE5) inhibitors like sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra or Staxyn), and other oral erectile dysfunction medications, have become a popular sexual enhancement aid among some men without ED. A study in the Journal of Sex Medicine found that, among a sample of 167 male medical students reporting no issues with erectile function, 9 percent of these med students reported the use of PDE5 inhibitors. Of those who had used PDE5 inhibitors in the past, 46 percent reported using the drugs more than three times, and 71 percent used them with alcohol. Why is this happening? 

With so much sexual prowess depicted in sexually explicit media like online porn, streaming series, social media, and campaign ads featuring buffed men with 6-packs and gleaming hairless chests, many young men feel they don’t live up to the standard. Clients who are more romantic types and need emotional triggers of closeness may lose their erection when with a partner they don’t know well enough yet. While these clients feel pressured to “make the first move” to show interest, they are not ready. Their mind and body are not in alignment and their penis sends the message. The pressure men feel may push them to use PDE5 inhibitors.

Men are surprised in therapy sessions to learn that the recreational use of Erectile Dysfunction medications (EDM) may have unintended negative effects. One 2011 study found that Recreational EDM college-aged users reported 2.5 times the rate of erectile difficulties compared to nonusers. In another study, recreational use of EDM has been found to decrease healthy young men’s confidence in their ability to get and maintain an erection on their own. 

Men who come into sex therapy who tell me they’re using PDE5 inhibitors, despite having healthy erections when they masturbate, express anxiety that they won’t be able to “crush it” in the bedroom. Much of the work with men with ED is teaching them what a realistic sexual response cycle should look like, how they can identify their needed erotic triggers and skills to communicate them to partners. There is a lot of myth busting around what authentic masculinity actually is that is part of sex therapy.

Treatment for Erectile Disorder

As a result of the biopsychosocial elements inherent in possible caused of ED, it’s extremely important to get a thorough sexual assessment by a sex therapist and urologist. When seeing a urologist for ED, the assessment might include a physical exam, blood and urine tests, penile duplex ultrasonography (a test to analyze blood flow in the penis), a penile angiography (x-ray with injected dye to view blood circulation), and a combined intra-cavernous injection and stimulation to assess the quality of an erection. 

When seeing a sex therapist, a client should expect the therapist to take the time to review one’s sexual history to find out possible medical reasons or injuries that occurred in one’s childhood, puberty and college years. The therapist can review the prescriptions and over the counter medications someone has taken in the past and/or currently, screen for alcohol and substance use and find out about psychiatric precursors that impact erectile problems.  

A sex therapist will frequently refer the client to a doctor for more tests to ensure there aren’t any underlying or comorbid conditions contributing to their Erectile Disorder. And if he’s currently part of a couple, it’s important that the man’s partner/spouse be invited in to be part of the sex therapy treatment.

March is National Disability Awareness Month. 2022 is the 28th year that the United States has dedicated a month to raising awareness around the support available to people with disabilities and their rights. 61 million people living in the United States are living with a disability. That means that 1 out of every 4 people you know has a disability as defined by U.S. disability law as a physical or mental impairment that substantially limits their life activities including employment and engagement in social and romantic relationships. 

March is also Endometriosis Awareness Month. Endometriosis–a condition affecting 10 percent of people assigned female at birth–occurs when tissue similar to that which grows inside the uterus is found on other parts of the body. The endometrial-like cells found in the uterus can grow on the lining of the abdomen, ovaries, bladder, or colon. The symptoms vary from person to person but can include pain during periods, bowel movements, urination, and chronic pain in the pelvic area and deep vaginal pain during sex. 

Doctors have historically been quick to dismiss the painful symptoms of endometriosis. As a result, it  takes an average 10 visits to the doctor and 10 years to be diagnosed with endometriosis. In fact, more than 75 percent of cisgender women who ultimately receive an endometriosis diagnosis report being misdiagnosed with another physical or mental health condition. The gold standard of care to definitively diagnose endometriosis is through laparoscopic surgery and biopsy. 

The majority of people who receive an Endometriosis diagnosis experience significant changes to their psychological health, quality of life, and sexual relationships. Female-at birth clients enter sex therapy when the pain they’ve endured for months or years becomes overwhelming in their day-to-day life. Some of my clients have reported losing as many as 10 days a month to debilitating bleeding and crippling pain. If the definition of a disability includes impairments that affect a person’s ability to…

• Be mobile
• Think clearly 
• Engage in gainful employment 
• Sustain fulfilling social relationships
• Retain good mental health

…shouldn’t workplace organizations consider endometriosis a disability?

