Author Archives: ADeng

What if the problem with frequent or problematic porn use was not the behavior itself, but how you, your partner, your religion and the culture around you judged it? For the past twenty years since pornography became easily accessible online, there has been a tremendous amount of attention on the potential addictive qualities inherent in porn. There has also been a huge growth in residential treatment facilities who offer sobriety and recovery programs for those that self-identify or whose partners identify them as “porn addicts.”

There have been much discussion in sexuality research and clinical circles on possible new diagnoses and treatment models including: hypersexual disorder, Impulsive/Compulsive Sexual Disorder (ICSD), nonparaphilic compulsive sexual behavior disorder (CSBD) and Out-Of-Control Sexual Behavior (OCSB). As a sex therapist who sees clients who frequently come to treatment in crisis when their out of control sexual behaviors are threatening their marriages, relationships or jobs, I often hear clients self-diagnose as “porn addicts.” I recently began to run Out of Control Sexual Behavior Men’s Group in my practice. While there was not enough research to warrant a formal diagnosis in the most recent revision of the Diagnostic and Statistical Manual (DSM5) in 2013, in 2019 the World Health Organization included the novel diagnosis of CSBD in the 11th revision of the International Classification of Diseases.

Porn Use and Relationship Challenges

In a recent study by Beáta Bőthe et Al. from a large sample (13,778 participants) researching hypersexuality and problematic porn use, the results indicated that both impulsivity and compulsivity were weakly related to problematic pornography use among men and women, respectively. There is however, growing research that tells us that the frequency of porn use may not be the most critical variable associated with a person’s feeling dysregulated or out of control. Self-Perceived Problematic Porn Use (SPPPU) is a term referring to an individual who self-identifies as addicted to porn because they feel they are unable to regulate their porn consumption, and that use interferes with everyday life.

However, within academic research (Grubbs, Lee, et al., 2020; Vaillancourt- Morel et al., 2017) and my clinical practice, people who report problematic pornography use may do so independently of the actual number of times a week they’re using porn or the length of time spent online while watching porn. Thus, there is evidence that quantity or frequency may not be the only determining factor in whether a person reports feeling out of control in their use of porn.

The problematic porn or self-described ‘porn addiction’’ use can be viewed more as a symptom of deeper psychiatric issues and/or relational conflicts the person has with others.

In my clinical experience, which has been primarily with cisgender male clients, a client feels out of control due to the shame he feels when the type of porn he is watching is discovered by a partner and he/she feels disgusted by his erotic interests.

In other situations, a client may feel angry with himself for paying a large amount of money to watch porn secretly. He feels guilty for what his partner and he may look upon as a ‘filthy habit’ that has eaten away at their joint savings. At other times, if a client feels resentful of the sense of powerlessness he feels in his relationship or at work, his use of porn may be an unconscious expression of anger, freedom, revenge and liberation, a powerful antidote to this concoction of emotions that centers erotic and sexual pleasure to silence the feelings he can’t communicate effectively.

Part of the Sex EsteemⓇ model used with clients is to teach them how to identify what he is feeling by using mindfulness techniques to initially locate the emotion in his body. If it’s anxiety, frequently a client will feel tightness in his chest, with shame he may report a nauseous sensation in his stomach. If he has not come to terms with his own rage, he may feel clenching his jaw area. Frequently these clients report masturbating to porn then feeling deep guilt and shame afterwards. What he learns through individual and group therapy is that although he had a moment of reprieve from these intrusive feelings, his conflicts have not been resolved or communicated to the person about or to whom he feels angry, frustrated, ignored or worried.

In a 2021 paper by Joshua B. Grubbs and Shane W. Kraus, the authors state that “although there is evidence that pornography use can be longitudinally predictive of negative relational outcomes, it is not clear whether such links are causal in nature, how prevalent such associations are in practical terms, and whether third variables (e.g., sexual orientation, sexual dissatisfaction, sexual misalignment between partners, religious differences between partners) are potential moderators.” As a couples sex therapist, I hear about longstanding conflicts and misunderstandings that have been swept under the carpet repeatedly for years at times resulting in both partners feeling angry, defensive and frustrated. The porn use may then be a strategy to avoid further conflict with a partner and more of a symptom of a deeper relational conflict.

