The Movember Movement Supports Men’s Mental, Body Image, and Sexual Health

Movember is an international charity that brings attention to major issues like men’s prostate and testicular cancer, mental health, and suicide prevention. During the month of November for the past twenty years, they invite men to grow a “mo” or mustache to raise money and awareness on illnesses that have long remained in the shadows. Each of these diagnoses directly impacts sexual functioning and relational health. Movember has added research showing that body image concerns, commonly associated with women’s mental health challenges, can deeply impact men too. 

The results of a 2025 longitudinal study by Süleyman Agah Demirgül et al. in Sexuality Research & Social Policy echoed the Instagram study cited earlier related to women’s self body image.  Following 3,700 young men and women, researchers found a bidirectional link between pornography use and body dissatisfaction only among men. Men who consumed more pornography at baseline reported greater Body Dissatisfaction one year later, and those that had higher levels of Body Dissatisfaction at baseline reported increased pornography use one year later.

The more pornography men were consuming, the more they developed concerns about their bodies due to the films’ unrealistic display of muscular physique and genital size. This led to not only self-criticism but also an avoidance of intimacy. When heterosexual couples come into treatment for therapy, there is a deeper shame in both partners when they report that the partner exhibiting lower desire is the man. Their female partners sometimes unwittingly contribute to the problem by believing the myth that all men have higher sex drives than women. For couples visiting family/friends or traveling over the holidays, the problem can worsen, privacy disappears  and old family wounds can get triggered, leaving little space for desire or connection.

In a 2022 study, Moynihan, Igou, and van Tilburg found that when people, across genders, felt bored or emotional discomfort, they were more likely to turn to pornography for relief. In addition, men can also use pornography for entertainment and erotic/sexual release. With less privacy for masturbation, men who rely on frequent porn access might also feel emotional and physical tension and project it onto their partner over the holidays.  

Men have been raised in a society that centers on a narrow range of acceptable emotional expressions that align with masculine ideals. While hegemonic masculinity ideals vary depending on racial, regional, cultural, and religious backgrounds, it might be a helpful tool for therapists to invite their male clients to check out Movember’s website as a conversation opener. Encouraging male clients to talk about how their body image, sexual desire, and intimacy behaviors might be impacted during the holiday season can be therapeutic.  

From Critique to Connection

Some evidence-based strategies to help shift self-judgment into connection this season:

• Writing kind notes to oneself: This may sound silly, but it is shown to be effective. The Mindfulness study by Gracias & Stutts (2024) found that short self-compassion writing exercises reduced negative body image. Taking a few minutes to speak gently, self-reflection can really improve body satisfaction and mood.

• Movement for pleasure, not focusing on weight loss: Adding little things like walking, stretching, or dancing to one’s favorite holiday music can elevate dopamine levels and support the body without reinforcing a restrictive mindset.

• Intentional social media boundaries: To protect against unrealistic comparisons, take a step back from scrolling on social media and enjoy the time with loved ones. 

• Ongoing communication about sexual needs and emotional vulnerabilities: Schedule time for open conversation, especially before the hectic holiday season begins, so each partner can express their needs regarding intimacy. Then look at the calendar to intentionally set times to be intimate during the holidays and define what that means for each partner. Honor that time so it centers and emotionally nourishes the mental health and relationship needs of both partners

While these may seem simple and obvious interventions, they do require intention, compassion, and planning. The holidays are filled with external noise, like familial expectations and potential judgments, so using a more curious lens as opposed to a critical one can really change the whole holiday experience. 

How to Go From Feeling Stuffed to Feeling Sexually and Emotionally Satisfied  

When one reports feeling  “stuffed”, it is not only a physical feeling they’re describing but often an attempt to fill up emotional and sexual hunger with food, alcohol, substances, and/or distracting pastimes. True holiday nourishment doesn’t come from restriction or seeking perfection, but from authentic communication, rest, mindful eating, self-acceptance, and sexual intimacy (whether partnered or solo). 

For women who are struggling with negative body image, it’s helpful to journal about what they truly desire over the holiday season. By carving out time and deciding what to say yes or no to, one can begin to practice sexual self-care. That might mean lighting a candle and taking time to reconnect with a person’s own pleasure, or setting aside intentional moments of touch and closeness with a partner.

Similarly, for men, Movember’s message extends beyond physical screenings. This serves as a reminder over the holidays that caring for the body includes planning ahead to care for the mind, emotions, and erotic and sexual pleasure. By the time the holidays wind down, sexual and emotional satiation often comes less from indulgence and more from feeling seen and authentically connected to oneself and to loved ones. 

While the holiday season is supposed to be filled with joy, connection, and lots of filling up on delicious holiday dishes, for many people, the pleasures fall short of their hopes. For some people, Thanksgiving and Christmas celebrations inspire stress, pressure to live up to family expectations, overeating to feed one’s emotional pain, along with psychological and/or physical isolation. Parents juggle restless kids in unfamiliar settings, hosts fret over creating “perfect” gatherings, and privacy can be hard to come by. Given the stressors of travel, pressure to ensure that everyone is ‘happy’, difficulty sleeping, and/or negative body image stirred up due to eating more than usual, these challenges can contribute to an overall body/mind/spirit feeling of “stuffed” and erotically and sexually unsatisfied. 

According to a 2023 American Psychological Association survey, 43% of U.S. adults felt that the stress of the  holidays makes it hard to enjoy them. In addition to that, a more recent 2025 study published in the Eating and Weight Disorders journal, Thomas et al. analyzed over 10 million social media posts that showed a body image dissatisfaction spike during this season. The study found that due to unwanted weight gain from the holidays, followed by New Year’s resolutions and fitness goals caused negative body-image issues. To strengthen this point, in 2023 Abdulan and his colleagues in Nutrients found that on Christmas, people ate 3 times their recommended daily calories with some meals coming out to almost over 6,000 calories. 