The U.S. Social Security Administration does not have an official disability listing for endometriosis, but it can be categorized as such. Bringing awareness to endometriosis and its impact on women’s lives is in and of itself important. Identifying it as a disability is crucial.

Medical Providers and Cultural Stigma Around Infertility

Unfortunately, the medical avoidance and cultural secrecy around the mental health, sexual health, and sexual pleasure of people assigned female at birth means that endometriosis is often treated as a secret–or hidden disability.

Sex therapy clients report that they haven’t felt empowered to ask their medical providers about the pain issues affecting their sex lives due to embarrassment. Medical providers have traditionally not received much in the way of sexual health education during their professional training and may feel awkward about asking their patients about their sex lives. Particularly taboo are the mental health issues that an endometriosis diagnosis can cause. Especially common are mental health issues related to difficulty getting pregnant that are compounded by societal judgment of people assigned female at birth who remain childless (due to infertility or choice). As a result, many clients begin to doubt they can be what society might call a “good partner”. 

Endometriosis and Partnered Sexual Pain 

According to a Canadian Health research and educational site more than 50 percent of people with endometriosis feel pain during or after intercourse. They can experience “deep pain” during penetrative sex or “superficial pain” anywhere in the pelvic area and around the vagina. 

While over half of women with endometriosis experience a deep pelvic pain during penetrative sex, some experience entry pain only around the opening of the vagina. Entry pain is commonly caused by a different condition called provoked vestibulodynia (ves-ti-byew-low-DIH-NIA) not endometriosis. This can feel like pain, burning, stinging, stabbing, or rawness at the opening of the vagina. The discomfort can be constant, or only happen when the area is touched. There is a 30 percent overlap between people who experience provoked vestibulodynia (also referred to as PVD) and deep pelvic pain caused by endometriosis. 

Inability to have comfortable–let alone pleasurable–sex because of endometriosis or PVD can cause someone to feel that they aren’t able to be a “normal” sexual partner. As a result, people without partners may refrain from exploring the possibility of new sexual or romantic partners, and those with partners may experience issues around sex and intimacy in their relationships.

In fact, endometriosis in particular is associated with higher levels of sexual and relational distress. Partners in which one person experiences sexual pain report poor sexual communication, higher instances of erectile disfunction, less expressions of affections, and less overall satisfaction in their relationships–all else being equal. One of my clients who was unable to have penetrative vaginal sex with her husband because of intense sexual pain told me she felt like a “failure”. What she called her “brokenness”–her inability to have pleasurable, “normal” sex–outweighed her success at a fulfilling job, loving familial relationships, and emotionally loving relationship with her husband.

Partners of Females with Endometriosis 

Because of the systemic nature of sexual pain, I recommend that clients struggling with these disorders to invite their partners in for couples sex therapy. Many couples continue to have vaginally penetrative sex while the partner with endometriosis is clenching or wincing in pain. This has an effect on their partner who may begin to feel anxiety and a sense that they are sexually coercing their partner–feelings that can create a negative self-identity and even a sense of self-disgust.  Male  partners may begin to avoid all aspects of sexuality in order to avoid their partner’s pain and their feelings of shame, or due to erectile, orgasmic and ejaculatory difficulties. 

Sex Therapy with Couples Challenged by Endometriosis 

The ability to engage in pleasurable and regular sex has profound increases one’s overall well-being. It affects how they view themselves, their value, and alters how they show up in their relationships and in their lives. It’s time to bring a large spotlight on endometriosis and chronic pain’s impact on people’s lives; centering female sexual pleasure.

There is hope for partners experiencing these difficulties. My initial intervention with couples dealing with endometriosis is educating both partners on the challenges of the illnesses. I recommend that couples take a break from painful sexual activity while the partner with endometriosis works with a gynecologist. I then invite the couple to imagine a larger sexual menu and make changes to their sexual script. Together we brainstorm new or previously enjoyed erotic and sexual play in order to reestablish emotional and playful intimacy in their sex life.

