Category Archives: Sex Therapy

Four Relational Contributors to Heterosexual Women’s Low Sexual Desire

In a recent study, titled “The Heteronormativity Theory of Low Sexual Desire in Women Partnered with Men”,  researchers Sari M. van Anders, et al. found that lower female libido can be a result of many societal norms, especially related to heterosexual couples. This article is extremely important since low sexual desire is a common, though not-often-talked-about, sexual struggle for women and a frequent treatment goal of sex therapy clients and couples in a therapy practice. 

Sex is often seen and related only to reproduction (Anders, S. et al), placing women in a box of being a “mother” and a “caretaker”. Studies have found that men do not equally share parenting and housekeeping responsibilities, which creates resentment from their female partners and contributes to a decrease in desire for partnered sex. Although more recent studies show an increase in men’s domestic contributions in heterosexual marriages, women still do most of the chores and/or family organization leading to lower satisfaction with their marriage, as stated in the article “Perceived Housework Equity, Marital Happiness, and Divorce in Dual-Earner Households” by Michelle Frisco and Kristi Williams, which isn’t exactly an aphrodisiac in the desire department for women. 

Anders, S. et al found four predictions of how heterosexual relationships lead to low sexual desire: 

Prediction 1: Inequitable gendered divisions of labor leads to inequitable gendered divisions of desire: Women are often responsible for relationship maintenance and family management. Women also often do the recurring chores like cooking, washing dishes, cleaning and laundry. These are all considered “low-schedule control” tasks. Men often take care of “high-schedule control” chores like house and car maintenance and paying bills, which are performed less frequently and with more flexibility. These differences in chores and responsibility can cause stress on the women in the relationship, leading to low sexual desire. Women can often feel more like a mother than a partner, and society regularly desexualizes mothers and parenting. Men may have more time to spend on being a “partner”. Women are expected to achieve more in the house, women have to ask men to share responsibility or “nag” them to be equals in the house. Marginalized women often have a harder time asking and receiving help and women who rely on men financially often have a harder time standing up for themself or feeling like they have a right to ask for more help with the house and kids. These inequities between partners often have negative effects on the sexual aspects of a relationship. Tasks at home can add up to a lot of stress, with chores constantly being added to the to-do list, women feel like sex gets relegated to a lower priority. One woman stated that they “would rather make sure the bills are paid, clean the house, do things that need to get done than participate in sexual activity.”

Prediction 2: Having to be a partner’s mother dampens women’s sexual desire: Heterosexual couples have traditionally thrust women into a role of  nurturer and caregiver. Once children enter the picture, relationships can go from partner-partner to mother-child, with one partner becoming caregiver dependent. Women will do the same tasks for their husband/partner that they do for their children including; 

  • reminding/planning/organizing of chores and social events 
  • buying clothes
  • planning/shopping/preparingdinner every night. 

Heterosexual male partners/husbands sometimes still expect their partner/wives to care for them like their mom did, as it is what was modeled for them in their parents’ marriages. This is not usually a role women are choosing to have between them and their partner, which can frequently lessen their sexual desire.

Prediction 3:Objectification of women downregulates women’s desire: Heteronormativity focuses on women’s sexual appearance over their pleasure. Women are taught early on that they should appear sexy rather than feel their sexuality for themselves. Women are for men to get enjoyment from, making women’s wants and needs a low priority. Men believe women’s bodies are offered to them as part of a marriage contract, they can have sex whenever they feel like it and the women are expected  to consent . Women’s desire is often based on whether men find them  desirable, causing women to feel like they need to spend a lot of time on their appearance for the other. The study found that women who have lower self-esteem tended to have lower sexual desire and lower sexual pleasure. In many cultures and families, children are taught that women’s genitals are “dirty” or nonsexual, this belief can distract women as adults during sex and lead to low self-esteem. Sex education focuses on vaginas as a reproductive organ , rather than focusing on the clitoris, vulva and labia, which are the pleasure centers of the female genitalia . The study observed that men view sex as a way to show off their technical skills, often viewing access to women’s sexuality as a trophy to be won, rather than focusing on women’s enjoyment during sex. 

Prediction 4:Gender norms surrounding sexual initiation contribute to women’s low sexual desire: Sex is often started when men initiate it, some women feel uncomfortable making the first move. Women are taught to want to have sex when men are ready, they are shamed for having their own desire, having been called a “slut” if they initiate too directly. Yet when women turn down  a sexual initiation they have traditionally been labeled a “prude”, “stuck up” or a “tease”. The study shows that women reported  feeling  like masturbating might be seen as cheating by their partners, so they avoid solo sex even if they want to. Heterosexual sex is painted as real sex, which has traditionally still been shown as offering a low rate of orgasming without direct clitoral stimulation. When sex does not lead to sexual pleasure it brings down one’s sex drive. Women continuously say that they view sex as a “job requirement”. The study states that “Women may be unable to refuse sex because of justified fears of violence or resource withdrawal…”, that is why “marital rape” needs to be discussed much more widely.

Stress, Future Research and Treatment: 

Stress is a major contributing factor in low sexual desire. Women may feel stress from pregnancy, whether wanted or not, babies/children, physical pain from breastfeeding, carrying, rocking and lifting, as well as sexual abuse. 