Porn Use and Internalized Cultural Shame

For clients brought up in highly strict families or communities, sexual activity is rarely discussed among family members and informed sex education may be missing from one’s development. Frequently children and young teens internalize shame and guilt about sex in general including the experience of having sexual fantasies.

Many self-perceived addictions are shame-based. Unlike diagnosed addictions to substances, porn addiction which one prescribes to oneself is, more often than not part of an internal conflict with values learned implicitly and explicitly in one’s family of origin and larger culture as to the:

“Right” way of having sex
“Normal” masturbation frequency
Accepted sexual orientation
Unacceptable fantasies if one identifies as heterosexual
Potential sinful nature of masturbation in general
Derogatory views of a person paying for pornography

Therefore, part of the Sex EsteemⓇ assessment is an in-depth inquiry into the implicit and explicit lessons learned from childhood around sexuality, religious beliefs, cultural norms, familial expectations regarding marriage, erotic taboos and the use of sexually explicit media. I have worked with clients who have had strict Catholic, Muslim, Hindi and Jewish religious upbringings and educations. While they may still practice these religions and believe in a deity, they have not come to terms with how they want to have sexuality in their lives and relationships.

In another study by leading porn researchers Joshua B. Grubbs, Samuel L. Perry, Joshua A. Wilt & Rory C. Reid the authors regard the problematic sexual behaviors a person who self-describe as porn addicts better understood “ as functions of discrepancies—moral incongruence—between pornography-related beliefs and pornography-related behaviors.”

This study puts some finality into the answers as to whether porn addiction is a true addiction. By reframing “porn addiction” as an “an incongruity between morals and behaviors,” the paper showed that the amount of time spent using porn does not predict problems with porn; rather, religiosity seems to be the bigger problem.

New Findings About Religiosity and Porn Addiction

An exciting new 2021 study from the Archives of Sexual Behavior by researchers David C De Jong and Casey Cook found that religiosity–the belief in a deity–had indirect effects on perceived addiction via shame. “…religious primes were associated with higher shame, and in turn, perceived addiction among individuals high on both organizational religiosity…” With regard to pornography addictions, those who self-reported as religious and who were more morally disapproving of porn were more likely to perceive addictions.

Religiosity, then, emphasizes the moral incongruence of porn by forming a system of belief. For those who worship a god, the use of porn depends less on the amount of minutes spent watching porn than the amount of pressure a sense of religiosity imbues on the time spent watching porn. Time is subjective. The misalignment between religious beliefs and pornography use can alter time.

Larger Cultural Myths in the Media

Unfortunately, the self-help industry is able to perpetuate this sense of shame for their

profit. In this way, religiosity and capitalism promote feelings of shame in their own self-interest. These are some things a “porn addiction clinic” may try to shame people into thinking:

“People can become addicted to pornography in much the same way they can become addicted to drugs.”
They often conflate “sex disorder” with “porn addiction.”
“Porn addiction is the result of smartphones, social media and the Internet.”
“There is too much pornographic content in the world.”
Do not thoroughly examine the root causes of the problem.
They encourage a separation between the stresses of daily life and pornographic addiction.
“There is such a thing as excessive porn use.”

The treatment models of Sex EsteemⓇ and the Out of Control Sexual Behavior used in my practice looks at porn use as an expression of all sorts of internal conflicts including moral incongruence, relationship struggles and potential symptoms of some underlying disorders that have never been assessed or diagnosed. For example, a client may have ADHD and plays out in the distraction of porn to avoid doing mundane aspects of their jobs. He may have a debilitating Anxiety Disorder and the porn use is a way of overwhelming feelings of anxiety.