Other interventions including mindfulness and cognitive behavioral therapy provide additional hope for struggling couples. Mindfulness based cognitive therapy were found by Brotto et al. to help cisgender women decrease distress and rumination and improve their sexual satisfaction with provoked vestibulodynia. Evans et al. found that mindfulness practices can help couples to relax, reframe chronic pain, and ultimately help people with endometriosis to feel more embodied and empowered–particularly in communicating with their partner about intimacy. A recent study by Mikocka-Walus et al. also found that yoga and cognitive behavioral therapy is likely to have a positive impact on the quality of life of people living with endometriosis. These interventions bring hope to individuals and couples who are struggling with the debilitating effects of endometriosis and sexual pain.

As endometriosis can limit a person’s ability to work, care for themselves, engage in social and intimate relationships, and has a significant impact on their mental health, I would argue that it should be included as a legal medical disability. However, an endometriosis diagnosis does not have to mean a loss of intimate connections, pleasurable sex, and sex esteem. I have seen people with endometriosis and other forms of sexual pain make significant improvements to their health, sex lives, sex esteem, relationships, and lives by talking to their doctors, using mindfulness practices, and engaging in sex therapy.

A recent survey by the National Coalition for Sexual Health and the Kinsey Institute examined how Americans’ sex lives have been changed by the COVID-19 pandemic. For some partnered Americans, the pandemic and resulting quarantine strengthened their relationships by increasing their commitment, and emotional and sexual satisfaction. However, the majority of partnered Americans are having less sex, experiencing low sexual interest, and having trouble orgasming.

Americans are, by and large, less sexually and emotionally satisfied as a second COVID Valentine’s Day approaches. These decreases in sexual experiences may be the result of the responsibilities of a full house with little time to intimately connect with our partners or increased stress and anxiety due to job loss and homeschooling. They may also be the result of a preoccupation with the fear of either our loved ones contracting COVID or getting it ourselves.

The Power of Fantasy

A year ago, folks were preparing for their first COVID Valentine’s Day. A simple Google search of “COVID Valentine’s Day” produces countless articles from 2021 with tips for enjoying and celebrating the holiday with your partner. The widespread panic about how to make the day special in the context of decreased sexual interest, emotional disconnect, COVID stress and anxiety, and limited options for spending the day outside of the house safely was pervasive.

As the second COVID Valentine’s Day approaches, what can be done to spark sexual and emotional connection? Can actions taken on Valentine’s day spark long-lasting changes in how partners are interacting and ultimately their sexual and emotional satisfaction? Can folks overcome what Adam Grant so eloquently described in his New York Times piece as languishing and upcharge our Sex Esteem?

Sexual fantasizing is remarkably prevalent, but not always used for a partnered erotic connection. Common fantasies center around sensuality, dirty talk, changing power dynamics, and risk-taking. However, according to a Kinsey Institute study led by researcher Justin Lehmiller, the pandemic has changed why and how often people are fantasizing considerably. Participants in the study reported that they were fantasizing more because they were bored, needed to escape reality, relax, or mentally fulfill their unmet sexual and emotional needs. These findings tell us that when people are struggling with their mental health and their attachment needs are not being met, they turn to their private fantasy world for comfort at times rather than reaching out for their partner.

Sharing your sexual fantasies with your partner—which is one of my Sex Esteem principles of accessing curiosity—is an important technique for fostering intimacy and sparking sexual and emotional connection. In fact, it has been shown that couples who share their fantasies and actively fantasize about each other are more easily aroused by their partner and more likely to engage in positive behavior towards them. What kinds of positive behavior did the researchers hear about?

• Intentionally increasing pleasure for their partner in sexual encounters
• Demonstrating affection more freely
• Completing acts of kindness that make their life easier day to day

Although these positive behaviors are major incentives for sharing fantasies, many couples struggle to share those intimate thoughts. The practice is frequently avoided by many partners I’ve treated in my practice, for fear of feeling awkward, embarrassed, or judged by their partner.

One way that you and your partner can make sharing your fantasies easier is by being playful with one another. While at times this is easier said than done, there is a myriad of ways to intentionally encourage playfulness in your relationship.

Laugh Together

No doubt laughter is good for the soul. It is also good for your relationship. A University of North Carolina study found that the frequency in which a couple laughed together was closely related to their perceptions of relationship quality, closeness, and social support.

