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 Amazon.com, 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.

Seeking Orgasms and Female Sexual Satisfaction

If a woman has never experienced an orgasm, does this mean she would be diagnosed with Anorgasmia or, as it is now called in the DSM 5, Female Orgasmic Disorder (FOD)? In the recent film  Good Luck to You, Leo Grande, 55 year old British widow Nancy Stokes, played by Emma Thompson, has never had an orgasm. At the start of the film, Nancy (a retired religious school teacher) has only ever had penetrative sex with one man (her recently deceased husband) in one position. She describes her body as a carcass she’s been dragging around with her for decades.

Soure: DepositPhotos/AndrewLozovyi

The inability to orgasm is a common presenting issue brought to a sex therapy practice. It is estimated that up to 41 percent of women worldwide do not experience orgasm and 50 percent of those who do, are dissatisfied with how often they orgasm. A number of factors that contribute to a women’s inability to orgasm including internalized shame about sex, religious conflict, body image issues, previous sexual trauma, fatigue, stress, depression, and shyness about asking for adequate touch. After conducting a sexual history, a therapist would diagnose FOD if the client has not been able to orgasm after a normal sexual excitement phase in all (or almost all) sexual encounters.

A sexual history of Nancy would have revealed that she has never attempted to self-pleasure and that her husband never offered to stimulate her manually, orally, or with a sex toy. Given this history, a sex therapist would not have diagnosed Nancy with FOD, but rather honed in on the behavioral issues contributing to her unexplored orgasmic potential. A sex therapist might begin by debunking the societal myth that women should be able to orgasm solely through vaginal penetration with a partner. In a study exploring middle aged women and touch researchers discovered that women who rarely or never engaged in sexual touching, were almost 3 times less likely to climax than those who always engage in sexual touching.

In the film, Good Luck to You, Leo Grande, Nancy does not employ the help of a sex therapist, but rather a young sex worker who goes by the name Leo Grande. After the death of her husband, Nancy’s embarrassment about her limited sexual knowledge and experience is outweighed by her desperation to find out what she has missed out on–including the elusive orgasm. 

Nancy and Leo’s banter throughout the film ranges from witty and playful to thoughtful and moving–exploring the themes of aging and sex, women’s critical self-image, and feelings of guilt related to pleasure. Nancy, like many women, begins the film believing that the desire for sexual pleasure is irrational, gluttonous, and shameful. She is unable to prioritize her erotic feelings and sexual desires after years of catering to a husband’s needs and shunning her own.

Source: DepositPhotos/starast

In their first meeting, Nancy reads Leo a list of sexual activities she wants to experience. When Leo begins to initiate touch and tries to remove Nancy’s clothing, she withdraws and repeats negative descriptions of her older body, assuming that it disgusts him. Like Nancy, so many women experience body shame or dysphoria. Body image issues have been shown to cause low sexual desire, difficulty with lubrication and orgasm, and painful or unpleasurable sex. While women of all ages carry body shame due societal beauty standards and what the media centers as “beautiful”, post menopausal women carry unique issues resulting from the natural weight gain that ensures after one stops having a period.

Part of the work of sex therapy is encouraging clients to become embodied, and to view their physical bodies with compassion and curiosity so they are open to experimenting with erotic and sensual touch. An important element of this is an invitation to put aside a goal of having an orgasm–which Leo communicates to Nancy. For a woman like Nancy, learning to be present and in the moment is the most important first step. 

The theme of being cut off from one’s body is also explored as it is related to the societal role of women, and mothers in particular, who spend more time in their heads making lists, planning ahead, and chastising themselves than they don’t meet all their goals including being sexually responsive. When Leo tells Nancy that in order to enjoy their time together she’ll have to let go of the part of her that watches and judges her from the outside–a phenomenon that sex therapists refer to as “spectatoring”–, she tells him that that voice is the only thing that keeps her life on track.

For many women, another intrusive voice is the one that pressures women to constantly put the needs of their families above their own. When Nancy’s daughter calls her numerous times, Nancy tells Leo that she always–no matter what–answers her phone. Many mothers who seek out sex therapy report feeling guilty if they are not fully available for their loved ones, but then resent their loved ones when they are unable to be in the moment.