Many therapy clients begin to experience anticipatory anxiety in early November as they begin planning for family gatherings, cooking and/or hosting responsibilities and the concerns around triggering old attachment wounds or trauma. If clients are already struggling in their dating, relationship and/or sex lives, figuring out how to sustain intimacy during Thanksgiving, Christmas, and New Year’s can fall way down on the list of other goals that are prioritized. 

How Holiday Stress and Sleep Disruptions Impact Sexual Satisfaction and Functioning

Sex therapy clients report that when they travel for holiday gatherings, the first thing to get disrupted is their sleep schedule, which inevitably leads to less sex. While there’s plenty of research informing us of the importance of nightly sleep for overall mental health, there are even more disruptions during the holiday season due to several factors, including: 

• Increased alcohol intake
• Children’s disrupted schedules
• Late-night conversations

The research backs up clinical observations. In a large wearable device study analyzing over 10 million sleep episodes, Heacock et al found that during major holidays, sleep regularity declined about 14%. That may seem subtle; however, in the Journal of National Sleep Foundation, Sletten et al. discovered that not only less sleep, but also inconsistent sleep can affect the body’s circadian rhythm. In their 2023 consensus, they found that having many different sleep times led to flatter cortisol rhythms and elevated stress. 

In a 2019 Psychoneuroendocrinology study, Rosemary Basson and her colleagues discovered that lower morning cortisol can also be detrimental to one’s libido. More recent research echoes this connection between sleep quality and sex. In a 2023 study in the Journal of Psychosomatic Research, Pigeon et al. found that adults with poor sleep had significantly lower sexual satisfaction and higher rates of sexual dysfunction. The women in the study reported trouble orgasming and lower sex drive, and for the men, it was difficulty maintaining erections and lower sexual satisfaction. 

Together, these studies show that disrupted sleep, which is very common during the holiday season, can dampen one’s mood, desire, and overall sexual pleasure. These problems contribute to less frequent sexual intimacy at a time when one may be in more need of that emotional closeness and tension release. 

Why Women’s Negative Body Image Increases over the Holidays

Negative body image has always been a roadblock in women’s overall well-being and sexual desire, and pleasure. With the holiday season coming up, the challenge of internal body shame has the potential to increase. Between larger portions at holiday meals, endless photos for social media, the lure of diet culture, and relatives’ potential fat-shaming comments, many women report feeling torn between enjoying the food and celebration and fearing weight gain or self-loathing. Many sex therapy clients report being “in their head” during intimacy because of their internal body shaming, frequently comparing themselves to social media influencers who unrealistically portray society’s idealization of beauty standards. 

In a 2024 study published in The Journal of Medical Internet Research, Anna Hinsch et al. investigated the relationship between Instagram use, self-criticism, and body dissatisfaction. Among the participants (90.2% of whom identified as women), those who spent over 3 hours/day viewing content centered around physical appearance exhibited higher levels of self-criticism and body dissatisfaction scores.

During the holidays, this internalized self-loathing can increase since social media platforms like Instagram and TikTok are flooded with photos of idealized tablescapes and holiday outfits modeled on ultra-thin women. Generally, this scrolling is continued during the holiday season as emotional regulation. Negative body image is associated with lower sexual desire, leading to decreased partnered or solo sexual activity.  

Every year on October 10th, the World Health Organization (WHO) partners with international organizations to bring awareness and support to people living with mental health issues on World Mental Health Day. According to the WHO, 1 in 8 people live with a mental health condition. Together with the World Association of Sexual Health (WAS), they recognize that sexual health AND sexual pleasure are a critical component of overall mental health throughout the lifespan.

While mental health disorders are being more understood by the general public because of their commonality, most people aren’t as informed about the frequency of sexual health disorders. In 2024, researcher Ramírez-Santos and his colleagues published a meta-analysis (a combination of many studies) in the Sex Med Review analyzing over 4,000 studies. They found that sexual dysfunction was prevalent in 31% of men and 41% of women, and these disorders were often linked to distress, depression, and anxiety.  Unfortunately, many of these sexual disorders, like Erectile Dysfunction, low desire, Orgasmic Disorder (for women and men), and Genito Pelvic Pain/Penetration Disorder (GPPPD), were found to go underdiagnosed. This was due to many medical professionals lacking proper sexual health training in their residencies. Because their screenings were inconsistent, the researchers estimated that the true percentages are likely to be higher. When sexual disorders go untreated, it can lead to even poorer mental health. In their discussion, the researchers stressed that better screening and more awareness are needed to prevent the spike in mental health disorders and sexual dysfunction.

Another 2024 review of 63 studies by Vasconcelos et al. in the Bulletin of World Health Organization, also found that in almost all the studies, there were significant connections between positive sexual health and lower levels of Depression and/or Anxiety, as well as increased life satisfaction. These associations included men, women, older adults, pregnant women, and those in both same-sex and mixed-sex relationships. 

As World Mental Health Day is honored on October 10th, it offers an important opportunity for therapists, medical professionals, and patients to explore how sexual health and mental health are interconnected. By making sure discussions about sexual health are not overlooked on this day, providers and their patients can gain a better understanding of what treatment is needed. This could include referrals to specialists such as: 

• Certified Sex Therapists
• Doctors specializing in sexual health
• Pelvic floor physical therapists and/or  
• Support groups

The Dual Link Between Sexual and Mental Health

As witnessed in sexual therapy clinical practice and in the professional literature, the relationship between sexual health and mental health travels in both directions. On one end, people who struggle with things like Anxiety and Depression tend to report having lower desire levels and more Anxiety when a partner initiates a sexual encounter. And on the flip side, people who struggle with sexual disorders report higher levels of emotional distress and sadness.

