Author Archives: ADeng

The Importance of Rituals During this COVID-19 Thanksgiving

COVID-19 Holiday Season

Now that the presidential election has been called, Americans are gradually coming to terms with the results whether that’s letting out a celebratory exclamation of joy or sadly mourning the loss of their candidate. While many citizens are still worried and anxious due to the president’s refusal to concede, the holiday season is beginning with advertisement campaigns. Family members’ anxiety may be further fueled by the increase in COVID cases and deaths. The uptick may result in texting, chatting, and/or Facetiming one another with last-minute plan changes to the traditional Thanksgiving gathering.

In what has already been the most challenging 2020 year–given the COVID-19 pandemic, job losses, quarantine, and deaths of so many–the prospect of holidays spent apart from extended family and chosen family members can feel like a big mountain that feels too big to climb. As we begin to think about the upcoming holidays of Thanksgiving, Diwali, Christmas, Chanukah or Kwanzaa, it is really important to give space for both the sadness of who and what will be missing, AND consider what can be created anew to provide nourishment for the soul.

Pre-COVID Holiday Stress

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While pre-COVID Halloween is usually celebrated with the nuclear family or among adult friend groups, the upcoming holidays of Thanksgiving and Christmas are usually gathering times for extended family.  Holiday gatherings offer emotional and psychological grounding that is part of the foundation of our identity within our community. Meeting with those we love also reinforces our self-esteem.

The holiday season is difficult enough for many. It is notoriously the season of breakups, folks challenged by Seasonal affective disorder (SAD), facing ostracization due to gender non-conforming status or sexual orientation, and increased alcohol intake. Unsurprisingly, forced joviality often has the opposite effect, making one feel inauthentic and disconnected from oneself and those around us. The numerous additional stressors of 2020 present an even greater threat on Americans’ mental health than previous national crises. According to a recent study by Czeisler et al published by the CDC,  “the prevalence of symptoms of anxiety disorder (in 2020) was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%)”.

Rituals For Holidays and Lifecycle Events

In her paper “Rituals in the Time of COVID-19,” family therapist Evan Imber-Black writes of the importance of rituals. “Special time demarcates ritual time from regular time, enabling us to look forward to a ritual, whether it is daily, seasonal, or yearly. Special place may be a church or a hotel or restaurant or graveyard—or it may be a backyard, a kitchen table, a living room, all transformed by a ritual to become a special place.”

I have always let my clients know that it is helpful for one’s sense of agency, connection and continuity to consider restrictions as creative opportunities to come up with new rituals. As a former choreographer, dance pieces commissioned on a tiny stages required me to imagine movements I never would have created. Rituals like art provide us with structured time. Art is a way of marking the time as special and out of the ordinary, and imbue meaning that reflects our deepest values. They fortify our identity, and strengthen the connections to the people we love.

When past clients have had to face miscarriages, abortions, separations or coming out, I’ve encouraged them to create a ritual that is meaningful to them. Then, client could perhaps repeat each year to honor the pain, loss, relief and joy of a lifestage milestone that hasn’t been recognized in society or certain religions.

COVID Creativity; Innovative Rituals to Bring People closer During Holidays and Lifecycle Events.

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Around the world, families are coming up with creative ways to celebrate the holidays together in various states of distance: physical (due to a global pandemic) and, in some families, political (the drawn-out 2020 U.S. election). People across the world created new rituals for Easter, Ramadan, and for life-cycle events like weddings and funerals.

For instance, Ramadan, a holiday that starts on the evening of 4/23 and culminates on 5/23, sees Muslim fast during the daylight hours. As mosques closed due to COVID-19, those observing the holiday found ways to pray at home. Practicing Muslims focused on individual prayer habits and turning the isolation into inner peace. For Easter, families celebrated from a distance by decorating homes, playing virtual Easter-themed games like bingo, and hosting online family gatherings on Easter Sunday. Weddings and funerals became virtual affairs as well, with slideshows, streaming, and postponements becoming the norm. During the earlier days of COVID-19 I attended two shivas and a funeral via Zoom. They actually felt very intimate. One shiva created breakout rooms where I could speak with the mourner one-on-one. This is a good example of restrictions providing fodder for newer meaningful rituals.

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The wedding industry developed a new vocabulary in light of the virus. Many to-be-weds celebrated with “minimonies,” microweddings, or elopements. Graduation ceremonies this May took to the road, with teachers and families driving down neighborhood streets to mark commencement. Former President Barack Obama and Oprah Winfrey. addressed graduates in livestreamed speeches. Students recreated proms and yearbooks over social media. Witty pregnancy announcements went viral, with jokes about parents not social distancing and buying the wrong protection.