When seeking help for what one might experience as problematic porn use, it is critical to ask a potential therapist what their beliefs are regarding pornography. Many therapists are also impacted by the culture at large and may regard frequency as a sign of compulsivity rather than using a larger biopsychosocial lens to help clients get more focused on what the behaviors mean, if they want to moderate them and giving them tools to do that individually, in a group and/or in couples therapy.

Will a New Year’s Resolution to Have More Sex Lead to More Happiness?

December 18, 2020

ADeng

Many couples seeking to reinforce their relationships may resolve to have more sex in the new year. However, does more sex really make partners happier? Is this belief held up equally among single, gender-fluid, gay, lesbian, and polyamorous folks?

Whose happiness matters during sex?

The assumption behind the oft-made resolution to have more intimate/erotic times with one’s partner assumes that upping sex will make a relationship stronger and bring about more happiness between two partners. While some studies do show a correlation between partners’ sexual habits and their happiness, the nature of these studies’ participants reveals an intrinsic bias. There is bias about what is a working definition of sex for each partner, who experiences pleasure in couples, and whether by “couple” they mean heterosexual couples. Then, the bias continues: which partner’s opinions on pleasure are more readily available through research studies in general?

A November 2015 study from the Social Psychology and Personality Science titled “Sexual Frequency Predicts Greater Well-Being, But More is Not Always Better” points to the idea that more sex for heterosexual married couples tends to lead to more happiness for both people in the relationship. According to a press release from the Society for Personality and Social Psychology, the subjects “are most representative of married heterosexual couples or those in established relationships.” But does this type of claim take into account the different meanings of happiness for all genders?

In sex therapy, the experience of “happiness” can also have intersectionally different meanings. For a Black woman who may feel less-empowered in her relationship with a Latinx man, happiness may mean that she focuses more on her partner’s pleasure and less on her own, with the thought that this will protect their relationship from a non-consensual hookup or affair. However can she be keyed into her own sexual pleasure within a sexual encounter? For an Indian-American first generation man, penetrative sex in which both he and his wife, who is white & third generation, climax, may have him report feeling “happy” since they both have orgasmed, but may have a meaning that has more to do with his feel masterful and turned on because he’s proven himself “worthy” of her. Whereas his wife senses that he’s not fully present to his own experience and this leaves her feeling like the sex they’re having is more performative. Perhaps she feels like her orgasm is for him and less about what kind of sex she would rather be having.

Sexual Quality over Sexual Quantity

For those in consensually monogamous heterosexual relationships, more sex might be a good resolution; but some studies bring in the variable of affection to see if it changes the happiness quotient. In a March 2017 study published by Personality and Social Psychology Bulletin, researchers asked sixty couples to take notes on their phones about their sexual and non-sexual activities, and when they individually experienced affection.

The study found that sex created feelings of affection not just immediately after the sexual act, but hours later. This suggests that sex can be a means to an affectionate end. A clear takeaway from this study is the idea that sex with affection between sexually-exclusive consensually monogamous couples can be the glue that makes that particular type of relationship stronger.

This may seem like an obvious result. However, what clients report in the therapeutic space is that while some partners want more frequent sexual connection, the quality of the sexual experience helps to make them feel either closer to or more distant from their partner.

In fact, in another study researchers explored the hypothesis that more sex would enhance a couples happiness. They asked one group of heterosexual couples to double the amount of weekly intercourse sessions they normally would have. The findings surprisingly showed that partner did not report feeling happier. I have clinically found through clients’ reports in sex therapy treatment that if partners create more time and relaxation around a sex date they are more likely to feel more intimate. Bringing more intention to their sexual and emotional connection and staying embodied is more likely to be increase pleasure on all body/mind/spirit levels.

Communication and Sex Within the LGBTQ+ Community

There are many assumptions in the aforementioned March 2017 study published by Personality and Social Psychology Bulletin to the finding of sex as a reinforcer for a happy relationship between a committed couple: one needs to examine the meaning of the terms: “committed,” “happiness,” and “couple.” Largely, these terms belong to the world of consensually monogamous, sexually exclusive, heterosexual relationships. One needs to keep in mind that the sixty couples who were subjects were most likely to be married, heterosexual couples, and not representative of some parts of the population who don’t identify with one or all of these variables.