No matter how long a woman reports she hasn’t been able to climax, there is hope. Between 80 and 92 percent of women who have never had an orgasm are able to orgasm after sex therapy  treatment. Included in this statistic are women like Nancy, who desire sexual fulfillment and are no longer willing to participate in the charade that they are enjoying themselves. Sixty-seven percent of women who have faked an orgasm are no longer willing to do so as they age.

Source: DepositPhotos/Rawpixel

Good Luck to You, Leo Grande is a movie about the mental prerequisites for experiencing sexual fulfillment–feeling entitled to happiness and pleasure, contentment with oneself, and peace with one’s body. In the film, two people learn about themselves and one another through intimacy, being fully present, and honoring and communicating boundaries. The movie ends (spoiler alert!) with Nancy experiencing her first orgasm through self-pleasure. When Nancy stands gazing at her naked body in the mirror at the end of the film, it is clear she has learned to treat herself with compassion rather than judgment, experience mindful embodiment, and how empowering sexual arousal can be–all lessons that are important at any age.

“Dating Sucks”: Identifying dating burnout and how to fix it

5 signs you have dating burnout

1. You are losing hope

Whether it is because you’ve had your heart broken one too many times or because you’ve been on one too many dates where conversation dwindles before the appetizer arrives–it’s easy to start believing that dating sucks. So many people do! “Dating sucks” is a common adage represented in books, movies, and heard in therapists’ offices. If you are one of the many people who has expressed feeling hopeless in the search for a romantic partner, you may have dating burnout.

2. It’s affecting your mental health

All our relationships impact our well-being and mental health. However, romantic relationships are particularly impactful. Intimate, passionate, and committed relationships bring about heightened emotions, romantic and erotic fantasies, and meaningful hope. As a result, the state of a person’s romantic relationships is closely related to their experiences of anxiety, depression, substance abuse, self-worth, self-esteem and overall mental health.

3. You aren’t prioritizing self-care

Dating can be time consuming! Especially in our culture in which we believe that the more “work” you put in (or in this case the more dates you go on) the better the result. More dates in a week does not necessarily mean you are more likely to find the right person or relationship–particularly if you are not showing up to those dates as your best self. Dating burnout may mean you are sitting across from romantic partners feeling tired, unable to focus, and without the ability to show your date your authentic self. 

4. You are struggling with rejection

Source: Depositphotos/brnmanzurova.gmail.com

Modern day dating, particularly on dating apps, means that people are rejected or are rejecting others a number of times a day as they casually swipe on Hinge or Tinder. The 70 million adults in America that use dating apps have developed a rejection mindset that makes dating feel particularly unpromising and exhausting. Rejection–whether you or your potential partner is saying no to pursuing a relationship, situationship, or another type of  non-monogamous partnership–is an unavoidable part of dating. If you’re already in an unhealthy headspace, getting turned down or ghosted can feel like a reflection of your lack of worth, attractiveness, or ability to make a romantic relationship work. When you’re in a healthy headspace, a rejection is just par for the course in the search for a romantic partner (“thank u next”). 

5. You feel like you’re going through the motions

Going on autopilot on a date prevents you from truly learning about the person sitting across from you, and ultimately deciding if you are interested in them romantically or not. Autopilot prevents you from bringing the playful, curious, and engaging parts of your personality to the table and conversation. It may feel like a way to conserve your energy and get through dates, but the return on investment for that kind of dating is slim to none. 

7 ways to bounce back from dating burnout

1. Take a break

When dating feels like a chore or a drain on your social battery it is important to carve out time for yourself. Whether that means spending time with people you love or engaging in some sort of physical activity–taking a break can re-nourish the soul and increase energy levels allowing you to show up to dates refreshed and optimistic.

Source: Depositphotos/GaudiLab

2. Be more intentional

Before committing a huge portion of your time to dating, it is important that you consider a few important questions like “What do I want from dating?” and “What are my non-negotiables in a relationship (do I want a family, to live in a certain area, practice a religion jointly, etc.)?” Pay attention to how you are feeling internally–what kind of dating has been fun in the past and, even if the romantic connection isn’t there, how can you make dating an intellectually expansive and pleasurable experience for yourself? 

3. Date people you want to date, not just those who want to date you   

Agency prevents burnout. It is important that you are choosing to continue dating people who you find attractive, intriguing, and sexy. The ego boost from someone expressing their interest in you is short lived and continuing to date someone you’re not that into is ultimately unlikely to lead to a meaningful connection.