Unfortunately most research on women’s sexuality is still done with white, middle class, able-bodied, heterosexual, cisgender and monogamous women, so any women outside of these categories should and do feel like they cannot get evidence-based answers or care for their low desire or other sexual questions and needs. As a sex therapist and general psychotherapist we witness the ways in which individual CBT and psychodynamic therapy and couples counseling  can improve concerns related to low female desire, decreased sex in relationships and marriages as well as lower intimacy and attachment in relationships. As a systemically oriented couples and Certified Sex Therapist, I am also aware that sexual desire is an intersectional experience and has to be addressed by using thorough biopsychocultural-spiritual assessments and collaborative treatment goals. 

How the Psychology of Gifting Can Help a Sexual Relationship

According to the National Retail Foundation, 54% of the money spent on Valentine’s Day in 2021 was spent on a significant other. The act of gift-giving–an activity inextricably linked to Valentine’s Day can be, nonetheless, one of the more stress-inducing activities of this holiday, but it can also offer us lessons in how we relate to partners with intimate and erotic behaviors. In a recent research review by Galak, J et al of studies researching gift-giving, the authors hypothesize that many giver-recipient discrepancies are partly due to the notion that when givers choose a gift, they are focused more on the anticipated moment of when their gift will be unwrapped and viewed for the first time, whereas receivers usually focus on how valuable a gift will be once they own it.  Gifts are valued expressions of warmth, love and friendship to and from others. However at times, gifts may also be used in a more transactional manner or even as expressions of competition or power as in: “Which one of us bought the more expensive gift?”  Most folks, though, give gifts on Valentine’s Day because they desire to make a partner or best friend happy, and choose to provide them something, even if it is a modest present or a thoughtful act, to provide joy, and to show the receiver that they are held with warmth or love in the giver’s heart.

So during the Valentine’s Day season, I invite you to consider lessons partners can glean from this gift-giving-receiving process and how it might relate to couple’s offerings and accepting sexual and erotic behaviors to one another? How does the process of gift-giving relate to challenges partners confront when it comes to sexual initiations? 

The first thing to consider is that some partners don’t want to give or receive a gift from their partner similar to the way a partner identified as Asexual has decided they want to be emotionally close to a partner without engaging in a sexual act.  Another example occurs when a partner feels so anxious or frightened of getting the wrong gift for their partner, much in the way a person who is suffering from sexual pain, Erectile Disorder or traumatic history  avoids any initiation of intimacy for fear of physical pain, embarrassment, disappointment and disassociation. While these couples might agree to pause on any or some sexual activity with one another, other couples need help in finding better ways to initiate intimacy into their sexual practice.  

So how does a partner consider their sensual offerings without falling victim to the most common mistakes social psychologists have discovered when it comes to gifting?  During Valentine’s Day, when one is deciding on what gift to get a partner, it’s critical to put themselves in their partner’s shoes beyond the moment of when they will be unwrapping their gift. Similarly partners need to understand what their partners’ primary erotic language is and initiate an erotic or sexual experience in the  language that aligns with the partner’s sensibilities and what will feel pleasurable to the receiver.   

Another common error that people make whether they’re purchasing Valentine’s Day gifts or initiating a sexual encounter is that they offer their partner what they, the giver, would want to get, not necessarily thinking about what the receiver might desire. Whether it’s a habit of just responding to advertisements or an unconscious way to send a partner a not-too-subtle hint that they feel underappreciated, giving-to-get-back can be experienced as transactional by the receiver.  For example, if one partner likes to be seduced by having their genitals touched directly they might approach the second partner in the same way and turn them off with this approach because it’s not their preferred way of being invited into intimacy.  When thinking about initiating much as in deciding on what to get as a V-Day gift, a partner would be much better off by asking their partner what sexual or erotic signals they find meaningful or exciting. This process doesn’t always have to be drawn-out, either. Ask your partner directly and listen carefully. 

Oftentimes, a receiver might feel pressured by the invitation and respond immediately to an initiation by saying no. Giving and receiving are two sides of an experience, so a receiver can also gain skills on how to express gratitude for an initiation whether or not it’s a good time for them and offer in return further insight into what they’d love to experience. Just as a receiver would say thank you for a VDay gift even if it’s not what they most want, first expressing appreciation in positive tones goes a long way to the gift and initiation scenarios. 

 Both sexual encounters and gift exchanges require skill and nuanced responses for givers and receivers. The giver may do the bare minimum in choosing a gift or signaling they want to have sex, but that latent desire to please is rendered meaningless if the receiver begrudgingly takes what is put in front of them to satiate a partner who is putting pressure on the other. Frequently a receiver responds to what the giver wants for themselves with the hope of receiving pleasure later on in the event in a transactional way (as in I “do” you then you “do” me), or because it is expected (“we should be having sex”).  What can also become a negative exchange occurs when the receiver communicates abruptly that they don’t want to accept it because it’s not exactly what they want, or it was given at the wrong time of day which will most likely cause the giver to feel misunderstood, criticized and/or rejected.  If the giver got it wrong, the receiver should find something positive in the gift/sexual initiation and then gently explain how the receiver’s needs were misunderstood and how they might pivot by rescheduling, finding an alternative activity in the moment or deciding to try something the receiver suggests.  The receiver should still take into consideration the giver’s thoughtfulness in making the initial gesture with expression of gratitude for their efforts. To give and to receive are not mutually exclusive. 