Daniele Mollaioli, PHD, and his fellow researchers published a study in  the The Journal of Sexual Medicine illustrating the connections between mood and anxiety disorders and the subjects’ reports around sexual intimacy activity during the COVID-19 pandemic lockdown period.  Published in 2021, the study showed that people who maintained a healthy sex life during the lockdown were better protected from the risks of quarantine-related anxiety and depression in all genders. 

While the pandemic was an extraordinarily unique and unprecedented time, more recent studies have also drawn the connection between mood disorders and sexual functioning. In a 2025 study published in the Journal of Affective Disorders, Chen et al. found that adults who had less frequent sexual activity issues with their sex life experienced significantly more depressive symptoms. Additionally, a study published in The Journal of Sexual Medicine by authors Dominguez-Bali and Hernandez, on menopausal women, highlighted the mental and physical benefits of experiencing orgasm, even through self-pleasure. This shows that there is no pressure to engage in frequent partnered sex to maintain sexual and mental well-being.

We can now see that in study after study, people’s mental health, especially symptoms of Depression and Anxiety, are strongly tied to their sexual health and satisfaction.  In 2023, Pigeon et al., in The Journal of Psychosomatic Research, insisted that when people have healthy sex lives, they have better sleep, less stress, and fewer mental health issues.   

The Impact of Sexual Stigma on Mental Health

In the modern digital age, Millennials and GenZers often brag on social media platforms like TikTok or Instagram about how frequently they are having sex. This trend, unfortunately, contributes to many sex therapy clients’ sense of failure about their own sex lives or lack thereof. However, in the sex therapy clinical setting, clients report that their most satisfying sex happens when they are relaxed, safe enough to express their authentic erotic selves, and are confident that each partner is fully consenting to and enjoying the experience. What most people truly need help with is developing their sexual agency or what this author refers to as Sex Esteem®, to practice an authentic, regulated, and differentiated way of communicating and listening to each partner’s needs.  

Understanding that there is no one universal definition of a “good” sex life alleviates the pressure people feel to live up to a standard being depicted in sexually explicit media like porn, movies or social media influencers’ posts . For some people, it will be having sex less often, while for others, it can be exploring a new kink experience. However, there is one thing that stays consistent in all the research and clinical observations: when couples create a safe space and have clear communication in the bedroom, they are more likely to have a more authentic and pleasurable sex life, which can improve their overall mental health.

Identifying as a sexual minority can also be challenging for many people. The stigmas and threats of physical violence on the LGBTQIA+ community adds to their sexual and mental health concerns. When researching for the Clinical Psychological Science journal, Pachankis et al. found that people who experience sexual shame are more prone to Depression. There is a great need for more therapists and medical providers to be properly educated and trained in order to provide inclusive care to clients from sexual minority groups.

Steps to Care for Your Sexual & Mental Health 

The WHO’s goal for World Mental Health Day on October 10th is to raise awareness and improve access to sexual and mental health education and services for those in need.

Here’s how you can care for your own and/or your partner’s mental AND sexual health:

• Visit psychotherapy or healthcare practices that offer specialties in sex therapy, sexual health education, and sexuality informed medical treatments.  
• Ensure your medical provider and/or therapist initiates discussions on sexual well-being AND mental health status. 
• Keep yourself informed about the latest in sexual and mental health research, updated treatment guidelines, and share this education with others who might also need to learn.
  

When mental health and sexual care are seen as integral components of overall healthcare,  rather than distinct silos of concerns, people are more likely to feel physically, emotionally, sexually, and psychologically healthy.

This Pride month, cities around the globe celebrate the wide expanse of sexual identity. People honor the labels many use to identify themselves. Identities like gay, lesbian, bisexual, or queer are written on posters and floats, indicating the long hard-earned rights to declare who they are to the world. Beyond the hardships many of these folks are now facing in America, the therapy world needs more insightful education to help clients explore nuanced experiences in their sexual lives. Research suggests that difficulties in defining and categorizing sexual orientation can have negative implications for many individuals and/or partners in general. Psychotherapists, couples counselors, and medical professionals are in need of deeper knowledge to better serve their patients.

Sexual Identity Labels Often Don’t Fit

A 2010 study by the National Defense Research Institute states that the research on sexual orientation often relies on three main categories of definition –  sexual/romantic attraction, sexual behavior, and sexual identity (self-labeling) – which frequently do not align into one clear label. This puts people into labels that don’t fit exactly right, which runs the risk of ignoring the diversity that plays a huge part in sexual identity development.

Lisa Diamond, a renowned psychologist working in sexuality, gender, and intimate relationships, discusses the differentiation between labels, thoughts, and actions. She states in her 2016 study in Current Sexual Health Reports that rates for same-sex orientation are highest when measured by attraction, followed by behavior, and lowest when based on self-identity. ​​In a separate study in 2019 by the Journal of Official Statistics looking at these intersections, 9.1% of self-identified gay women, 3.9% of bisexual women, 8.4% of gay men, and 14.3% of bisexual men report being exclusively attracted to the opposite gender, which contradicts their sexual identity.

Clinicians must recognize that their clients’ sexual identity cannot be exclusively described in simple labels. Therapists who quickly place clients in prescriptive identities may show unconscious assumptions which can cause harm.