4. Be disciplined–track the time you spend on the apps

It is important that you track the amount of time you spend on dating apps. Studies have shown that every additional hour a person spends scrolling on their phone decreases their psychological well-being–increasing anxiety and emotional instability and decreasing self-esteem. While it may seem productive to spend time swiping left or right, doing so is negatively impacting your mental health and ultimately making it more difficult to find a romantic partner.

5. Let go of your timeline to meet “the one”

Many people consciously or unconsciously subscribe to a dating timeline–meet someone by 25, get engaged by 28, get married by 30, etc. But that kind of timeline is arbitrary and, in fact, detrimental to your dating success. Dating because you really want to be dating is different from dating because of the stress of a self-imposed time crunch. Releasing yourself from this pressure to perform in a given timeframe will be reflected in the decreased anxiety you bring to your dating experiences. 

6. Change up your usual dating activities

Source: Depositphotos/apid

Instead of going to a bar or coffee shop on a first date, do something different. Suggest a short hike, a bike ride, a visit to a sculpture park, or volunteer together. Trying something new with someone new can increase your dopamine levels, excite your body and mind, and break the cycle of same old, same old dating. Novelty can be a powerful trigger for erotic fantasy so incorporating adventure into your dating might just be the catalyst you need to feel inspired by the person you’re with and energized internally.

 

7. Generate insightful conversation

There are a number of ways you might improve conversation on dates with potential partners. I suggest going on dates with the intention of identifying what makes the person sitting across from you unique as opposed to their “stats” or information about where they grew up, went to college, or what they do for work. Other inspiring ways to generate meaningful conversation include these 36 questions by researcher Arthur Aron, or this card game created by Ester Perel. 

7 Critical Talks To Have Before Your Wedding Day

June marks the beginning of wedding season. According to the wedding website The Knot, 80 percent of weddings take place between May and October each year. In 2021 there were a total of 1,934,982 weddings in the U.S. After postponing and re-postponing their nuptials because of COVID, 2.5 million people are expected to be married this year–a 15 percent increase from 2021.

COVID-19 has shaken up the so-called traditional wedding “rules” and partners are now celebrating their nuptials in increasingly non-traditional ways. After waiting for two years to get married, couples feel less pressure to participate in religious or conventional wedding traditions that aren’t meaningful to them and are less likely to have a wedding party, walk down the aisle with their parents, throw their bouquets, or have the ceremony conducted by a religious figure. 

Source: DepositPhoto/halfpoint

The millions of people getting married this wedding season are planning these celebrations–whatever they might look like–in the context of inflation, continuing supply chain issues, rumors of a recession, and the uncertainty that comes with new COVID-19 variants. It is vital that, despite these stressors, couples keep the desire to make a deeper commitment to their relationship at the center of the celebration. Here is a list of essential conversations couples who are getting ready to walk down the aisle should have: 

Create boundaries with each of your families of origin

Leading up to the wedding, couples may feel a lot of pressure from their family of origin to center certain beliefs, rituals, and values in their wedding ceremony. However, a wedding marks the creation of a new family. You and your partner need to decide on what is important to the family you are building–whether that family will involve children or not–and set up boundaries with family members to protect those values. 

Discuss having children

Many of my clients were ambivalent about having children at the time of their wedding. They were enjoying their time as a couple and thought that they would make decisions about children down the road. However, I’ve found it vital to the longevity of a relationship for couples to enter into marriage having discussed their long-term desires to be a parent. Critical questions include, “Do you want to be a parent in your lifetime?”, “How do you imagine us parenting together?”, and “Why would we decide to bring children into the world at this time?”. 

It takes a village

 

Source: DepositPhoto/halfpoint

Just like it takes a village to raise a child, it takes a village to support a couple. Modern marriages tend to come with an expectation that a person’s partner will provide them with everything they need. But one person cannot realistically meet all of the emotional, psychological, practical, sexual, and social needs of another person. Building community outside of your marriage–particularly of people who support that marriage–is so important to the long-term success of the relationship.

 

Tell your partner you appreciate them

When a couple first starts to date they often tell each other what they find special, beautiful, and enthralling about their partner. After some time, couples tend to stop verbalizing what they appreciate about their partner. People have a deep need to be seen, witnessed, and celebrated. Verbalizing what you appreciate about your partner, whether they are the same reasons you fell in love with them or ways they have grown or adapted over time, is vital to the success of a relationship. 