As a sex therapist who works with many types of couples, including LGBTQ+, consensually non-monogamous, kink-identified, in addition to sexually-exclusive heterosexual couples, I have found that the bonding or glue comes when there are two (or more) partners fully present in a sexual experience. When one partner is not fully present or is going through the motions, the experience of bonding may not be mutually enhancing.

When one partner is continually giving pleasure to another partner, they may not experience feeling as bonded. In addition, if one partner feels it is their duty or responsibility to have penetrative sex, it may actually alienate that partner from their own embodied pleasure. This is why I give many mindfulness-based exercises to clients so that they can check in with themselves to see whether they are turning themselves off, avoiding feeling excited or feeling distracted from the sensations and experience. These sexual encounters don’t always result in happier or more bonded couples.

The queer community might have higher rates of orgasm

A 2017 study from Archives of Sexual Behavior published by the NIH found that in heterosexual relationships, heterosexual men were most likely to say they usually-always orgasmed when sexually intimate (95%), while the women they were sleeping with reported the lowest likelihood, at 66%. The queer community had the higher reporting of orgasm, on average: gay men (89%), bisexual men (88%), lesbian women (86%), and bisexual women (66%).

In the clinical setting, LGBTQ+ clients tend to have a wider menu of sexual activities than heterosexually-identified clients. While it is not a requirement that all partners need to orgasm every time they have a sexual encounter, it is important that partners check in with one another on whether they’re satiated. It is part of my Sex Esteem®️ model as a sex therapist and coach to help clients expand their sexual menu to include many erotic and sexual experiences. Orgasms are an important menu item for all genders.

Another step in the Sex Esteem®️ model allows for each partner to communicate the array of options they would be open to explore with a partner, whether they are a longtime sexually exclusive partner, a longtime consensually non-monogamous partner, or a person they are dating or hooking up with.

For those seeking to make a New Year’s resolution for a current romantic relationship, be aware that the resolution to “have more sex” is riddled with preconceptions about happiness, sex, orientation, relationship status and identity. It would do one well to do a deep dive into how you feel about each of these topics’ meanings for yourself personally before diving under the covers with one’s longtime bae or a new partner. This type of inquiry and practice would be what I call a New Year’s Sexolution and would boost your Sex Esteem®️ intelligence.

Watching The Crown’s Portrayal of Bulimia as a Sex Therapist

December 6, 2020

ADeng

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Princess Diana’s Bulimia Disorder

The Crown‘s latest season shows Princess Diana’s longtime cycle of Bulimia, an eating disorder involving binging on food then vomiting it up soon afterwards. The depiction of Diana’s patterned rituals is quite graphic in its detail. In this period of social distancing, increased loneliness and upcoming meal-based holiday season, here are some psychological concepts audiences can learn from the Netflix show.

After eating emotionally during a hearty holiday meal, it is all too easy for a person suffering from disordered eating and eating disorders to engage in a litany of self-criticism and potentially binging. The intensely negative self-talk often leads to internal negotiations around forms of restriction. Inevitably, the unforgiving rules imposed on oneself in moments of harsh guilt will reach a tipping point. At that moment, the person’s shame and rebellion lead to an overthrow of the restrictive policies leading to new overeating or binging. This is the cycle of eating disorders and disordered eating.

We see extreme cycles of Bulimia in the latest season of Netflix’s The Crown. The introduction of Lady Diana to the royal family was presented as a fairy tale romance in the press. Her public image, however, was somewhat a foil to her private life. In the television drama, we see Princess Diana in a secretive isolating cycle, experiencing years of intermittent bulimia. Starved of physical touch, kindness, sympathy, and sexual intimacy from Prince Charles, Diana sought control, expressing hurt, anger, loneliness and possibly vengeance by binging on royal delicacies and then making herself throw up afterwards.