For some time now, sexuality researchers have been identifying men through their sexual behaviors versus labeling their identities. They label men who have sex with men as “MSM” versus “gay” or “bi”. This began most likely in the late 1980s by HIV and AIDS researchers, as many men who identified as heterosexual shared sexual encounters and behaviors with other men but did NOT identify as gay or bisexual. Separating the sexual behaviors from identities let researchers glean information as part of their battle against an epidemic crisis which at that time was causing a large number of men to die and the medical providers without an effective cure.

The Impact of Therapists Misusing Labels

This lack of clear categorization and the non-alignment of attraction, behavior, and identity among people can create internal conflict. In the article Sexuality and Gender: Findings From the Biological, Psychological, and Social Sciences, researchers Mayer and McHugh state that there can be a pressure to be “sure” about one’s identity and to adhere to the “born that way” hypothesis, creating a fixed biological basis for sexual orientation. If a client feels unsure about their sexual orientation, they may feel pressure to identify themselves with one exclusive label in order to feel accepted and supported by their community.

This pressure to conform is linked to mental health challenges. The article Sexuality and Gender by Lawrence S. Mayer et. al. discusses higher rates of poor mental health for LGBTQ+ individuals generally and explores the adverse consequences of concealing aspects of one’s identity. While labeling can have negative mental health effects, expressing thoughts and feelings is linked to improved well-being. If a clinician assumes and uses labels with which a client does not align, it contributes to the client feeling less open to sharing more complex feelings and attractions to their therapist. 

Comfort Discussing Sexual Material in Sessions

The Journal of Marital and Family Therapy in 2008 published a study of 175 clinicians assessing how their training, education, perceived sexual knowledge, and comfort with sexual material influenced their willingness to engage in sexuality-related discussions with their clients. The findings stated that Marriage and Family Therapists who perceive themselves as having higher levels of sex knowledge were not more likely to initiate sexuality-related discussions. In fact, perceived sexual knowledge did not have a significant effect on sexual discussions in the path model. 

Their results indicate that the combination of sexuality education AND supervision experiences are the cornerstone for a therapist’s base level of comfort. This is how sexuality knowledge is gained. When therapists I teach and/or supervise tell me they consider themselves sexuality-educated based on their lived experiences or having volunteered for a college peer program, I know that this isn’t enough to have productive, comfortable therapeutically effective sessions with clients around their sex lives within their clinical exchanges. It requires supervision that teaches the deeper understanding of the biological, medical and sexual health issues that intersect with therapy clients’ lives whether they are no matter their relationship status or identity. 

Using Label-Free Language

I encourage the therapists I train and supervise to use neutral words or phrases to describe sexual behaviors with clients and emphasize that they understand it might be difficult to share these sensitive subjects. Using terms that aren’t labeled allows more openness for the client to discuss and explore often conflicting and overlapping fantasies, behaviors, and identity. Instead of asking: “Have you had any gay/lesbian/queer relationships?”, I encourage my therapists to ask: “Have you ever had any same gender emotional, sexual or erotic experiences growing up?” or “Have you had fantasies about a person that presents as a transgender?”. These gender descriptions of the person with whom they shared a sexual behavior or fantasies does not make assumptions about the client’s self-identity or orientation.  

Therapists must get more didactic education and supervision to learn neutral language to use with their clients about sexual fantasies and experiences. It is through in depth training that all therapists and medical professionals can allow clients to feel more authentic with themselves in their psychotherapy journey and within the therapeutic relationship.

“Eighty percent of women masturbate. Ninety-five percent of men masturbate. And the rest lie.” 

This humorous but true quote comes from Jocelyn Elders, the former Surgeon General who was the first African American and only the second woman to be appointed to this position. She was also forced to resign by non-other than President Bill Clinton (yes, the president who was impeached who chose NOT to masturbate but instead have sexual activity with an intern) when she spoke honestly about the importance of including masturbation in sex education guidelines at the 1994 UN World AIDS Day Conference. As Mark Twain observed: “Truth is stranger than fiction” and given that May is International Masturbation Month, it’s wiser for therapists to approach the topic of masturbation in as direct and honest manner as the former and illustrious Surgeon General Dr. Elders. It is still surprising that the topic of masturbation is hidden by clients in therapy as a subject that is too private, guilt-ridden, and/or shameful. Masturbation is for most people a common and healthy sexual behavior that at times remains a taboo topic for them to even discuss, let alone to share with a sexual partner. Self pleasuring can be a great way to learn about what one likes and being able to vocalize that to a partner. If folks can’t be honest with themselves about what feels good, how can they effectively communicate their needs and desires to a partner?

Historical Contributors to Negative Views on Masturbation 

Self pleasure has been seen, throughout Western history, as something that is actively wrong and immoral. Religious dictums, social stigma, and medical distortions created the narrative that masturbation is an act that should be condemned. Author Michael Patton wrote about how society arrived towards such negative views of masturbation in his journal article “Twentieth Century Attitudes Toward Masturbation”. In early Judeo-Christian history, early church members “regarded masturbation as a threat to the survival of the human race” and created doctrine to discourage those from self-pleasuring. As the world became more secular, the language used by the new authorities, namely the medical professionals  (all male and mostly white) shifted.  

According to an article by psychologist Kenneth Zucker, doctors declared that masturbation was the “primary etiology of insanity” while “Freud viewed masturbation as an actual neurosis, but also believed that it was important for psychosexual development from infancy to puberty.” 