Fully appreciating both the giving/receiving relational dynamic can be challenging for many partners whether on Valentine’s Day or below the sheets. While some people may struggle to conceptualize what their partner would truly desire, others may know erotically what it is their partner desires, but not how to enact it. For the former group, discussing erotic turn ons is critical so that these fantasies or desires can be spelled out and each partner can give examples of each turn on.  For the second group they may still need guidance verbally or nonverbally on what techniques would satisfy their partner’s erotic and sexual turn ons.  If, for example, one’s partner is particularly into tactile expressions, the giver might think about getting them a new vibrator, dildo, or clothing that has the feel they find sexy. Or a giver may begin by asking the receiver to guide their hand onto their skin to demonstrate how they want to be touched.  

Sexual intimacy can be nourishing when both halves of the pair are ready, willing and able to work as a team to give and receive pleasure with humility and erotic inquiry.  Gifting can be reconceptualized as an opportunity for learning more about your partner, yourself and improving sexual attachment. Everybody has a different language of love, just as everybody has varied erotic desires. These are steps in creating a more authentic emotional and erotic relationship on Valentine’s Day and going forward.. 

Cultivating 6 Practices of R.E.N.E.W.A.L. to Usher in The New Year

Each New Year and the month of January inspires people to renew their commitments to meaningful intentions. This is why people take on resolutions, whether to lose weight, get in better shape by joining a gym (More than 12 percent of gym members join in January, compared to an average of 8.3 percent per month for the full year, according to the International Health, Racquet, and Sportsclub Association (IHRSA)), partake in a “Dry January”, or to decrease stress and improve their relationships by starting therapy.  The commitments that are made globally the minute we cross into the new year express a collective consciousness of shortcomings and individual strides towards living more fully and healthily. Instead of resolutions which often get put on by the wayside by mid-February, I propose a practice of RENEWAL to integrate throughout the year.  This RENEWAL includes actions, internal inquiry, to go beyond the goals set by folks when they make New Year’s resolutions. This RENEWAL practice strongly reflects the way that I invite clients to subtly say or begin new behaviors to align with their sex therapy or sex coaching goal. At times I will encourage partners to create new rituals for themselves and with one another when they are creating time for intimacy to shift their oft-repeated sexual script or routine. Through R.E.N.E.W.A.L., I have created an acronym representing practices you can cultivate throughout this year not just for the first 30-90 days.


French Sociologist Emilie Durkheim wrote about his studies of rites and rituals in his book Elementary Forms of Religious Life and  regarded religion as the incarnate of society’s conscience collective–or its “collective consciousness” or “collective conscience.” While a 2020 Gallup poll stated that only 47% of American adults say they belong to a house of worship, many clients who come to sex therapy self-identify as spiritual.  And like many spiritual practices worldwide, rituals express the consciousness or larger mission with which people align their larger life’s purpose. 

R: Rituals were, for Durkheim, sites of “collective effervescence”, moments when the very fact of congregating to perform set religious actions imparted special energy to the participants–which lends meaning to a certain point in time, a specific event or a particular life cycle moment. For this new year, I invite clients to create a ritual from scratch, adopt a ritual from another culture to address a specific experience or emotion one wants to process, or collaborate with a partner to while paying tribute to either or both your cultural or religious heritages. Sometimes people create rituals for a joyful occasion like moving in with a partner, deciding to open up a relationship to welcome another partner, or deciding to adopt a child as a single parent. These are moments in one’s life that contain many emotions and psychological meaning but are not necessarily represented in traditional religions. People may invite people they feel closest to to cocreate the collective effervescence of the ritual or decide to do it on their own. 

E: Engage with people you care deeply for. In this societal era where digital communication–where we convey our emotions using emojis and profess our feelings through text–is considered touching base, strive to engage in person or through video calls with those you hold dearest or those with whom you’d like to become closer. Opt to engage with more intention: intention through physical proximity and intimacy, as well as intention with whom you choose to spend your time. 

N: Nesting is a practice we associate with parents who are expecting a baby, where to-be parents adjust their behaviors to ones that demonstrate a protection for the child coming into the world. However, I say we extend this practice of creating a warm, clean, loving home space to part of a yearly cleaning out and bringing in peaceful energy. A Feng Shui for the soul, to sweep out the past and create a peaceful place for new opportunities and connections to grow.  

E: Erotic Embodiment is for anyone in the relationship they have with themselves, and it is important in developing great Sex Esteem. It is accomplished through engaging one’s body in a mindful way that focuses on the development of a deeper body/mind/spirit connection. This mindfulness and bodily connectivity, be it through yoga, T’ai Chi, or a dance class, is helpful in renewing your sex life, whether or not you have a partner. Learning how to identify and cultivate your own erotic energy is a key element of juicy sexuality.