If you feel like you and your partner haven’t laughed together since the onset of the COVID-19 pandemic, or perhaps before, there are things you can do to create laughter in your relationship. You can watch a comedy together or send each other TikToks that make you laugh. You can take time to think about inside jokes you haven’t shared in a while or experiences you’ve shared that are now hilarious stories. Remember that despite any sexual or emotional distance you might currently feel, you know your partner well and know what makes them laugh.

Flirt

Perhaps you haven’t felt “flirty” in years, and most definitely do not feel like flirting with the person you’ve been stuck inside with for the past year and a half. However, flirting can be extremely beneficial to a relationship.

The study “Flirting With Meaning” talks about the different reasons people engage in flirtatious behavior. Flirting can be used as a way to initiate sex, but also as a relational maintenance tool, a way to bring fun to an interaction, and a way of increasing your own or your partner’s self-esteem.

There are a number of ways you can do these things through flirtatious behavior that do not feel like a big deal. The first way is to prioritize eye contact. This study found that prolonged eye contact can quickly build intimacy and change how much a person is attracted to another. Another easy way to flirt is by telling your partner something you appreciate about them while touching. This doesn’t have to be a big gesture and is a way to break the cycle of irritation and frustration with one another.

Finally, keep your date night and change it up—especially on Valentine’s Day. Be sure to spend time together without technology or other distractions, and try to do so in a new place. If you aren’t comfortable dining outside the home due to the recent rise in COVID cases, you can eat in a different place in your home, or with a different tablecloth and different candles.

Play a Game

Nothing says playful like a game. You can play games that don’t require any additional props or materials like “never have I ever”—maybe you will learn something new about your partner by naming things you haven’t done and seeing if they have. Rather than taking a sip of your drink when you hear a certain word in a show, kiss your partner. Write a word with your finger on your partner’s back while they guess what it is. You can also put a sexy spin on common board games you have around the house: Add stripping to your poker game, or a dare each time you pass go in Monopoly. If you’re willing to spend some money on a game, you can search for erotic board games online and purchase one for this Valentine’s Day. A variety of games exist that facilitate role play, new sensations, communication of desires, and sexual exploration.

Once you’ve established a new playful environment with your partner, the possibilities are endless. Perhaps the connection you’re seeking this Valentine’s Day will come from the play itself. Or perhaps the games and playfulness will make space for you to reach for your partner and share your erotic fantasies. Either way, you have the opportunity to try something new with your partner and spark the kind of intimacy you’ve been missing. I encourage you to intentionally be playful, try new things, share your fantasies, and ultimately reconnect with your partner this second COVID Valentine’s Day.

By Aly Pancer, Mindful Wellness Coach

Happy 2022! We have arrived at a brand new year, with brand new beginnings, goals, hopes, and dreams. We get to begin again. We set New Year’s Resolutions that include better nutrition, better sleep cycles, a regular exercise routine, and the decision to lose weight. We then pick an ideal weight and size, and go on a diet where we learn to restrict food in an effort to become thinner than we are. We tell ourselves we will start our diet on Monday.  “In fact, by the end of December, many people have made that promise to themselves 52 times” (Merendes, Gabriel, MD, Mayo Clinic, 2021).

Food. We need it, we crave it, we love it, and sometimes we have a challenging attachment to it. Like the diverse and negative attachments we enact in romantic relationships, our relationship to food itself is a symptom of how we are anxiously, avoidant or securely attached to our self. Many folks try to have three meals per day with a few snacks in between. Often, we are eating a meal or snack while multitasking, such as watching TV, checking Instagram, watching the latest Tik Tok video our friends shared, socializing, working, walking, driving, etc. We take the first bite of what we have chosen to eat, enjoy the taste, and then continue to eat the rest of our food in auto pilot, where we have stopped paying attention to what we are eating. The next thing we know: we are stuffed, feel bloated, and more often than not, we have finished everything on our plate. Then what follows usually are the twin emotions of guilt and shame into a spiral of negative attachment to ourselves and food.