In keeping with the sexist notions around women’s sexuality of his day, Freud and generations of analysts who followed him aligned with his view that while it was normal for girls to experience sexual pleasure from their clitoris, adult women had to shift their focus exclusively to vaginal intercourse or risk suffering from psychological disorder like hysteria. The early 20th century community and political leaders (also mostly white men) followed suit, pointing to the solitary sexual activity as an antisocial sexual deviation

It wasn’t until the women’s movement in the 1970s that laypeople forced leaders and medical providers began the fight to stop the double standard around masturbation to alleviate women’s shame. Through consciousness-raising groups in the mostly white feminist spaces in the 1960s and 70s, women began sharing their experiences regarding lack of sexual pleasure through intercourse and learning about their own bodies. The late sexuality educator and pioneer Betty Dodson began offering her Bodysex workshops for women to learn how to appreciate and love their anatomy, learn the proper names of each part by using a mirror to examine their own vulvas and how to develop a self pleasure or what she called a solo sex practice. And while these workshops and her book Sex For One that followed in the 80’s opened doors to women’s internal sense of confidence and agency, women are still lacking in full sexual expression and pleasure in their sex lives due to what my colleague Laurie Mintz has called the “orgasm gap”. Why?  Because there are people of all genders worldwide denied thorough, accurate, normalizing sexuality education and humans still live in a patriarchal heteronormative society that offers better education to people who belong to majority communities. 

What Does Science Tell Us about Masturbation? 

Even with these systemic stigmas, self pleasuring still remains important to a healthy sex life. Research shows that even in long-term, heterosexual relationships, women who are more open about self-pleasure can increase and help maximize both their and their partner’s sexual satisfaction. Specifically, women’s masturbation practices have been seen to have a positive correlation to a healthier partnered sex life. Solo sex practices are part of the principles of Sex Esteem®, is a sexual self-agency model utilized in clinical practice and the Erotic Intimacy Academy SEE IT  Certification training. 

There are many reasons why solo sex creates more enjoyable sexual experiences with a partner. Firstly, masturbating on one’s own promotes self-awareness. By exploring one’s body in a safe and private space, they can gain knowledge about their erogenous zones, the types of touch they enjoy, and their individual arousal patterns. This heightened body literacy can translate into more fulfilling partnered sexual experiences, as they become better equipped to guide and communicate with partners.

Secondly, acknowledging masturbation as a normal part of the human experience helps to reduce shame and stigma that has persevered for centuries. By bringing the topic into the light, without shame, one can challenge these negative narratives and foster a more positive and accepting view of one’s own sexuality. This destigmatization is so important for mental and sexual well-being. It allows individuals to feel comfortable and confident in their bodies.

Due to the prevalence of stigmas and shaming body-image messages that are spread and learned at viral speed through social media at ever younger ages, it is even more critical for parents, educators, and yes, psychotherapists to provide accurate, open, and non-judgmental spaces to initiate normalizing conversations about self-pleasure. Providing normalizing education around masturbation or solo sex (either on one’s own or in partnered sex) are imperative to stop the shaming and increase Sex Esteem® in intimacy.

This blog is a continuation of my last post, which you can find here! 

Once a client begins to intellectually comprehend that the trigger responses they have been experiencing are part of the parasympathetic nervous system’s response to danger, the therapist can begin to invite them to try some somatic inquiry.  Somatic inquiry is the first step used in techniques like Mindfulness Based Stress Reduction (MBSR), created by Jon Kabat Zinn* who codified a Buddhist tradition into a secular, step-by-step technique.  

After they begin to intellectually understand the way the body reacts automatically when triggered, the therapist can gradually begin to ask permission to ask them if they are experiencing somatic responses like this during sexual encounters or at other times. Indeed, the therapist can ask them if they have had any of these reactions in the session itself as the therapist was discussing this information or asking them questions.  This second step is introducing somatic inquiry, an invitation to begin noticing what is occurring physically and emotionally in the here and now.

These slow-paced therapeutic interventions of Somatic Trauma-Informed Sex Therapy can lead to a new language the client creates or chooses to describe the bodily states and symptoms that are triggered by sexual and erotic intimacy.  The sex therapist can gradually invite the client to introduce mindfulness meditation, slow yoga, tai chi or any other slow present-focused movement practice to help the client calm their nervous system and create more skills and thus agency to regulate themselves when triggered. The sex therapist, if working with the survivor and their partner, can then introduce the concept of a choreographed ‘safe space’, a position that they go to immediately if the survivor becomes triggered during a sexual experience. This intervention was introduced by Wendy Maltz in her book The Sexual Healing Journey.  This is a position the survivor states is the position they feel most safe with their partner and will help calm them.  An example might look like this: a survivor sits up in bed, she and her partner both put robes on and she sits up cross-legged, faces her partner, they both close their eyes, take deep breaths while the survivor’s hands are placed face down on top of their partner’s open palms.  This very choreographed position comes solely from the survivor who asks her partner whether they are willing to do this for them to help downregulate the trauma reaction in her body.  

Using Developmentally Age-Appropriate Sex Education To Begin the Building Blocks of Sex Esteem®

For some sexual abuse/assault survivors whose trauma occurred in childhood or early adolescence, the opportunity to learn the norms around sex education, anatomy, and sexuality functioning at age appropriate levels was usually completely absent.  One way to provide this information is to ask a client if they could pinpoint the age they emotionally feel internally rather than the present age, what age would they say they are? Many clients can pinpoint the point at which their psychological and emotional development froze. Offering a client who feels grossed and/or disgusted by adult terms for sexual acts is counter therapeutic.  Instead it’s helpful to offer a sex ed book that is written for children (if their abuse started in early years) or teens with diagrams rather than more graphic photos or imagery.  A book like You Know, Sex: Bodies, Gender, Puberty, and Other Things by Cory Silverberg and Fiona Smyth is an animated book for middle school-aged children that cover topics like anatomy, body autonomy, disclosure, stigma, harassment, pornography, trauma, masturbation, consent, boundaries and safety.