W: Wonder Cultivation is accomplished in adults through acknowledging what captivates your wonder–a feat admired in youth, but often shut down in adults–both now and from your experience as a child. By allowing space for noticing what captures your current curiosity you allow room for wonder to grow. Wonder allows for inquiry and the opportunity to learn new things about the world around us, the people with whom we share the Earth, and ourselves. One doesn’t have to accept that wonder is lost after working hard to achieve once-distant goals; one can utilize adult wonder in a complex manner. Psychologist and researcher Jeffrey Davis describes how, compared to his children, he has a larger awareness of mortality, which “heightens my experience of wonder and actually helps me be even more present to the moment with them or with you or with other human beings that, understandably, they don’t. They have a wide eyed wonder, and we have a more grown up wonder.”

A: Allow yourself to create a real period of time to relax. True relaxation means a quieting of the internalized “shoulds” list of things to be done in the future and “should-haves” of regret of things that weren’t done in the past. Without truly being at rest, the blood in our veins and capillaries can’t flow freely. Without relaxed blood flow, we can’t fully feel pleasure in intimacy. 

L: Lovingkindness  as defined by renowned meditation teacher Sharon Salzberg, “about opening ourselves up to others with compassion and equanimity, which is a challenging exercise, requiring us to push back against assumptions, prejudices, and labels that most of us have internalized.” Lovingkindness, which is different from what is presented as romantic and/or sexualized love, is a feeling and an action of compassion that need not be suppressed but, through its expression, can enhance deep moments. Lovingkindness is not a soft virtue, but a powerful force whose power can spread exponentially just through expression. I invite clients to either use the traditional blessings of lovingkindness or create original blessings for oneself, one’s loved ones and then all the world’s beings.

Erectile Disorder and 8 Masculinity Myths Part 2

Myth #5 Erectile Disorder is All in Your Mind

Erectile Disorder has comorbid origins in medical diagnoses and at times is the early harbingers of underlying illnesses like MS or Cardiovascular Disease. While sex therapists do a thorough assessment that includes psychiatric diagnoses like Major Depression, Anxiety Disorders, Bipolar Disorder, ADHD, and  PTSD that can impact erections, they also do a thorough history-taking of medical issues and medications that can frequently impact a man’s erectile functioning including: Diabetes, PTSD, Parkinsons, and past genital injuries.  There are also many medications that have sexual side effects like SSRIs and statins.

Additionally, there is a  recent study by Kevin Chu, Et Al  showing an increased chance of new onset Erectile Dysfunction post-COVID-19 infection.  

In this study conducted by the University of Miami Urology Department, it was observed that the likelihood of having an erectile dysfunction diagnosis was 20% higher if the male patient had a prior COVID-19 diagnosis. This may be due to virus-induced cell dysfunction. Nonetheless, many people with penises may have recently been wondering why they have been having newfound issues with performance. If a COVID-19 diagnosis is in their past, this data may provide men a resolve to the confusion and frustration, and encourage them to seek treatment from a urologist.  

Myth #6 Erectile Dysfunction Is a Man’s Problem to Deal with on His Own

Men are taught that in order to be ‘a man’, they need to “pick themselves up by their own bootstraps” (which by the way is a phrase originally intended as a sarcastic Physics-derived comment on the impossibility of such a task).  Frequently partnered and married men come in to sex therapy on their own with the misguided notion that since they are having a problem with their penis, the responsibility lies solely with them to resolve it.  What many of these men miss is that they are part of a relationship system and that there is an impact and a relationship feedback loop that can help and at times hinder progress in healing the erectile issue.  In other words, they are better off not going at it alone. Sexual chemistry and well-informed, clear and compassionate communication (all cornerstones of higher levels of Sex Esteem) are essential for increased pleasure in partnered sex and what couples can address in couples therapy with an experienced sex therapist. Further, the increasing emphasis on surgical and pharmacological solutions to erectile dysfunction has led to a neglect of the importance that couples dynamics including attachment must hold in the conversation–in terms of the genesis and response to erectile challenges. This is true for heterosexual and LGBTQ+ couples.  According to a study by Kristen. Mark “Attachment style appears to be a more important contributing factor to satisfaction than desire amongst diverse sexual orientations”. 

Myth #7 Erectile Dysfunction Only Affects Older Men

There has been a notable rise in complaints of erectile dysfunction in younger people, chiefly between the ages of 16-35 years-old. This demographic includes people with traits such as psychiatric diagnoses (anxiety, depression, bipolar). Erectile dysfunction is associated with major depressive disorder (MDD), and treatment is associated with decreased rates of MDD. A recent study by Sirpi Nackeeran Et Al showed that men who received ED therapies had lower rates of depression compared after ED treatment to those who did not. Further, relationship concerns, performance anxiety, technological savviness and many other issues can be resolved by ED treatment. 