The Connection between Infidelity, Betrayal and Eating Disorders

Eating disorders (like Bulimia and Anorexia) and disordered eating patterns are interpersonal as well as intra-personal disorders, meaning that they are triggered by feelings of betrayal or abandonment by others then turned inward as hatred or humiliation of oneself. What Diana experienced was an extreme sense of isolation almost immediately after she first became engaged to Prince Charles. Soon after the engagement announcement was made public, she became aware that Prince Charles was still romantically involved with Camilla Parker-Bowles. In Diana, In Her Own Words, a documentary also on Netflix featuring secret recordings of Diana, she states that: “The bulimia started the week after we got engaged.”

After discovering that the whole engagement and courtship was totally fake and that the marriage was solely “a call to duty” and nothing more, Princess Diana experienced infidelity’s pang of betrayal as a deeply interpersonal wound. Turning Charles’ rejection against herself, she tried to be more of what she thought her husband wanted, hoping to win him back. As a sex therapist working with couples after the discovery of infidelity or an affair, the betrayed partner frequently takes out feelings like self-blame and anger at their partner out on their own bodies. At times they begin behaviors of binging, purging or restrictive diets to lose weight in an effort to compete with their partner’s lover or a paid sex worker, who they assume are thinner than they are.

In a BBC1 Panorama Radio Interview Diana gave in 1995, she described how after spending her days fulfilling her royal duties visiting charities which involved comforting others, she was left feeling emotionally depleted and rejected by Charles who was giving his emotional and sexual attention to Parker-Bowles.

“I’d come home feeling pretty empty, because my engagements at that time would be to do with people dying, people very sick, people’s marriage problems, and I’d come home and it would be very difficult to know how to comfort myself having been comforting lots of other people, so it would be a regular pattern to jump into the fridge.”

Eating Disorders in the Media

While in reality, Diana’s eating disorder thrived in secrecy and shame for years, The Crown’s decision to portray bulimia in graphic scenes could be seen as glamorizing the disorder. Mary Anne Cohen LCSW, author of French Toast for Breakfast, says: “[Depictions of eating disorders in the media] can be a tremendous relief and, hopefully, become the first step to make the decision to get help and share one’s burden.”

Generally, eating disorders are treated by therapists who are specialists through individual and group therapy with a focus on healing a client’s attachment style, learning regulation skills, and mindfulness techniques while creating new habits.

Attachment Styles and Eating Disorder Treatment

Secure attachment to caretakers extends to one’s secure attachment to comfort in eating and feeling comfortable in one’s own skin. Insecure attachments, on the other hand, come from early unmet developmental needs. Diana revealed through her secret tapes In Diana in Her Own Words that she had been treated like “the virgin, the sacrificial lamb” by Prince Charles, the royal family and her own family. “Isolation with pastry needs to be replaced by intimacy with people,” writes Cohen.

A crucial element of eating disorder treatment involves helping a client learn how to express their emotional needs directly to people they can rely on and to cognitively shift from a diet mindset to an anti-diet mindset. An anti-diet mindset is precisely what eating disorder specialist Alexis Conason Ph.D. recommends for those struggling with this punishing cycle.

A New Year’s Resolution Worth Trying: The Anti-Diet Mindset

Dr. Conason suggests a sustainable and fundamental shift in mindset. “You haven’t failed your diet,” writes Dr. Conason, “Your diet has failed you.”

An anti-diet mindset is an agreement to eat in a way that honors your body’s needs, connecting to one’s body in a nurturing and peaceful way rather than a belittling, abusive one. Repairing this relationship with your own body is a way to repair the insecure attachment of childhood and the as outcome of infidelity.

People have traditionally created New Year’s resolutions to begin a diet after weeks of emotional holiday (Christmas, Chanukah, Kwanzaa) eating. However, given that 2020 saw an avalanche of COVID-19 weight-gain memes, with people feeling so guilty about their added pounds, we can logically expect the 2021 New Year’s diet self-recriminations to be even more rigid and punishing.