It’s crucial to let the client know that sexual consent is necessary and needs to be crystal clear for every type of sexual interaction.  Survivors need to be taught that sexual consent can be withdrawn at any time, even in the middle of an encounter including what behaviors they want to engage in, what protective barriers they expect each of them to use and what areas of their body are off limits. Sexual trauma survivors also need to learn that consent cannot be inferred in silence unless there is an agreed upon non-verbal signal discussed ahead of time and agreed to by a partner. A sexuality-educated erotically-informed trauma therapist must have enough training and comfort in themselves in order to discuss terms like devising a safe word or non-verbal signal and  ahead of a sexual encounter that will be honored by your partner. 

Helping sexual assault trauma survivors re-engage with their own bodies and with their partners using somatic trauma informed sex therapy and bibliotherapy is multi-disciplinary approach for survivors and their partners as they work their way into consensual sexual pleasure. 

Defining the Terms of Sexual Assault

The first step in helping patients who are survivors of sexual trauma is allowing them to choose the words they may want to use to describe their experience.  Many survivors come to sex therapy for sexual disorders like Genito-Pelvic Penetrative-Pain Disorder, Anorgasmia, or lack of desire. They may come individually or with their romantic partner because their sex life has been lacking, or at times a movement will trigger a violent reaction in the survivor. According to RAINN, sexual assault is defined as sexual contact or behavior that occurs without explicit consent of the victim. Some forms of sexual assault include:

• Attempted rape
• Fondling or unwanted sexual touching
• Forcing a victim to perform sexual acts, such as oral sex or penetrating the perpetrator’s body
• Penetration of the victim’s body, also known as rape

These acts include situations where the victim is incapable of giving consent due to incapacitation, age, or disability.

When a Survivor Refuses to Use the Terms: Trauma or Assault

It can be a delicate clinical situation when a client states they have experienced something that is non-consensual, but doesn’t identify it as an assault or trauma. The decision and specific request by the client NOT to use these terms during therapy sessions can stem from a variety of reasons: 

• Deep shame and guilt over what they consider their fault over the experience
• Disassociation of the experience(s) that have been repressed and compartmentalized
• The normalization of certain behaviors in some communities 
• Confusion about the depth and meaning of words and non-verbal communication needed to give consent
• Internalized societal expectations based on sexist, racist, and homophobic tropes

Even if a sexual assault survivor doesn’t identify their experience as sexual trauma, researchers and clinicians understand that they cause or worsen mental health problems. A 2020 systemic review and analysis on women who have experienced sexual assault indicates that they are more likely to experience psychological disorders such as post-traumatic stress, Depression, Anxiety, and social adjustment issues. When general therapists begin treating a survivor, it’s critical they are not only sexual trauma-educated, but sexuality-educated and erotically-informed. Why? In order to help survivors not only heal from their trauma but also engage in consensual romantic and/or sexual experiences in the future, a therapist will need to be informed and experienced in how to ask the right questions, offer appropriate interventions and understand how to educate the client around sexuality at the developmental stage and pace they are ready for. 

Initial Psychoeducation Therapists Can Utilize with Clients in Trauma-Informed Sex Therapy

While some general therapists feel like it’s their duty to tell a client what occurred to them is rape, abuse or assault, the more trauma-informed sexuality-educated therapist will initially let the client set the pace of therapy and ask them what words they would like to use. Agreeing to use the terms they choose is one of the first steps to create a trusting alliance. 

One of the next interventions is offering a client to learn more about the body/mind connection in the aftermath of non-consensual/unwanted/invasive/coercive sexual behavior. If they accept, it’s critical for the therapist to remind them they can stop the information giving at any point if they feel overwhelmed or physiologically triggered.  The trauma research is then offered as psycho-education. Introduce the 4Fs of traumatic responses as it relates to everyday interactions and sexual experiences: 

• Fight- pushing a partner away, tight jaw, feeling a pit in one’s stomach, urge to punch, suddenly without warning screaming at a partner during sex.  
• Flight- getting up and leaving, over exercising, tingling in arms and feet, avoiding situations of physical touch or initiation of any affection that could progress into a sexual or erotic encounter.
• Freeze- pounding heart, body feeling leaden, pale skin, decreased heart rate, maintaining one’s body in a limp, passive mode during the sexual experience.
• Fawn- complimenting a partner, over inflating how much one enjoys the sexual stimulation the partner is giving them, faking orgasms, ensuring the other person is satisfied with the whole sexual scenario. 

Any of these reactions often includes the experience of Disassociation, which is the experience a person has when their psyche emotionally “leaves” their body. While the client may be aware that they have done this, their partner(s) past or current might not pick up on it. The next psycho-ed then involves explaining how the different parts of the brain react during and after an experience in which they felt fear for their safety. Explain how brain scan research has shown us that the frontal lobe, responsible for logic, planning, decision-making etc. shuts down when a person is triggered. The Amygdala located in the middle of the brain sounds an alarm that immediately activates the brainstem in the back of the brain into one of the 4F reactions.

Another intervention is to ask the client if they would like to read, listen to, or watch some more educational information about common physical reactions clients have to negative/traumatic/non-consensual/assault sexual experiences. This is a way of both normalizing the symptom clusters experienced by many sexual trauma survivors while also providing a wide span of unique reactions that a person might have. Gradually, a client will begin to come to their own conceptualizing and begin to center the words that resonate best with what was done to them.