Define what monogamy means to each partner

When getting married, couples often express their commitment to monogamy and fidelity. But what those concepts specifically mean to each person is often only discussed after one person feels the agreement has been broken. One partner may think that a drunken kiss or online video chat with someone outside of the relationship does not break their commitment while the other person feels betrayed. Once one person feels the agreement has been broken, the couple is in crisis mode and discussing how monogamy and fidelity are defined is extremely difficult to do. It is vital they happen at the start of a marriage.

Be your partner’s emissary to your family of origin

Wedding planning is notoriously stressful and can be a source of conflict for partners and their families. If your partner is in conflict with someone in your family, it is important that you step in, represent your partner’s interests, and work to resolve the conflict on their behalf. You have a history of resolving differences and conflicts with your family members that your partner does not. They may need help representing their views and good intentions. Showing support for your partner and representing their wishes is critical to family integration and will benefit your marriage in the long run. 

Discuss religious and spiritual beliefs and practices 

Engaging in deep conversations about your current and historical religious and spiritual beliefs is vital to any new marriage. While your partner may not be following any religious practices or rituals now, they may have an emotional relationship to those traditions that may crop up later on in their lifetime–particularly in the context of raising children. For example, the idea of having a Christmas tree or going to temple for high holidays may not have deep religious meaning for one partner, and strike the other as counter to the spiritual upbringing they want for their children. Understanding how both you and your partner would want to raise children in relation to religion and spirituality is key. 

Source: DepositPhoto/yurakrasil

While these conversations are critical before a couple walks down the aisle, they are also conversations that would benefit any couple at any stage in their relationship. Particularly because people change! How a person feels about having children, monogamy, or spirituality might shift several times over the course of a marriage. Having these conversations ahead of the wedding will lay the groundwork for an open line of communication over a lifetime about your individual needs and desires and your marriage as a whole. 

The 7 Myths Held By Betrayed Women After Infidelity is Discovered: Part 2

Research estimates that about 25 percent of committed monogamous relationships face infidelity at some stage of coupledom. After infidelity, many women make misguided assumptions about themselves, the relationship and their partner based on myths that permeate our culture. The first part of this two part series focused on the myth that the relationship is over, and myths that the infidelity happened because the unfaithful partner fell out of love or attraction or because of their narcissism. This second part of this two part series, will bust myths #5 to# 7 of the most common myths believed by betrayed partners.

5. If I had just been less needy…they wouldn’t have cheated

6. I should have known

7. I will be alone forever 

Myth #5 “If I had just been less needy…they wouldn’t have cheated”

Women who have discovered their partner’s betrayal often tearfully exclaim: “I expressed my insecurity, and pushed them away!” It is important to distinguish between expressing one’s needs and being “needy”. All humans have needs, and communicating one’s needs and desires is a cornerstone of any good relationship. Because most people don’t enter relationships with the ability to ask for what they need in a way that resonates with their partner, another cornerstone is how to set expectations and boundaries. If the cheating partner/spouse did feel overwhelmed or distressed by their wife’s or girlfriend’s expression of needs or their anxious attachment style, it is their responsibility to set clear expectations about how they are or aren’t able to support her.

As my colleague Esther Perel stated about recent expectations of marriage in The State of Affairs: “So we come to one person, and we basically are asking them to give us what once an entire village used to provide.” The weight and responsibility of helping someone you love through negative emotions may be overwhelming. It can create negative relationship cycles and diminish both emotional and physical attraction between partners over time. In post-infidelity couples therapy, I encourage each partner in a couple to do some deep inquiry as to what their needs are, re-learn how to express these needs to their partner, and learn to accept that their partner may not be capable of holding all of their needs. In betrayed women’s coaching groups, clients are encouraged to support one another as they review what they were looking for from their partner, why they may have grown up expecting certain psychological support, how they communicated those needs, and whether their partner is equipped to provide what they need.

Myth #6 “I should have known”

Source: Deposit Photo/AndreyPopov

Betrayed partners frequently fall prey to the idea “I should have known.” They beat themselves up for not knowing that their partner was having an emotional or physical affair. In Buddhist tradition, this kind of emotional self-flagellation is called the second arrow of suffering and increases the pain itself. In most cases, the infidelity revelation comes out of the blue. In others, betrayed women had an intuition or gut feeling about the infidelity, but their partner lied and gaslit them with such dexterity that they ignored that intuition or gut feeling.