Myth # 8 Online Remedies for ED are Effective 

Due to the heightened rate of erectile dysfunction, be it as a result of psychiatric stressors, medical illness and/or medications, relationship issues or following a case of COVID-19, many men are seeking remedies outside of a medical practice. With an increased demand, erectile dysfunction supplements (ED-S) have been featured on online marketplaces like, with dedicated pages and claims that they naturally treat ED. However, their efficacy and safety are largely debated, which limits the ability to counsel patients regarding their use. Human studies that evaluated the efficacy of ED-S ingredients are limited and have yielded no definitive findings of the effects on ED. This is to say, patients who are considering ED-Ss should receive appropriate counseling by an experienced medical provider and potentially include sex therapy as part of their treatment plan. 

Men often learn about their bodies and sex through societal standards displayed on TV or in porn. In short, men are told they must conform with traditional masculinity in the bedroom–be strong and dominant–and that they must always be down for sex–get turned on fast, be aroused easily and finish just as quickly. These notions are not standards, far from it, and many more men are being diagnosed with some form of erectile disorder. This can manifest in many forms from difficulty getting and/or maintaining an erection to getting less hard, and these symptoms appear for myriad reasons that do not make one less of a man. Stress, relationship struggles, ADHD, even diet, and now COVID-19 can be underlying conditions that lead to erectile dysfunction. There is no uniform way in which sexual activities should be performed, no base rate for hardness and no timer going for erection duration. The ways in which a man has sex is not able to be generalized, and to perform in a way that does not align with commonly held notions does not necessitate a lack of masculinity. Very often, and increasing daily, men are discovering that they have erectile disorders that can be caused by external stressors. There is no shame in this, and to talk with a sex therapist and seek a diagnosis is very beneficial to one’s sexual confidence, and in turn, one’s mental health.

Erectile Disorder and 8 Masculinity Myths Part 1

Many men approach a sex therapist having self-diagnosed themselves with Erectile Disorder. Frequently a man may have intermittent trouble obtaining or maintaining an erection but these situations aren’t consistent enough or continue over a period of 6 months or longer to qualify for the DSM 5 diagnosis of Erectile Disorder.  Here are the symptoms of Erectile Disorder: 

  • Inability to get an erection during sexual activity
  • Inability to maintain an erection long enough to finish a sexual act
  • Inability to get an erection that is as rigid as previously experienced
  • the problem causes stress or loss of self-confidence, affects a relationship, or is found to be a sign of an underlying health condition that requires immediate treatment

Myth #1: Men are Always Ready, Willing and Able to Have Sex

From a young age, boys and teens are often told, or it’s depicted that “real men” have to demonstrate power over their sexual partners and take charge while having sex, whether  engaging with female partners or as a top in sex with men. Through generations of conditioning to this end, there has been established a societal belief that males are always DTF (ready to be erotically turned on every time it’s on offer) , and should be ready to go at a moment’s notice due to a perceived heightened sexual prowess. This is simply not true. Many factors, such as diet, sleep, stress, illnesses and relational satisfaction affect one’s desire and ability to become aroused enough to get an erection. The pressure “to perform” is ingrained in men’s psyche in most societies such that men will avoid any flirtation, dating or relationship encounter in order to avoid feeling deep shame if their penis isn’t responding to a partner. 

Myth #2 A Bigger Penis Makes You a Real Man and Sex More Satisfying.

Boys also learn through watching sexual explicit media, stand up comedians or colloquial sayings which they overhear that a penis has to be large if they’re going to pleasure a partner. People have all sorts of erotic and sexual desires and the size of a partner’s penis may be low on the erotic prioity list of many women, men and non-binary partners. For example, 75% of women require direct clitoral stimulation to bring them to orgasm so that vaginal or anal penetration is not as high on their desire list as oral, manual or sex toy stroking and licking. Some men who have sex with men prefer non-penetrative sexuality and would prefer being a side where both partners can self-stimulate or stimulate one another through oral or manual stimulation. Some partners’ primary turn on may be the sound of emotionally intimate talk, dirty whispers or dominant commands rather than the size of a partner’s penis. A 2020 review of research on penis size found that the average length of an erect penis is between 5.1 inches and 5.5 inches. However, the girth of a penis and the potential for intravaginal stimulation has been shown to be more alluring to a small sample of colleage-aged heterosexual women. while a study by Nicole Prause Et Al using 3D models of erect penises contrasted the penis size heterosexual women found desirable in a one-time sexual experience from what they found attractive in a long-term partner.

Myth #3 Porn is a Realistic Depiction of Real Sexuality

Porn or sexually explicit material is a form of entertainment to trigger an erotic response. Much of the porn/SEM industry is owned and  produced by men for men who watch it in larger numbers than women. However, as in PG films, the actors are just performers who are chosen for their physical looks including what their genitalia look like in a close up.  These performers are also acting, so that when a woman squeals with excitement without any kissing, caressing or receiving any stimulation from her male partner, the film is misrepresenting what many women state they need in order to get turned on psychologically and emotionally as well as physically aroused.  

Myth #4 Sex Needs to Include Ejaculation

While most men expect to have an orgasm/ejaculation if they are engaging in a sexual act, it doesn’t mean that it should be a given or a demand.  Studies of white heterosexual couples in relationship have shown us that there is an orgasm gap between the amount of times women come to orgasm with partner sex, and a gap between how often men think their female partners have reached orgasm and the actual number of times they do orgasm.  Sex is a sexual umbrella under which many sexual behaviors are included.  It is more important to focus on what each person desires and defines as a pleasurable and satisfying experience each and every time since each person’s body is in a different state each day and each moment.  And while male partners may feel discomfort or pain when they don’t climax after sexual arousal, suffering what is colloquially called “blue balls” isn’t dangerous and the feeling subsides. 