Part of the psychoeducation includes defining terms like small ‘t’ and Big ‘T’ trauma.  The way we differentiate between small ‘t’ and Big ‘T’ traumas are as follows: 

• Big ‘T’ include war, natural disasters, severe accidents, physical or sexual assault, and other catastrophic events that pose a serious threat to one’s physical or emotional health. 
• Small ‘t’ trauma includes: emotional and psychological abuse, bullying, financial abuse, sexual guilt, constant criticism, sexual coercion, taunting or humiliation, gaslighting and infidelity.   

Depending on the client’s experiences including outside of their sexual trauma, they could have had many types of boundary crossings, and identify with both types of trauma. Once this point has been reached, you can introduce the somatic inquiry interventions, which I will cover in my next blog.

April is Sexual Assault Awareness Month. According to RAINN, sexual violence and assault impacts 1 in 6 women and 1 in 33 men in the US every year. The aftermath of sexual assault results in what therapists refer to as “Big T” trauma which frequently seriously impacts sexual and emotional intimacy in romantic relationships. Many survivors find themselves struggling to regulate and communicate contradictory emotions as well as somatic shutdowns internally, which prevent them from experiencing authentic pleasure in their sexual lives. These struggles are common among survivors of sexual trauma. It is important to know that healing and reclaiming sexual pleasure is possible. 

Understanding Sexual Trauma:

When a sexual trauma survivor experiences Post-Traumatic Stress Disorder, seemingly normal stimuli can cause them to feel as though their life is in imminent danger. Research shows that trauma may change the way the brain functions. Bessel Van de Kolk, a ground breaking trauma specialist, writes in his book The Body Keeps the Score that the frontal lobes in PTSD patients often don’t work properly. The frontal lobe (responsible for planning, reasoning, and decision-making) often shuts down in survivors’ brains so that the medulla (responsible for regulating many bodily survival functions) can react quickly to escape the threat of violence. This is essential to survival when a person is indeed being threatened. 

With sexual trauma, any erotic stimuli can cause survivors to push their partner away in anger, go numb and disassociate (feeling as though the body and mind are separated), avoid the situation entirely, or grin and bear it through intimacy. These survival instincts automatically become triggered and are expressed by one or more of what trauma therapists call the 4 F’s: 

• Fight
• Flight
• Freeze
• Fawn

What sex therapists treating both the survivor and their partner in couples therapy must provide psychoeducation on these neurological processes, and tell them it’s not the partner’s fault if the sexual trauma occurred in a previous encounter or relationship. Sex therapists will need to support both the survivor AND their partner who may not know or realize the full extent of the sexual trauma.

Reactions to Sexual Trauma:

Many survivors will dissociate during intimacy after their assault. Dissociation is often linked as a precursor to other PTSD symptoms that can continue to grow in severity. Sex Therapists assess and name what they call “spectatoring”, where survivors feel their psyche is floating above their body and watching the motions of sex but not feeling integrated pleasure or connection. While the body may respond physically to the stimuli by getting aroused and may even orgasm, the psyche and soul are not registering this as a body/mind/spirit integrated enjoyable experience.  

Most survivors report that something is inherently broken inside them due to these experiences with partnered sex. Wendy Maltz, renowned sex therapist, discusses that the first step for trauma and sexual therapists to do is to help clients make the connection between their past sexual trauma and their present-day somatic reactions to intimacy. This can be challenging, as some clients may have suppressed memories or might not even identify their experience as abuse, assault or trauma. Any instance where sex is used to harm or control, rather than for mutual pleasure, can be considered non-consensual and/or assault. Sexual trauma and boundary crossings do not solely include sexual assault and rape in its definition. Voyeurism, obscene phone calls, stalking, financial abuse and sexual harassment are included in the definition of sexual trauma.

In order to move forward, one must understand the long-term impact that sexual trauma has on sexuality. Maltz’s book, The Sexual Healing Journey, has included many of the most common symptoms that survivors, no matter their gender, can experience: penetrative pain, Erectile Dysfunctions, Anorgasmia, and Delayed Ejaculation. Trauma symptoms can emerge at any time, immediately after the assault or many years later. It’s critical that sexuality-educated and erotically-informed trauma therapists educate their clients on these symptoms as potential consequences of past abuse while offering hope that survivors (and their partners) can learn skills to heal and thrive in their sexual lives. 

How to Help Clients Heal from Sexual Trauma:

Sexual healing is a process of first identifying one’s somatic symptoms, learning how to calm the body’s alarm system after it has been triggered and letting a partner know that one needs some time to get grounded again.  Beginning somatic regulation exercises can include mindfulness and meditation exercises like: body scanning, deep belly breathing, visualization and grounding through tightening and releasing parts of the body, all proven exercises in treating trauma.  The wheel of consent, created by chiropractor, author and teacher Dr. Betty Martin (as seen here) is often one of the more intermediate and advanced techniques I utilize after survivors have learned the regulating exercises named above. In working with the wheel, therapists can teach survivors and their partners to break down any action into answering two questions: 

1. Who is doing the action? 
2. Whose pleasure is it for? 

The “giving” quadrant represents touching someone else for THEIR pleasure. The “receiving” quadrant means you are allowing someone to touch you for your OWN enjoyment. The “taking” quadrant represents touching a partner for one’s OWN pleasure. The “allowing” quadrant is letting someone touch you for THEIR pleasure . Couples are invited to go back to foundational basics to fully understand each boundary, who an action is for, and the permission to pause to check in before requesting action and responding to a partner’s request. 

By clearly naming and teaching survivors and their partners what the meaning and depth of each quadrant is, survivors can gain back power and agency around where their particular boundaries lie, what actually feels enjoyable, and the wide array of choices open to them. Recovery is indeed possible. Working with a somatically-trained, sexual-trauma-informed therapist is usually a recommended first step to addressing symptoms of dissociation, numbness, avoidance, and sexless relationships. This model can lead survivors to communicate more clearly, improve their somatic awareness, and create those mind-body connections that are crucial to healing and sexual pleasure. 