Many times people who are dieting may feel too weak or less desirous of sexual intimacy. Whether they are waiting to show their body to a partner when their body is at the “perfect” size, or too ashamed to have their partner touch them for fear they will feel a part that has too much fat , many people with eating disorders deprive themselves of sexual pleasure.

Part of their healing is to understand that all emotions are human, including the desire for sexual intimacy and comfort. Helping them to turn toward a person instead of food or dieting to alleviate hurt and express anger is a critical step in their recovery.

The Trifecta: Sexuality, Eating Disorders and Body Dysmorphia

Sexual disorders, Bulimia, Anorexia and Body Dysmorphia are interrelated issues. Researchers in an NCBI study “Sexual Functioning in Women with Eating Disorders” found that more women with eating disorders had:

loss of libido
prevalence of sexual anxiety, tension, frequent changes and higher frequency of detached relationships
relationships without intercourse and fewer with intercourse
avoided sexual relationships

In Diana: Her True Story – In Her Own Words, Andrew Morton quotes the Princess of Wales saying: “My husband [Prince Charles] put his hand on my waistline and said: ‘Oh, a bit chubby here, aren’t we?’ and that triggered off something in me.”

Some of our CLS clients verbally express body disgust for their own bodies in session to their therapist in addition to directly telling their partner their aversions. Most often their partner still feels quite attracted to them, continually trying to reassure them of their desire for them, yet feeling helpless to have their compliments authentically received. If a comment about one’s weight is made unwittingly by a partner, the partner with the eating disorder catastrophizes and thinks their entire body is revolting.

Another important fact to consider is that Body Dysmorphia (BDD a persistent and intrusive preoccupation with an imagined or slight defect in one’s appearance) is not exclusively a women’s disease. In one American survey, for example, found that an estimated 2.2% for men and 2.5% of women suffered from Body Dysmorphia. Whether the focus is on weight, the thinness of hair or the longing for more muscles, men can be as secretive about their body shame and disordered eating as women. BDD interferes with male sexual desire and connection in similar ways as other eating disorders.

How to Approach the 2020 COVID Holiday Season as an Anti-Dieter

Understanding the larger context of a meal is the first step to enjoying the holidays as an anti-dieter. With the additional stressors of the COVID-19 pandemic this year, I encourage more self-compassion and present-moment mindfulness. Make sure you have a buddy who you can call on when feeling triggered to binge, purge or withhold food. Give yourself permission to take a walk to ground yourself if feeling overwhelmed.

Coach yourself to receive sexual pleasure. Erotic intimacy should be considered a place to play and feel aroused rather than a space in which one needs to perform or pose. High Sex EsteemⓇ means that one accepts the notion that erotic behavior is a pleasurable, connecting place we go to experience comfort, fun, stress relief and passion, all basic human needs. Given that most Americans won’t be travelling long distances to gather with large groups of relatives this holiday season, use the extra time to have some mindful, sensual touching sessions with a partner who you can rely on, whether that be someone else or yourself.

If you are struggling with an eating disorder, a free resource in the U.S. is The National Eating Disorders Association. They offer extra chat hours over the holidays: https://www.nationaleatingdisorders.org/.

The Importance of Rituals During this COVID-19 Thanksgiving

November 20, 2020

ADeng

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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

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.

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.

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.

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.

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.”

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.

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.

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?

October 30, 2020

ADeng

blog Couples Therapy Sex Therapy No Comments

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

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

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:

Provide sex education about Vulvodynia to both partners so they understand that this is a medical condition and no one’s fault.
Refer the woman suffering from pain to a well-trained sexual health medical professional able to diagnose and treat Vulvodynia and GPPPD.
Explain how the disorder impacts the entire couples’ system.
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.
While treatment for Vulvodynia is ongoing, outline a treatment plan to work on the pain treatment, their couple communication, and sexual alternatives.
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.
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

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