How ADHD Influences Your Sex Life and Intimate Relationships

It is not uncommon for a couple to seek out sex therapy and for the sex therapist to discover that one of the partners has been struggling for years with undiagnosed Attention Deficit Hyperactivity Disorder (ADHD/ADD). A recent research literature review by Soldati et al in the Journal of Sexual Medicine found “that subjects with ADHD report more sexual desire, more masturbation frequency, less sexual satisfaction, and more sexual dysfunctions than the general population.”  

For partners in which relational intimacy is their primary erotic impulse, a partner with ADHD  may struggle to foster and sustain sexually intimate relationships —be it brief or enduring due to the symptoms of the disorder including: impulsivity, novelty seeking, forgetfulness, rapid mood changes and challenges in consistency. Part of this break in intimacy may also be due to the dynamic of the partner who doesn’t have ADHD taking on more responsibilities in the relationship, household and/or with their children.  Over time the non-ADHD partner feels more and more resentment and may begin to feel more like a parent while the partner with ADHD may feel a combination of emotions including feeling:  nagged, disrespected, embarrassed and angry. These feelings all contribute to a less than desired relational pattern that can spark sexual passion. Part of the work a couples therapist can focus on is to have each partner write blocks of time or deadlines when tasks can realistically get completed in a joint family calendar and have the partner with ADHD utilize reminders or sounds to help them transition into chore time. 

Another point in this study was the pattern of partners going to bed at different times when the ADHD partner has extra work to catch up on or who may have poor sleep hygiene. One of the interventions a therapist can help couples with is intentional times that partners can go to bed together and help them create intimacy dates.  In terms of the actual sexual experiences, partners who have ADHD/ADD report having trouble attending to some types of physical stimulation when the sexual script becomes repetitive, predictable and less novel over time leading to a lowering of sexual desire, a lost erection, or an inability to orgasm.  When involved in a sexual script that is un-varied,  the mind of an ADHD person wanders to places that do not include the bedroom like work related tasks that they’re behind on which is a turn-off or alternatively the mind searches for more novel types of erotic fantasies that they’ve watched on sexual explicit media, have had in the past or wish they’d like to have in the future.   In fact some of the studies reviewed in this literature review found that the person with ADHD/ADD themselves may has less sexual satisfaction in partnered sexual experiences which may be due to their mind continually wandering. The potential problem when their focus goes to erotic imagination is that it might look like an emotional detachment to their partner, in fact some clients in sex therapy have described this occurence as their partner “ just going away”. These clinical observations are supported by a 2008 survey by Gina Pera of partners of people with ADHD who reported that “30% felt no connection when having sex with their ADHD partner, as if their partner was not there.” In order for emotional intimacy and sexual intimacy to form and grow, it is imperative there be an environment that is built on—and promotes—relaxation and playfulness and a sense of embodiment (a body/mind connection). One can cultivate this through present-focused techniques like yoga or meditation or introducing sex games that both partners would find fun and novel.

There are extensive other sexual difficulties that those with ADHD deal with aside from a lack of focus during partnered sexual activity: Medical News Today found that another desire issue was found in folks with ADHD; hyposexuality—that is, a level of interest or involvement in sexual activity lower than the norm, which is sometimes symptomatic of ADHD and sometimes an effect of medications used to treat ADHD symptoms; a healthy sex drive yet a struggle to reach orgasm despite prolonged stimulation, which is often due to boredom, trouble with focus, or an influx of other feelings; hypersensitivity—that is, a sense of discomfort in response to tactile stimulus, such as painful sensations in response to genital stimulation. It’s important to find out what kinds of touch a partner with ADHD finds pleasurable when working with a couple who have avoided sexual connection due to this issue.

ADHD can cause a person to thrive on excitement and to be fulfilled by an ever-changing landscape. This restlessness, only satiated by new phenomena, grows exponentially and often involves sexual fantasies as well for men. According to a 2019 study by Bothe et al, ADHD symptoms might be a critical driver in the severity of hypersexuality or out of control sexual behavior for folks of both sexes, whereas ADHD symptoms might only be significant with problematic porn use solely among men. The literature review by Soldati et al noted that people with ADHD have demonstrated an extensive use of online pornography, which, in such excess, leads to a difficulty in the formation of secure attachments. However, the studies reviewed bySoldati et al were not fully conclusive that people with ADHD were more likely to struggle with out of control sexual behavior or CSBD (Compulsive Sexual Behavior Disorder).  In a study by Bejlenga et al,  the  most common sexual disorders among men who had ADHD vs. men who didn’t have ADHD were orgasmic problems (10-14% vs 3%), premature ejaculation (PE) (13-18% vs 10%), sexual aversion (12-13% vs 1%), and negative emotions during/after sex (10%, no data in the control group), whereas women reported sexual excitement problems (8-26% vs 3%), orgasmic problems (22-23% vs 10%), and sexual aversion (15% vs 4%). There were no significant differences in the results between patients treated with ADHD medication and patients without psychostimulant treatment. 