Thanksgiving Rituals

Thanksgiving as a holiday is not considered religious by most Americans. However, some experience it as a spiritual ritual that binds families and friends to one another. Due to an increased number of COVID cases in many parts of the country right now,  some families may choose to celebrate apart from one another according to updated CDC recommendations. However, there is still a need to create an intentional family ritual and celebration.

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There are creative ways to create rituals and a sense of togetherness over Thanksgiving to celebrate this spiritual awareness. For instance, for my family’s Passover Zoom, my brother and I planned songs and improv assignments for each family. This way, every family contributed something fun or meaningful to the holiday.

Here are some ideas to create anticipation, connection and meaning to your 2020 COVID-19 Thanksgiving;

  • Order craft supplies online and have them delivered to each family member’s home ahead of Thanksgiving. You can create themed DIY projects together via Zoom. For example, you can buy the makings of a fall wreath and each family can work on it together while catching up on Zoom displaying their crafting ability.
  • Safely prepare dishes and deliver them to family and neighbors in a way that does not involve contact with others. For example, leave them on the porch.
  • A game of charades is always fun, and can be played virtually.
  • Karaoke is a good way to bring music into your celebrations–belt out your favorite tunes over Zoom.
  • Schedule a time to share a meal together virtually.
  • Have people share recipes ahead of the big day. This way, they can cook their turkey, dressing, or other dishes alongside one another via video calls.
  • Once seated for dinner with your loved ones online, go around the screen and say what one is thankful for. This would be a wonderful new ritual to emphasize family bonds and heal potential family rifts.
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Come up with mindfulness techniques to ground oneself and keep anxiety, worries and fears down.

You may also want to create a space for mindfulness during the holidays. This could be a private mindfulness breathing exercise each morning. Alternatively, one could host a mindfulness session with the family at the outset of the virtual gathering. Carving calm from the chaos is, as Dr. Jamie D. Aten writes, a necessity. “When disaster hits, life can feel chaotic, and our energy is used up fighting fires. But when the flames die down, it’s important to make space to do some of the things we once enjoyed doing.”

 

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One in four older adults report anxiety and depression amid the 2020 pandemic. Historically, epidemics are accompanied by higher suicide rates. Researchers predict mental health repercussions of the COVID-19 pandemic for years to come. The holidays are a high-pressure microcosm of the difficult year we had. Adjusting to a new normal is only possible by keeping track of your own mental health.

On the eve before election day, I led a mindful grounding session for colleagues who were feeling anxious. This was a way I could give service and help others remain centered. Sending food to tireless hospital workers working over the holidays who are now swamped with COVID cases is another nice way to give back to your community. Be sure to reach out to neighbors, especially those who may live alone. A simple text or phone call could be enough to brighten their day. If you don’t feel able to deliver food to those homebound or homeless, find ways to donate time or money so those folks can have a holiday meal. These are ways, with the support and willingness of a community, to still come together.

Get the whole family involved in exercise during the holidays.

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A recent study showed that the pandemic has had a clear impact on diet and physical activity and therefore cardiovascular health. Exercising during COVID-19 to weave into creative ways for the whole family to move together during a Zoom family gathering. Some examples might be:

  • A younger family member can bring a dance move learned on TikTok to teach everyone else.
  • A young adult or avid music fan can create and share a music playlist for the family to dance to over Zoom.
  • An older member of the group can bring a family story or poem that they feel exemplifies the spirit of the holiday.

 

 

 

Facing a Post-Election Holiday Season with Compassion.

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Because this Thanksgiving holiday takes place in the aftermath of a highly unprecedented election, it is important to create boundaries around political discussions before you all gather together (whether it’s virtual or in IRL).  Let family members know in advance that you plan to listen but would appreciate not discussing politics at the gathering.

It may be a opportunity this year, that relatives who have different political beliefs’ are at a greater physical distance. Physical distance might give family members a chance to focus on missing one another rather than attempting to win debates. We can use holiday rituals as an opportunity to heal political fissions by focusing on what we all have in common. This could be a great exercise in compassion. Meditation teacher and published author Sharon Salzberg emphasizes that compassion does not connote agreement; in fact, she says that agreement is not even a part of feeling compassion. “We are all linked, and compassion is the natural response of seeing that linkage. It is caring and concern rather than a feeling of separation into us and them…[Compassion] is the result of the recognition [of the interconnectedness of everything].”

Here are two guided gratitude meditations for the family or individual preparing for the holidays this year: Greater Good in Action and YouTube.

Developing mindfulness skills in advance of that Zoom holiday gathering or phone call might be the most powerful gift you can give yourself and your family/friends.