Endometriosis (Endo) is a condition where tissue similar to the lining of the uterus grows in areas like the abdomen, intestines, and bladder. In these other locations, the tissue develops into “growths” or “implants”, causing chronic pain and a range of other symptoms. While the symptoms of Endometriosis on cis-female’s physical well-being is widely discussed in medical journals and forums, it still takes 5 to 12 (at times very painful) years for a symptomatic patient to FINALLY receive a clinical diagnosis. Additionally, its effect on intimacy and sexual health is often overlooked by medical providers, leaving individuals and their partners feeling isolated and frustrated. This Endometriosis Awareness month, I want to shed light on this important aspect of living with Endo, drawing on recent research and clinical insights.

Describing and Defining Pain: Dyspareunia and Endometriosis

When I began specializing in sex therapy, I noticed more and more women in their twenties and thirties coming into my practice with issues of pain during and at times outside of vaginal penetration. This frequently leads to lower desire, arousal, lubrication and increased ‘hypertonic’ tone or tightening of their pelvic floor muscles. People with vulvas and vaginas with Endometriosis-caused sexual pain frequently experience feelings of sadness, anxiety, and frustration in not being able to have a “normal” life, including their sex life. Endometriosis pain can manifest as deep Dyspareunia, felt during deep vaginal penetration, often due to contact with endometriosis lesions on pelvic structures. Research illustrates that up to 50% of women with Endo experience Dyspareunia. Some may also experience superficial dyspareunia: pain at the vaginal opening with or without penetration. 

When women are brave enough to talk about their symptoms’ impact on their sex life before receiving an accurate diagnosis, their primary care or Ob/Gyn doctors usually recommend using lube or prescribing medication for bacterial vaginosis or yeast infection. Why? Because the majority of medical schools are not providing adequate training in Endometriosis or in pleasure positive sexual health. Due to Endometriosis causing Dyspareunia cis-women develop anticipatory anxiety of pain when the slightest sexual encounter is initiated by a partner. I most commonly see this presenting problem in my practice when a partnered woman reaches out on their own for individual sex therapy. During the admission call, they usually state that they need individual treatment “because I’m the issue”.  Female clients experience an enormous amount of shame around not being able to ‘perform’ in sexual encounters without anxiety or pain.

How Couples Sex Therapy offers a Systemic Holistic Approach  

Endometriosis-related pain during intimacy doesn’t solely affect the woman experiencing it. Partners also embark on their own journey. Studies on male partners of women with dyspareunia show increases in distress and their own sexual difficulties, including lack of desire, anxiety, erection problems, and orgasm difficulties. While it’s often assumed that similarity in partners’ sexual desire is beneficial, research suggests that both partners simply feeling supported through intimacy helps with engagement for everyone. Having open dialogues with a partner around pleasure and intimacy is crucial to creating a meaningful, positive sex life for everyone. This may mean offering couples therapy so they both can learn to reframe the way intimacy can be shared and expand the definition of what partnered sex actually can mean. 

Challenging What is “Normal” by Expanding the Definition of ‘Sex’

Often, the idea of “normal sex” in the heterosexual world is defined as penis in vagina (P in V) penetrative intercourse. However, for individuals with endometriosis-related pain, this definition can be limiting and distressing. You don’t need penetration to have sexual pleasure and intimacy for each partner. Rosemary Basson’s Sexual Response model introduced the idea of responsive desire, which is critical to understand when one is suffering with sexual penetrative pain, fatigue, and the many symptoms that are associated with Endometriosis. Responsive desire is a feeling of motivation based on erotic context or a partner’s approach. What Basson’s model offers us is a willingness to enter an erotic or sexually pleasurable experience that isn’t exclusively based on desire. What I invite readers and clients to take away from this Sex Esteem® lesson is that partners don’t exclusively need penetration to enjoy a wide range of sexual pleasure!

Sex researchers have identified a wide range of motivations for sex, categorized as approach motivations (positive aspects like pleasure) and avoidance motivations (fear of disappointment or rejection). Pushing through painful sex often stems from these avoidance motivations, which can lead to more pain and negative associations with intimacy. Part of healing is to rewire the connection between your body and mind that sex will lead to pain. Helping clients to forge a new neural pathway between the body and mind will help a client and couple experience relaxed sexual pleasure. To do this, many women and their partners need to take a break from vaginal penetration and begin a new practice of pleasure-focused sexuality either through solo pleasuring or what sex therapists call: partnered ‘outercourse’.

Initial Steps for Outercourse

• Begin by using mindful breathing to invite your psyche to become aware of your body’s senses without judgement.
• Give yourself sessions where you explore your pleasure zones first by yourself then with your partner (if you are partnered).
• Find a vibrator that has just the right pressure to arouse you externally.
• Show your partner the wide menu of erogenous zones on your body’s skinscape to caress, tease or stimulate.
• Explore erotic fantasies through your imagination, listening to erotic stories, or watching ethical feminist sexual media. Notice the sensations that get activated as a result of erotic thoughts. 
• Invite your partner to touch you in exactly the place and manner you enjoyed on your own
• Ask your partner what kind of touch they would like. Consider if you’re able to provide all or any of this request and then let them know.  

Positive intimate experiences are possible for those with Endometriosis and/or suffering from Dyspareunia. By openly communicating with one another, looking outside the rigid beliefs about what ‘sex’ is, and reducing shame surrounding pain and intimacy, women and their partners can pursue pleasurable and more fulfilling intimate lives.