Frequently people blame ourselves for having consumed too much. This can lead to a cycle of feeling depressed, anxious, self-conscious and isolated for overeating. They shame and criticize the way their body looks, which can lead us into developing eating disorders. “While there is no single cause of eating disorders, research indicates that body dissatisfaction is the best-known contributor to the development of anorexia nervosa and bulimia nervosa (Stice, 2002)”.  Distorted thoughts encourage people to climb onto the scale too often, or ignore it all together as part of an avoidant attachment to their bodies. An attempt to fit into clothes that are sizes too small in an effort to be the “ideal size” only furthers a magical thinking that leads to unrealistic diet fantasies. Many folks feel helpless if they dare to look at themselves in the mirror perhaps even calling themselves some negative names we believe describe our bodies.

The fantasy continue as people make 2022 New Years’ resolutions by restricting food through diets, fasting, and other unhealthy rules about food in an effort to reach a goal weight which feeds into the multi-billion dollar industry of diets.  There have been a slew of recent articles about Noom arguing that the way it markets itself as the ‘un-diet’ is just good marketing.

Consider for a moment changing your relationship with your food by exchanging the words and actions of “MindLESS Eating” to “MindFUL Eating”. What would that look like? How would it feel to abandon many fad diets, where you are being told about how to eat, what to eat, how much to eat, etc by others? How would it feel to be guided by your OWN cravings and satiety cues, from the inside out,  using mindfulness techniques for yourself, so that you can organically enjoy your food, moment by moment, bite by bite, and feel a secure attachment to your body and ultimately yourself?

The Mindful Eating skills I teach through coaching are based on the Mindfulness Based Stress Reduction model pioneered by Jon Kabat-Zinn. It invites you to slow down the pace of eating, to awaken all your senses, to focus on every bite you take and ultimately to give yourself permission to stop eating when you notice you are satiated.

I find it exciting to work with mindful eating clients who are eager to establish a wellness journey that focuses on intention and practice rather than fantasy and anxious attachment. One can create a secure relationship to food, and in doing so, be fully present, embodied and able to show up fully in their life.

From the end of December through January 1st many people will spend time with their families to celebrate Christmas, for non-religious gatherings, and to welcome in the New Year. Generations of family members will gather at dining tables across the country to share meals and spend time catching up on their lives since last holiday season or, for many, since before the pandemic. For some, these gatherings are something to look forward to, but for others–particularly young couples and single people–they can be stressful. While 95 percent of people believe that spending time with family around the holidays is important, 40 percent admit it is stressful to do so, and 45 percent of Americans say they would rather skip out on celebrations than deal with the stress. 

Some couples, like many I see in couples sex therapy, have unresolved psychological and emotional dynamics with their parents, in-laws, siblings, and/or extended family. For these people, celebrations can be experienced more as obligations. Couples with children often describe attending holiday gatherings as a sacrifice they are willing to make so that their children can experience extended family rituals. I advise partners to create non-verbal signals to one another so they can take breaks when triggered by a relative’s comment or leave when their bandwidth for conversation runs out. 

My single psychotherapy clients experience the added emotional stress of prying questions, comments, and unsolicited advice from family members about their dating status. I have heard countless stories of crossed boundaries and unwelcome instructions into the private lives of single folks in my private practice and in my recent online talks. The anticipatory dread that uncoupled people experience, both emotionally and physically, is palpable to me as I listen to descriptions of their feeling like a deer in headlights at family gatherings–whether they are in their thirties, forties, or over fifty. The most anticipated question for them is: “So, are you seeing anyone? 

Generational differences on coupledom and family life

American family gatherings are likely to hold five different generations this year. Each family member comes from a generation that has been affected by a wide array of experiences (including world events, technological advancements, economic shifts, Coronavirus, and social change) and are in a different stage of life from one another. As can be expected, there are  varied generational views on current events, ever-changing social order expectations, as well as on family, dating, and relationships. 

For many people in the older generations (the Silent Generation, Boomers, and Generation X), there was only one blueprint for the majority population on adulthood and family life. Between 1950 and 1965, divorce rates dropped, fertility rates rose and the nuclear family thrived. Twenty-six percent of Boomers got married between the age of 18 and 21 compared to only 7 percent of Millennials and 4 percent of Gen Z. Therefore, parents, aunts, uncles, and grandparents at one’s Christmas gathering may expect that a person is lonely or something is awry if they are not partnered, married, and/or talking about having kids. My clients have heard comments like: “You’re such a catch, are you putting yourself out there?” or “Sometimes people need to be more practical and less idealistic when looking for a husband/wife. These young people today are so picky they’ll drive two miles for a perfect latte.”