Years of clinical experience has shown me that after infidelity discovery, in addition to loss of trust in their partner, most hurt partners experience a loss of trust in themselves. They stop trusting their perceptions, gut instincts, and abilities to judge people’s character. Part of the healing process is rebuilding and reclaiming the trust in one’s authentic self and pushing back against the harsh inner critic–the internal voice that insidiously whispers: “I should have known.”

Myth #7 “I will never find another partner”

Almost all my female-identifying clients facing the potential end to their marriage or relationship  after infidelity fear they will never find another partner. This catastrophic thinking can prevent someone from ending their monogamous agreement even when they know it is the best choice for them. According to CDC research, 54 percent of divorced women remarry within five years and 75 percent of divorced women remarry within 10 years. 

If a woman’s relationship does end, individual or group coaching supports her growth as she gains a deeper understanding and healing of the family of origin wounds both you and your partner brought into that relationship. She can learn skills to calm her intrusive thoughts, mourn the loss of the relationship, develop more communication skills to articulate her own desires and needs, expand the village of folks she can depend on for these needs and regain trust in herself to make strong, grounded decisions about future relationships–and ultimately build a stronger, more fulfilling relationship. It takes a village to raise a child and it certainly takes a village to help a woman heal from partner betrayal.

Source: Deposit Photo/Wavebreakmedia

Sex therapists’ goal when working with betrayed partners whether in individual therapy, couples therapy, or in a women’s group setting is to create a safe space to mourn the loss of what was, bust cultural myths around infidelity, and explore the deeper meaning of the relationship’s breakdown. Through this work, they can emerge with a deeper knowledge of what kind of life they want for themselves, whether they create a stronger, wiser second iteration of the relationship to the partner who betrayed their monogamous agreement, or decide to forge ahead with a new life as a stronger, supported single woman.

7 Myths about Infidelity Believed by Betrayed Partners: Part 1

Most sex therapists, at one time or another, find themselves sitting across from a woman who has just discovered that her husband, boyfriend, wife, or partner has cheated on them. Before those sessions, I work to ground myself so that I can hold space for their shocked, hurt, and rageful reactions. 

Research estimates that up to 25 percent of committed monogamous relationships struggle with infidelity at some stage of coupledom. Whether that infidelity is emotional or sexual, involves texting, online chat rooms, or meetings in person, is an ongoing affair, or one-time hookup, involves paid sex workers, or sexually compulsive behavior–infidelity’s emotional impact is immense. It is akin to the fallout of an earthquake in which the ground under the hurt partner has cracked open to reveal the seismic fault lines of the relationship below.

Many women make misguided assumptions about themselves, the relationship, and their partner based on infidelity myths that permeate our culture. This is the first blog of a two-part series, which will bust myths 1 to 4 of the 7 most common myths believed by betrayed women. Part 2 will cover myths 5 to 7. 

  1. The relationship is over
  2. My partner/spouse cheated because they don’t love me
  3. My partner/spouse isn’t attracted to me anymore
  4. My partner’s narcissism is the reason they cheated

Myth #1The relationship is over”

Many of my clients whose partners have had extra-monogamous affairs or casual hookups fear that if they don’t leave, she is and will be seen by others as a loser who is letting someone “walk all over” her. Feeding this fear is the common cultural belief that infidelity means the end of the relationship–but that is not true. In fact, according to a study by Marin et al., 60 to 80 percent of married couples remain together after an instance of infidelity. 

Whether a woman wants to remain or leave their relationship, it is crucial that the therapeutic space is left judgment free. It’s critical that hurt partners are encouraged to express all their divergent emotions in treatment after infidelity discovery. While friends or family members in their lives may express strong opinions about what they ought to do (frequently based on these cultural tropes), the therapy or coaching should be centered on exercises, techniques and reflections that allows each woman to wade through those divergent emotions–including relationship ambivalence. 