It is critical for those folks seeking help for these sexual problems to be sure their therapist has the experience to conduct a thorough biopsychosocial assessment to explore the possibility of an ADHD/ADD diagnosis. A therapist needs to address the ADHD/ADD diagnosis, the consequences of this disorder on the couple’s relationship over time and the sexual disorders to which it has contributed. I will add some Sex Esteem tips for couples in a future blog.

This is What Black Women’s Sexual Pleasure Looks Like in America

What if the gender, racial identity with which you identify and the positive sexual pleasure you had was repeatedly ignored by sexuality scientists? What if the most common sexuality topics researched about your community with whom you identify were exclusively focused on (unplanned) pregnancy and sexually transmitted infections (STIs)?  Would you feel the racist stereotypes associated with your racial and gender identity hopelessly stuck in American society? In celebration of National Women’s History Month (and International Women’s Day), I wanted to center this month’s blog on a much-needed discussion regarding what American Black women’s sexual pleasure in relationships really look like.

While we sex therapists see Black women in treatment discussing their dating, relationship and sexual issues, queer identity, and/or their issues that might come up in their interracial partnerships, there have been a dearth of studies exploring Black women’s erotic and sexual pleasure. 

Thankfully, there is a brand new study by Ashley Townes, et al. titled Partnered Sexual Behaviors, Pleasure, and Orgasms at Last Sexual Encounter: Findings from a U.S. Probability Sample of Black Women Ages 18 to 92 Years in The Journal of Sex and Marital Therapy . The study exclusively focuses on American Black women’s partnered sexual pleasure and orgasms in the Journal of Sex and Marital Therapy bringing us factual information about a group long excluded from academic research.  Dr. Townes is a Sexuality Researcher and Educator based in Atlanta.  I was fortunate enough to get some of my own questions answered by Dr. Townes which I’ve edited for the blog below.

In the study, Townes and her colleagues found that over 74% of Black women respondents indicated that their most recent sexual experience was with a male friend, significant other or spouse. In other words, these partners were known to the women and many were intimate partners. According to several researchers and authors including Patricia Hill Collins, Black American women continue to be racially profiled as promiscuous, hyper-sexual, sexually free, and as having “animalistic” sexuality. The study emphasizes the ways in which Black women have been oppressed and abused through the frame of their sexuality. These racist stereotypes are part of a longstanding litany of names attributed to Black women including: 

“Mammy, Aunt Jemima, Auntee, Jezebel, Sapphire, Sister Savior, Diva, and Freak” implying a wanton sexual desire to be assaulted have continued to be projected on women since the original period of slavery in America. 

SC: Beyond the sexualized racist stereotypes listed in the study, what are further stereotypes that Black women have to contend with in modern day media, dating apps, and relationship studies? 

AT: The “strong Black woman” stereotype creates an unrealistic expectation of strength for Black girls and women in all areas of their lives. This idea that Black women are not allowed to be vulnerable, weak, in pain, or deal with physical or mental illness actually can lead to greater physical and mental illness; it’s as if Black women are not allowed to express their imperfections.


Many of our BIPOC clients describe this same feeling when they talk about letting their partners down when they’re going through a hard time or experiencing loss of desire due to stress and fatigue.  They at times even express concern for their therapist when they have to miss a session due to extra work they’re doing in hopes of getting a promotion at work. They  worry more about what the loss of the session income will mean for their therapist rather than reflecting on what the impact of wanting or needing to over-deliver at work is on their own mental and physical health. 

I also noted that over 92% of the women in Townes’ study identified as heterosexual.  While the study mentioned that most Black heterosexual women choose Black men as partners, the heterosexual Black women we see clinically in the practice are frequently in relationships with men that identify as white and brown. I wonder if perhaps this is due to the fact that more than 50% of Townes’ respondents were from the south and the practice is located in the Northeast.  The interracial couples who come in to see me or my associates for help frequently bring divergent lenses when it comes to beliefs, values and rituals related to their sexuality desires and practices.  Frequently, these gaps in core values can lead to a misalignment and conflict in the bedroom. What a specific desire or sexual behavior one partner enjoys may be loaded with negative meaning for their partner due to the way they were raised.  They may also feel shame about letting their partner down if they’re experiencing penetrative pelvic or vaginal pain.  

What was also notable about these latest findings is the fact that most of the women had their most recent sexual experiences with a man they knew, were dating or who was a longstanding partner or spouse. 

SC: What do you make of that finding that most of the partnered sexual relationships were with a male partner that the woman knew vs. someone they had just met?

 AT:  For this finding, I think it is important to highlight the idea of “hookup culture.” There has been a thought or belief for decades that Black women are promiscuous and that young people, especially, are engaged in hooking up or sexual exploration with many sexual partners. Less than 2% of the Black women in this study had partnered experiences with men they had just met. I think this finding dispels the idea that Black women engage in “riskier” sexual behaviors (i.e., one-nighters).