Another generational difference is that “family” has a more expansive interpretation for Millennials and Gen Zers. People I speak with in therapy sessions and in talks I give frequently use the term “chosen family” when describing with whom they’re planning to share a holiday. In fact, ninety-four percent of respondents in a recent survey reported that they are more likely to feel “belonging” with communities based on shared values, beliefs, and hobbies than with their biological families. These younger generations are much more comfortable with “non-traditional” family arrangements. 

Additionally, one in every six Gen Z adults identifies as LGBTQI+, and a poll from January 2020 indicated that 43 percent of Millennials say their ideal relationship is non-monogamous. These surveys illustrate that Millennials and Gen Z are generally not going to follow in the footsteps of their parents and grandparents in terms of child-rearing and family. For some, the question 

“So, are you seeing anyone?” is confusing and disorienting to the single person to whom it’s addressed.  They may be thinking;  I’m not looking for a heterosexual relationship, or I am polyamorous and believe on many partners, or I don’t want to get married or be in a committed relationship. For others, these questions reinforce existing fears–fear that the pool of eligible partners is shrinking, fear that they will be the last single person in their circle, fear of the risks that come with having children later in life, and fear of pity and stigmatization.

Single stigma

Some of that fear of ostracization is well-founded. Researcher Tobias Greitemeyer found that single people are generally viewed as: less extraverted, less agreeable, less conscientious, more neurotic, less physically attractive, less satisfied with their lives, and as having a lower self-esteem than those with a partner. Despite not being well-founded in truth, the idea that single people are less satisfied with their lives is extremely pervasive in the U.S. Dissatisfaction with life without a relationship is at the center of numerous movies, television shows, books, plays, and additional media that we regularly consume. 

One recent example is the Broadway show Company–a recently revived 1970s musical with music and lyrics by the late Stephen Sondheim— that focuses on single gal Bobbie (gender swapped from main character Robert in the original production). All of her friends are partnered, engaged, or married. In one song, Bobbie’s friend Harry sings:

Bobbie ought to have a fella

Poor baby, all alone

Nothing much to do except to check her phone

We’re the only closeness she’s really known

Poor baby!

I coach my single clients to remain mindfully grounded around relatives they know will be asking questions or making comments about their relationship status. If they feel they can remain calm, I invite my clients to explain that they are feeling judged and that, despite not being romantic in nature, their friendships are intimate and fulfilling. In fact, while high quality romantic relationships have positive psychological and physical effects, low quality long-term romantic relationships have been found to have significant negative effects on a person’s well-being. In addition to considering if they are willing to take on the emotional labor of educating their relatives, younger single folks should consider how their internalization of the single stigma is affecting their emotional response to those questions. Is it possible to hear the question as just a question, and not a judgement?

For a client who recently had a breakup, holiday gatherings are a potential place of embarrassment as they anticipate intrusive questions about the ex-partner who “got away”. The client is still trying to understand the recent breakup and is hurting. Comments from family members like this one feels like salt being rubbed into his recent emotional wound. 

Setting expectations with family members in advance can be a useful strategy. Setting expectations can be done by emailing family members ahead of time saying that you are not ready to discuss the relationship and not bringing it up would be experienced as a loving act.  Another way to set expectations is to have an ally in the family who is able to step in and speak up. It may even be useful for the ally to explain that asking someone from a younger generation about their dating life is as uncouth as asking someone from an older generation how much money they make.

Generational differences and the experiences of single people in America mean that conversations around dating and relationships around the holidays can be tense. I encourage readers of all ages to give some thought as to how they can express their love for a relative in another age-group in ways that focus on their accomplishments, what relationships have helped them thrive through the pandemic, and what they are looking forward to in the new year. I especially encourage single readers to express their confidence succinctly by responding to questions like, “So, are you seeing anyone?” with “No, I’m an awesome party of one!”