Please keep several mental health resources handy this upcoming holiday season.
  • National Suicide Prevention Lifeline: (800) 273-8255
  • SAMHSA’s (Substance Abuse and Mental Health Services Administration) National Helpline: (800) 662-4357
  • National Eating Disorders Center Helpline: (800) 931-2237
  • Crisis Chat: visit link
  • Crisis Text Line: Text HOME to 741741

Why Are Women Still Staying Silent About Their Sexual Pain?

When it comes to women talking about sexual pain, omission is a form of communication. 

 

Vulvodynia = Women’s sexual pain.

 

Our society still grapples with the experience of female sexual pain. Specifically, Vulvodynia (vulvar pain) affects some 16 percent of women. “Vulvodynia is chronic vulvar pain without an identifiable cause,” reads a statement from the National Vulvodynia Association (NVA), a non-profit created in 1994 to help improve the health and quality of life of women suffering from sexual pain. “The location, constancy, and severity of the pain vary among sufferers. Some women experience pain in only one area of the vulva, while others experience pain in multiple areas.”  While some sexual pain may be located on the vulva or in the vestibule (the vaginal opening), some women may feel pain internally as well. Unfortunately, millions of women experiencing pain during sex are being misdiagnosed.  And so, millions suffer in silence.

Dyspareunia is an older term to describe all types of female painful sex. The most recent diagnosis of genito pelvic-penetration pain disorder (GPPPD) is the clinical diagnosis in the Diagnostic and Statistical Manual Version 5. It is the name of the conditions formally known as vaginismus and dyspareunia. Vaginismus results from involuntary contraction of the vaginal musculature. Primary vaginismus occurs in women who have never been able to have penetrative intercourse. Women with secondary vaginismus were previously able to have penetrative intercourse but are no longer able to do so.

 

How Women’s Sexual Pain Shows up in the Medical Realm

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Epidemiological studies indicate that only 60% of women with vulvovaginal pain seek medical help and among those, 40% never receive a diagnosis. The lack of support from the health care system may contribute to feelings of invalidation and stigmatization often experienced by women with Vulvodynia. When it comes to pain specific to female anatomy, like the vulva, diagnoses frequently veer off-course. Doctors suspect menopause, PMS, depression, or anxiety. Yet surprisingly, many of the women sex therapists see are actually younger than 40 and nowhere near peri-menopause or menopause.

This gap in a detailed assessment process leaves a woman with the wrong diagnoses and still in pain, with the additional psychological pain and loneliness of being misunderstood. Women presenting with genital pain frequently experience rejection from their biopsychosocial environment. This contributes to a belief that silence is better than being misunderstood and embarrassed.

“There’s a huge problem,” Dr. Elizabeth G. Stewart, M.D., told attendees at a session on vulvovaginal disorders at Internal Medicine 2011. “There’s virtually no vulvovaginal training for clinicians.” Due to the minimal training doctors receive about women’s sexual health in medical schools, doctors may feel stymied when their female patients report having genital pain. Stewart also added that “clinicians also tend to rely on patients’ self-diagnosis and manage their problems by phone, or don’t do a physical exam before treating, which leads to incorrect therapies.”

What might cause Vulvodynia?

In a recorded webinar presented by Center for Love and Sex (CLS) created for professionals with my colleague gynecologist Dr. Chris Creatura titled “How to Help Women with Sexual Pain and Low Desire,” Creatura let therapists and gynecologists know that while examining a woman with vulvovaginal symptoms, a doctor must consider many differential diagnoses. Although we still don’t know exactly what causes all Vulvodynia symptoms, she explained that some contributing factors include:

  • An allergy
  • Atrophy
  • A drug reaction
  • Sexually transmitted infections
  • Infection
  • Low estrogen
  • A dermatological source
  • Disease elsewhere in the body
  • A drug
  • Cancer or a precancerous condition
  • A combination of these factors

 

How Women’s Sexual Pain Affects Their Partners and Relationships

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Many women often keep the reality of the level of sexual pain or discomfort from their partners (whether they are new partners or longtime partners or spouses). Omission in the realms of sexuality and intimacy is a mechanism women resort to in order to feel more accepted by a partner and society out of fear of rejection, shame, and exclusion. Recent research cited in Michael Castlemen’s recent post also illustrates that it is a reaction to a patriarchal society that privileges men’s sexual pleasure over women’s desire and pleasure. Women reported that the reason they don’t tell their partners about their pain is because they felt “they should subordinate their erotic pleasure to their men’s.”