Sex therapists see a skewed population in terms of the fact that folks coming in for treatment are looking to get therapy for presenting issues like:  past trauma, neglect, painful penetration, lack of desire, anorgasmia, recent breakup or discovery of a partner’s breaking of a monogamous agreement. Although our therapists will always ask about sexual experiences that have included boundary crossings, abuse and assault, sometimes our clients will wait until they are several sessions into treatment before revealing past sexual trauma.  

As a white cis-gender female therapist I am conscious of the fact that a Black female-identified client may open up more cautiously in a cross-racial therapeutic relationship than they would with a BIPOC female therapist in the CLS practice.  What was surprising to me in this study was the fact that very few Black women reported “unwanted” sex and those that did were in a specific age group.  Differently than in a therapy practice where clients at times request to see a particular therapist, study participants are not aware of the researchers’ racial identities. I was curious to learn more.  


SC: What reflections do you have on the responses from respondents that the most recent sexual encounters they had were wanted in all but the 25-29 year old cohort of Black women studied? 

AT: Overall, less than 1% of Black women reported an unwanted sexual experience and this happened to be reported by women in the 25-29 year old age cohort. We report that a limitation of this study is that women who were invited to participate in the survey and were less comfortable with discussing sexual health may not have consented to participate or may have not answered certain questions, and therefore, contributes to limited information or nonresponse bias. As researchers, we do our best to ensure privacy and explain the nature of the study, yet some individuals may remain uncomfortable completing a sexuality questionnaire.

Unwanted sex may include sexual harassment, coerced sex, sexual assault and sexual abuse. These traumatic experiences are usually kept as secrets especially if they occurred at a younger age. I often encourage all the therapists I supervise to engage their clients in discussions around boundary crossings from time to time in treatment to ensure that the client is assured that the therapist can hear these stories if they aren’t readily shared in the initial sexual history taking. 

A big taboo subject for many Black women to discuss openly is their participation in Bondage & Discipline/Dominance & Submission/Sadism & Masochism sexual experiences.  Having been cast in the aforementioned stereotypes in America, sex that from the outside looks like a recreation of historical chattel slavery scenes might make a Black female kinkster feel extremely anxious about revealing to a therapist anything about their being erotically turned on by these experiences.   As a white ally and kink-aware Certified Sex Therapist, I collaborate with clients who identify as kinky on ways to navigate their desires and address the challenges they feel when they are dating or in relationships. I’m highly aware that BDSM can be judged harshly by those who are not part of the scene. I was curious about the fact that the Black women’s sexual behaviors studied here were by and large on a vanilla menu.  There are paltry few studies researching sexual practices of Black women in kink and BDSM play. 

SC: Are there reasons you chose not to include more kinky sexual behaviors into this study? 

AT: The 2018 National Study of Sexual Health and Behavior (NSSHB) was carefully planned and included a range of aspects about sexual/response functions, particularly, pleasure, desire, orgasm, and painful intercourse. There are other results from this nationally representative study exploring kink and BDSM activities experienced by Black women. Here are the results from that other wave of research: 

  • Public sex 37% 
  • role-playing 20% 
  • spanking/being spanking 36% 
  • Using anal sex toys >17% 
  • playful whipping 17% 
  • tying up/being tied up 9% 
  • having engaged in threesomes 8% 
  • Lifetime group sex, attending sex parties, sucking/licking a partner’s toes, and going to BDSM parties were uncommon each <8% 

While a minority of Black women in this last study are involved in various types of kink-type sex play, it is an area only recently explored more publicly by artists like: Jeremy O Harris’ whose play Slave Play took a deep dive into Antebellum power exchange and interracial relationships and the NY Times profile of Sexuality Educator and writer Mollena Williams-Haas who is a Black 24/7 slave and muse to her white husband composer Georg Friedrich Haas.  True erotic pleasure is a deeply personal, creative, transformative and at times revolutionary and healing act.  It’s an honor to see Black women’s authentic sexual pleasure given the time, respect and nuanced exploration by academics in the world of sex research. 



Townes A, Thorpe, S, Parmer T, Wright,B, & Herbenick, D. (2021): Partnered Sexual Behaviors, Pleasure, and Orgasms at Last Sexual Encounter: Findings from a U.S. Probability Sample of Black Women Ages 18 to 92 Years, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2021.1878315 

Townes A, Fu TC, Herbenick D, and Dodge B. (2018, June 14-17). Sexual diversity among black and Hispanic women: Results from a nationally representative study. [Conference presentation]. American Association of Sexuality Educators, Counselors, and Therapists 2018 Annual Conference, Denver, CO. 

Rosenthal, L., & Lobel, M. (2016). Stereotypes of Black American Women Related to Sexuality and Motherhood. Psychology of women quarterly, 40(3), 414–427.

Woodard JB, Mastin T.( 2005)  Black Womanhood: Essence and its Treatment of Stereotypical Images of Black Women. Journal of Black Studies.;36(2):264-281. doi:10.1177/0021934704273152 


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

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


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

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:

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

Lydie Salaun/DepositPhotos

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

Fabiana Ponzi/DepositPhotos

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

Dmitry Pochitalin/DepositPhotos

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.



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