It’s PRIDE 2020 and included in the rise of consciousness among so many citizens in the wake of George Floyd’s murder by a white police officer and the current swell of Black Lives Matter protests around the country is another reason to be hopeful.  In a huge victory for LGBTQ+ employees, the Supreme Court handed down the Bostock v Clayton County decision to include legislative protection for ALL LGBTQ+ folks in America. The majority decision written by Neil Gorsuch stated: 

“In Title VII, Congress outlawed discrimination in the workplace on the basis of race, color, religion, sex, or national origin. Today, we must decide whether an employer can fire someone simply for being homosexual or transgender. The answer is clear. An employer who fires an individual for being homosexual or transgender fires that person for traits or actions it would not have questioned in members of a different sex. Sex plays a necessary and undisguisable role in the decision, exactly what Title VII forbids.”

In the Bostock v. Clayton County case SCOTUS considered Title VII of the Civil Rights Act of 1964, which forbids employment discrimination that occurs “because of [an employee’s] race, color, religion, sex, or national origin.” While the Civil Rights Act didn’t set out to protect people who had same sex attractions and alternative gender identities, the context of equality embedded in this law is what was considered paramount.  

As a sex therapist who works with straight and LGBTQ+ clients who struggle daily with shame around their erotic desires and gender identity, this decision provides a long awaited public affirmation that their jobs are legally protected. I have heard many a client articulate why they need to keep their sexual behaviors on the down low, or dress one way at work for fear of appearing too gay, fem, butch or non-binary.   As a white therapist who sees Latinx, Black, and Brown clients individually or with their partners, I’m aware that sharing sexual experiences and challenges can be a harder bridge to cross due to racist experiences they have had with the majority of past authority figures along with generational racist trauma genetically inherited through their DNA.  I may also add to this load with unconscious statements that a client may feel angry about but won’t reveal to me. The fear a client experiences of being judged, blamed or dismissed by one more white expert is palpable in a session and I try to ensure the racism ‘elephant in the room’ is addressed early on by encouraging clients to let me know if I’ve said or done anything that triggers or angers them.  I ask them how they feel I am white and how they came to choose a white therapist. 

With this latest Bostock v. Clayton County decision, the Supreme Court justices have cleared a path for the wider protection of the Equality Act which will need to be finalized in the Senate since Congress already passed it last year.  According to Kevin Jennings, CEO of Lambda Legal: “We have a long way to go in securing the full and undeniable civil rights of LGBTQ people, especially those in our community who are Black, Indigenous and people of color for whom their sexual orientation or gender identity is only one of many barriers to equal opportunity in this country.  But today’s victory is a necessary step forward on the journey toward equal justice for all without caveats or qualifications.”

Most American citizens understand that discrimination is wrong, so the hope is that with the Equality Act,  the loopholes and cracks not addressed in this decision will be covered by comprehensive federal protections. The Equality Act updates and expands protections in the workplace not only on the basis of sexual orientation and gender identity, but also on the basis of race, color, sex, national origin and religion in the workplace, the marketplace, and beyond.”

Last June we celebrated the 50th anniversary of The Stonewall Riots begun by gay men, and trans-women who with their protests proclaimed they had had enough and refused to be beaten, arrested and killed sorely because of who they chose to have sex with and how they identified in gender expression. Stonewall marked the beginning of the LGBTQ+ Rights Movement.  Today we are in the midst of  a new chapter of a multi cultural response to continued violence and discriminatory arrests of BIPOC in every American city despite facing a deadly COVID 19 viral pandemic. 

However, just last year alone at least 18 transgender people the majority of whom were people of color, were murdered in the U.S. This SCOTUS decision could be the most hopeful moment in decades to pass a law that protects all LGBTQ+ folks and impacts Black and Brown queer folk at a time when the wounds of racism have been violently torn open once again.  When the outside world brings confirmation, validation and freedoms into the therapeutic work my associates and I do with our clients, it is a day to celebrate, even if it is cautiously.  I say cautiously because of a case that is coming down the pike to the Supreme Court next fall challenging the rights of religious organizations who feel they should have a broad right to engage in anti-LGBTQ discrimination. 

Remember that case brought by a bakery owner in Colorado who refused to bake a wedding cake for a gay couple’s wedding because his religious opposition to same sex marriage? Yep, that one. Well that’s the issue coming up again this fall to the Supreme Court in another case and Gorsuch sided with the religious bakery owners last time. So by all means let’s celebrate but the battle for racial, sexual orientation and gender identity equality is very much a slow work in progress.

                   Happy Pride 2020 !                                                                                          BLACK LIVES MATTER