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.

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.

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.

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.

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

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.

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

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. 

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. 

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

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. 

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. 

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”

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.

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.

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. 

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. 

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.

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. 

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. 

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.

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.

A recent survey by the National Coalition for Sexual Health and the Kinsey Institute examined how Americans’ sex lives have been changed by the COVID-19 pandemic. For some partnered Americans, the pandemic and resulting quarantine strengthened their relationships by increasing their commitment, and emotional and sexual satisfaction. However, the majority of partnered Americans are having less sex, experiencing low sexual interest, and having trouble orgasming.

Americans are, by and large, less sexually and emotionally satisfied as a second COVID Valentine’s Day approaches. These decreases in sexual experiences may be the result of the responsibilities of a full house with little time to intimately connect with our partners or increased stress and anxiety due to job loss and homeschooling. They may also be the result of a preoccupation with the fear of either our loved ones contracting COVID or getting it ourselves.

The Power of Fantasy

A year ago, folks were preparing for their first COVID Valentine’s Day. A simple Google search of “COVID Valentine’s Day” produces countless articles from 2021 with tips for enjoying and celebrating the holiday with your partner. The widespread panic about how to make the day special in the context of decreased sexual interest, emotional disconnect, COVID stress and anxiety, and limited options for spending the day outside of the house safely was pervasive.

As the second COVID Valentine’s Day approaches, what can be done to spark sexual and emotional connection? Can actions taken on Valentine’s day spark long-lasting changes in how partners are interacting and ultimately their sexual and emotional satisfaction? Can folks overcome what Adam Grant so eloquently described in his New York Times piece as languishing and upcharge our Sex Esteem?

Sexual fantasizing is remarkably prevalent, but not always used for a partnered erotic connection. Common fantasies center around sensuality, dirty talk, changing power dynamics, and risk-taking. However, according to a Kinsey Institute study led by researcher Justin Lehmiller, the pandemic has changed why and how often people are fantasizing considerably. Participants in the study reported that they were fantasizing more because they were bored, needed to escape reality, relax, or mentally fulfill their unmet sexual and emotional needs. These findings tell us that when people are struggling with their mental health and their attachment needs are not being met, they turn to their private fantasy world for comfort at times rather than reaching out for their partner.

Sharing your sexual fantasies with your partner—which is one of my Sex Esteem principles of accessing curiosity—is an important technique for fostering intimacy and sparking sexual and emotional connection. In fact, it has been shown that couples who share their fantasies and actively fantasize about each other are more easily aroused by their partner and more likely to engage in positive behavior towards them. What kinds of positive behavior did the researchers hear about?

• Intentionally increasing pleasure for their partner in sexual encounters
• Demonstrating affection more freely
• Completing acts of kindness that make their life easier day to day

Although these positive behaviors are major incentives for sharing fantasies, many couples struggle to share those intimate thoughts. The practice is frequently avoided by many partners I’ve treated in my practice, for fear of feeling awkward, embarrassed, or judged by their partner.

One way that you and your partner can make sharing your fantasies easier is by being playful with one another. While at times this is easier said than done, there is a myriad of ways to intentionally encourage playfulness in your relationship.

Laugh Together

No doubt laughter is good for the soul. It is also good for your relationship. A University of North Carolina study found that the frequency in which a couple laughed together was closely related to their perceptions of relationship quality, closeness, and social support.

If you feel like you and your partner haven’t laughed together since the onset of the COVID-19 pandemic, or perhaps before, there are things you can do to create laughter in your relationship. You can watch a comedy together or send each other TikToks that make you laugh. You can take time to think about inside jokes you haven’t shared in a while or experiences you’ve shared that are now hilarious stories. Remember that despite any sexual or emotional distance you might currently feel, you know your partner well and know what makes them laugh.

Flirt

Perhaps you haven’t felt “flirty” in years, and most definitely do not feel like flirting with the person you’ve been stuck inside with for the past year and a half. However, flirting can be extremely beneficial to a relationship.

The study “Flirting With Meaning” talks about the different reasons people engage in flirtatious behavior. Flirting can be used as a way to initiate sex, but also as a relational maintenance tool, a way to bring fun to an interaction, and a way of increasing your own or your partner’s self-esteem.

There are a number of ways you can do these things through flirtatious behavior that do not feel like a big deal. The first way is to prioritize eye contact. This study found that prolonged eye contact can quickly build intimacy and change how much a person is attracted to another. Another easy way to flirt is by telling your partner something you appreciate about them while touching. This doesn’t have to be a big gesture and is a way to break the cycle of irritation and frustration with one another.