In fact, studies show that male partners of women who experience sexual pain are also deeply affected by their own shame when they are aware of the pain. In a recent study published in the Journal of Pain researching women with Vulvodynia and their partners, women experienced greater pain when they also reported pain-related shame, while their partners experienced distress when they felt shame related to the pain they were causing their partner through sexual activity. Furthermore, on days they had sexual activity both partners reported greater levels of sexual distress. The authors of the study state: “Qualitative studies have reported that many of them feel inadequate, are apprehensive to speak about their pain, and fear this condition spells the end of their romantic relationship.”

 

How Can Sex Therapists Help Women and Their Male Partners

As a systemic sex therapist, I consider the reach and power of a woman’s genital pain, the impact on her partner, and their relationship. It is critical for a sex therapist to first validate and empathize with the woman’s pain, since most women feel like a complainer or at times even like a hypochondriac. To uncover the source, experience, and history of the pain, the sex therapist should conduct a thorough sexual status and history assessment. (The Center for Love and Sex offers two recorded webinars on these interventions for medical professionals including therapists, sex therapists, pelvic floor physical therapists and doctors.) But then they also need to conduct assessments of her partner.

Frequently, for women in committed sexual relationships (in the cases I provide here, the partner is male), the vulvar pain also has an effect on a man’s sexual functioning. Male partners, feeling guilty for causing pain in their partner during penetrative vaginal sex, may experience erectile dysfunction, uncontrolled ejaculation, or low desire. It is important for women to seek help not only on their own but with their partner as well.

The Plan

The research cited above provides a strong argument for therapists to work with both partners in couples systemic sex therapy. Within this type of couples sex therapy, it’s critical for sex therapists to:

  1. Provide sex education about Vulvodynia to both partners so they understand that this is a medical condition and no one’s fault.
  2. Refer the woman suffering from pain to a well-trained sexual health medical professional able to diagnose and treat Vulvodynia and GPPPD.
  3. Explain how the disorder impacts the entire couples’ system.
  4. Encourage the couple to use the therapy space to address both partners’ feelings of shame, anxiety, and sense of brokenness. Give them hope that these conditions can be treated, and that their reactions are understandable.
  5. While treatment for Vulvodynia is ongoing, outline a treatment plan to work on the pain treatment, their couple communication, and sexual alternatives.
  6. Teach them mindfulness techniques in order for them to become more relaxed and embodied and focused on giving and receiving sexual pleasure. There is a whole body of research and a recent book written by Lori Brotto showing the benefits of MBSR (Mindfulness Based Stress Reduction) for women suffering with sexual pain.
  7. Advocate and support women as they work with allied health care professionals.

 

Creating a Holistic Systems-Oriented Medical Team to Help a Woman and the Couple

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In the second of CLS’s webinars on sexual pain co-presented with Pelvic Floor Physical Therapist Amy Stein titled: (“The Collaborative Clinical Care Model Between Therapists and Pelvic Floor Physical Therapists”), a case example showed a client (all identifying information was removed) experiencing severe genital pain who described feeling like a freak amongst her sexually active college peers. Another woman described a breakup with a boyfriend, suspecting the cause to be her pain during sex and the consequent lack of sex. In another example, a high-achieving professional woman worried she would lose her supportive fiancé once he started business school. In almost all cases, these women felt extremely isolated.

Therefore, silence about pain, shame, and distress creates a vicious cycle of communication and intimacy breakdowns. Excellent communication skills and having a team may ameliorate and amend communications. The system around a woman in pain–her gynecologist, therapist, physical therapist, sex therapist, and her partner(s)–must all work holistically to treat Vulvodynia and sexual pain. Sex therapists can create and coordinate care among all these providers. They can encourage women to speak authentically about the sexual pain to their sex therapist, their medical providers, and their partner.

 

References

Kearney-Strouse, J. (2011, June 1). Vulvovaginal disorders common but commonly misdiagnosed. ACP Internist.

Millions Of Women With This Condition Are Being Misdiagnosed: Here’s What To Know About Vulvodynia. (2018, March 14). National Coalition for Sexual Health.

Paquet, M., Rosen, N., Steben, M., & Bergeron, S. (2019, April 1). (174) Let’s Talk about it: Daily Associations between Shame and Pain and Sexual Distress in Couples Coping with Vulvodynia. The Journal of Pain. Brotto, L. (2018) Better Sex Through Mindfulness: How Women Can Cultivate Desire, Greystone Books: Vancouver

Vulvodynia Treatments. (2020). The National Vulvodynia Association.

What is Vulvodynia? (2020). The National Vulvodynia Association.

 Brotto, L. (2018) Better Sex Through Mindfulness: How Women Can Cultivate Desire, Greystone Books: Vancouver