Source: DepositPhoto/Syda_Productions

While I don’t encourage couples to simply return to the way their relationship was before the infidelity, it is common that betrayed partners experience denial and go back into their previous cycles in order to stabilize their roller coaster emotions. This denial halts the therapeutic process. Unless the couple is able to identify what precipitated the betrayal, it will be challenging to rebuild a stronger, more authentic relationship. It sometimes takes up to a year for couples to repair their relationship/marriage after infidelity–but it is work that has long standing benefits.

Myth #2 “My partner cheated because they don’t love me”

There are a number of reasons that people commit infidelity. Some people may cheat because they have fallen out of love with their partner. Others cheat to explore a secret sexual interest, because of a need for intimacy that has been lost due to a variety of circumstances, or due to a desperate compulsive need for positive reinforcement after a childhood filled with bullying or abuse. While these are not excuses for breaking a monogamy agreement or marriage vow, they are explanations based on emotions that can co-exist with the love a person has for their partner.

All of these explanations are rooted in the person who cheats’ inability to communicate their emotions or needs to their partner. Often, the straying partner didn’t grow up around examples of securely attached romantic relationships, or relationships that model how to communicate relational needs. With no tools to communicate with their partner, someone may find themselves doing whatever it takes to have their needs met–even going against their own ethics or values. In many cases it is through therapy that the betrayed partner is able to see that it isn’t a lack of love for them that led to infidelity, but rather their partners’ internalized fear and desperation.

Myth #3 “My partner isn’t attracted to me anymore”

When my clients tell me they fear their partner is no longer attracted to or turned on by them, I try to educate and expand their definition of “attraction”. Our culture tends to define attraction as purely sexual–which is not the case. Someone can be attracted to their partner’s confidence, sense of humor and fun, openness, emotional intelligence, or intellect and wit. Sexual attraction is complex.

According to Janssen and Bancroft’s Dual Control Model of sexuality, the source of sexual excitation (or what we sex therapists refer to as the gas pedal) can be squashed by an increase in inhibitory responses (or the brake pedal). A person’s inhibitory response can increase due to anxiety, stress, panic, awkwardness, physical pain, or psychiatric disorders. And often, someone experiencing one of these inhibitory responses holds tremendous shame for having them. Untreated shame may lead people to have breakdowns, relapses, or result in internal split selves–which many partners consciously or unconsciously hide from their partners. Shame and secrets lead to a disembodied or disassociated sexuality rather than integrated or aligned sex that combines love and lust.

Source: DepositPhoto/AndrewLozovyi

Myth #4 “My partner’s narcissism is the reason they cheated”

Many people attribute infidelity to characteristics associated with narcissism. These include an increased sexual appetite, more permissive attitudes towards casual sex, and overly positive beliefs about their abilities–including their ability to hide their extra-monogamous relationship or  convince both partners to forgive their infidelity. While my clients often report that their partner has some of these traits, it does not mean that they have Narcissistic Personality Disorder.

I have found that some behaviors the betrayed partner interprets as narcissism is actually the result of resentments held by the person who cheats. Often, the betrayer will tell me that they feel their partner is ignoring their emotional or sexual needs. They might feel vindicated in breaking the monogamy agreement because they believe they are entitled to having their needs met and that their partner “let them down”. This kind of attachment breakdown may also be the result of growing up with poor models of communication.

COMING SOON! 7 Myths about Infidelity Believed by Betrayed Partners: Part 2

Young Men and Erectile Disorder: What you need to know when seeking help for ED

Erectile Disorder and Sex Therapy

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

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

Erectile Disorder 

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

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

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

Causes of Erectile Disorder 

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

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

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

Co-occurring Sexual Disorders

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

Source: Wavebreakmedia/Deposit photo

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

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

Psychological Contributors to Erectile Disorder 

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

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

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

Increased recreational use of erectile dysfunction medication

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

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

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

Source: plp609/Deposit photo

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

Treatment for Erectile Disorder

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

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

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

Endometriosis, Female Sexual Pain, and Reclaiming Sexual Pleasure

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

Source: Deposit photo/samotrebizan

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

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

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

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

…shouldn’t workplace organizations consider endometriosis a disability?

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

Medical Providers and Cultural Stigma Around Infertility

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

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

Endometriosis and Partnered Sexual Pain 

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

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

Source: Deposit photo/Wavebreakmedia

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

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

Partners of Females with Endometriosis 

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

Sex Therapy with Couples Challenged by Endometriosis 

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

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

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

Source: Deposit photo/tonodiaz

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