Finally, keep your date night and change it up—especially on Valentine’s Day. Be sure to spend time together without technology or other distractions, and try to do so in a new place. If you aren’t comfortable dining outside the home due to the recent rise in COVID cases, you can eat in a different place in your home, or with a different tablecloth and different candles.

Play a Game

Nothing says playful like a game. You can play games that don’t require any additional props or materials like “never have I ever”—maybe you will learn something new about your partner by naming things you haven’t done and seeing if they have. Rather than taking a sip of your drink when you hear a certain word in a show, kiss your partner. Write a word with your finger on your partner’s back while they guess what it is. You can also put a sexy spin on common board games you have around the house: Add stripping to your poker game, or a dare each time you pass go in Monopoly. If you’re willing to spend some money on a game, you can search for erotic board games online and purchase one for this Valentine’s Day. A variety of games exist that facilitate role play, new sensations, communication of desires, and sexual exploration.

Once you’ve established a new playful environment with your partner, the possibilities are endless. Perhaps the connection you’re seeking this Valentine’s Day will come from the play itself. Or perhaps the games and playfulness will make space for you to reach for your partner and share your erotic fantasies. Either way, you have the opportunity to try something new with your partner and spark the kind of intimacy you’ve been missing. I encourage you to intentionally be playful, try new things, share your fantasies, and ultimately reconnect with your partner this second COVID Valentine’s Day.

By Aly Pancer, Mindful Wellness Coach

Happy 2022! We have arrived at a brand new year, with brand new beginnings, goals, hopes, and dreams. We get to begin again. We set New Year’s Resolutions that include better nutrition, better sleep cycles, a regular exercise routine, and the decision to lose weight. We then pick an ideal weight and size, and go on a diet where we learn to restrict food in an effort to become thinner than we are. We tell ourselves we will start our diet on Monday.  “In fact, by the end of December, many people have made that promise to themselves 52 times” (Merendes, Gabriel, MD, Mayo Clinic, 2021).

Food. We need it, we crave it, we love it, and sometimes we have a challenging attachment to it. Like the diverse and negative attachments we enact in romantic relationships, our relationship to food itself is a symptom of how we are anxiously, avoidant or securely attached to our self. Many folks try to have three meals per day with a few snacks in between. Often, we are eating a meal or snack while multitasking, such as watching TV, checking Instagram, watching the latest Tik Tok video our friends shared, socializing, working, walking, driving, etc. We take the first bite of what we have chosen to eat, enjoy the taste, and then continue to eat the rest of our food in auto pilot, where we have stopped paying attention to what we are eating. The next thing we know: we are stuffed, feel bloated, and more often than not, we have finished everything on our plate. Then what follows usually are the twin emotions of guilt and shame into a spiral of negative attachment to ourselves and food.

Frequently people blame ourselves for having consumed too much. This can lead to a cycle of feeling depressed, anxious, self-conscious and isolated for overeating. They shame and criticize the way their body looks, which can lead us into developing eating disorders. “While there is no single cause of eating disorders, research indicates that body dissatisfaction is the best-known contributor to the development of anorexia nervosa and bulimia nervosa (Stice, 2002)”.  Distorted thoughts encourage people to climb onto the scale too often, or ignore it all together as part of an avoidant attachment to their bodies. An attempt to fit into clothes that are sizes too small in an effort to be the “ideal size” only furthers a magical thinking that leads to unrealistic diet fantasies. Many folks feel helpless if they dare to look at themselves in the mirror perhaps even calling themselves some negative names we believe describe our bodies.

The fantasy continue as people make 2022 New Years’ resolutions by restricting food through diets, fasting, and other unhealthy rules about food in an effort to reach a goal weight which feeds into the multi-billion dollar industry of diets.  There have been a slew of recent articles about Noom arguing that the way it markets itself as the ‘un-diet’ is just good marketing.

Consider for a moment changing your relationship with your food by exchanging the words and actions of “MindLESS Eating” to “MindFUL Eating”. What would that look like? How would it feel to abandon many fad diets, where you are being told about how to eat, what to eat, how much to eat, etc by others? How would it feel to be guided by your OWN cravings and satiety cues, from the inside out,  using mindfulness techniques for yourself, so that you can organically enjoy your food, moment by moment, bite by bite, and feel a secure attachment to your body and ultimately yourself?

The Mindful Eating skills I teach through coaching are based on the Mindfulness Based Stress Reduction model pioneered by Jon Kabat-Zinn. It invites you to slow down the pace of eating, to awaken all your senses, to focus on every bite you take and ultimately to give yourself permission to stop eating when you notice you are satiated.

I find it exciting to work with mindful eating clients who are eager to establish a wellness journey that focuses on intention and practice rather than fantasy and anxious attachment. One can create a secure relationship to food, and in doing so, be fully present, embodied and able to show up fully in their life.