Couples Pornography: What’s In It for You?

An article in The New York Times last week reports that, come January, Playboy TV will begin “shifting from traditional pornography toward a higher-quality, female-friendly slate of of reality shows,” called “TV for 2.” Designed to appeal to women’s preferences for “contextualized sex” -- intimate scenes that are part of realistic stories that feature believable characters -- the new programming will have an emphasis on intimacy and “learning as a couple.”

It will be interesting to see how their new market responds.

Sexual advisors and therapists frequently recommend watching sexy movies together as a way for couples to stimulate or improve or add spice to monogamous sex. But finding “explicit sexual content” that appeals to both partners can be tricky.

As the Playboy Channel has (rather belatedly) learned, women are not typically turned on -- and many of them are downright turned off -- by the purely visual, graphic sex that men find arousing to watch. More than a few of my patients have told me that they felt less (sometimes much less) sexually attracted to their husbands after viewing pornographic material their partners had inadvertently left open on shared computer screens.

And for a woman in her 40s or 50s who may be starting to feel less confident about her own body and its appeal, the air-brushed young women who appear on the covers of men’s magazines can make it even harder to conceive of herself as someone who’s still  got what it takes to be a desirable partner in bed.

Of course, watching X-rated movies together -- even ones that don’t appeal to both (or either) of the people watching -- can help a couple communicate about what each of them likes or doesn’t like and what they both might be interested in and willing to try. And anything that helps a couple talk about sex has the promise of increasing their erotic connection and their understanding of each other’s pleasures and desires.

What do you think? Will the business of producing “porn aimed at couples” be a good thing for women who want to have an active and satisfying sex life in their middle years? What role, if any, does sexually explicit media play in your own relationships? Are you planning to check out “TV for 2?” We’d love to hear what you think!

Hardwired for Sex?

Critics of the quest for “pink viagra” -- the elusive drug to increase female sex drive -- often argue that depressed libido isn't medical condition (like erectile dysfunction) that can be “fixed” with pharmaceuticals.

But a recent study by medical doctors at Wayne State University suggests that there may be measurable physiological differences between women who suffer from what researchers term “a distressing lack of sexual desire” and those who have a “normal” sex drive.

MRI scans of women viewing video clips that alternated between erotic scenes and nonsexual content found that areas of the brain that normally light up when thinking about sex remained dark in women with low sex drive, while other areas that usually don’t show activity lit up.

According to Wayne State’s Dr. Michael Diamond, who presented the findings at the annual meeting of the American Society for Reproductive Medicine last month, these brain pattern differences may provide the first “significant evidence” that, for some women, lack of sexual desire is a physiological disorder. One that could possibly be treated by meds -- pink or otherwise.

Although the study sample was small, and researchers have yet to understand exactly how these different regions of the brain relate to sexual arousal and response, for me these findings support the need for further research in this area. And raise hope that there eventually may be a medical option for women suffering from chronically low levels of desire.

We may find that some women are just wired differently and can benefit from a drug that improves their interest in sex, the way some people with ADD benefit from drugs like Ritalin and Adderall that improve their level of focus and concentration. Of course, some ADD patients prefer not to use medication and are able to make other adjustments that allow them to function well in their daily lives. And, if we do develop a “pink viagra,” it won’t be the solution for every woman. I’ve found that pain-free sex and a communicative partner can do wonders for the libido.

But I’d love to see the day when taking a desire-enhancing medication is a choice that a woman can make for herself. And studies like this one and the further research it will inspire move us closer to that goal.

Want Better Sex? Mark Your Calendar.

It’s interesting to me how many patients who come to me with concerns about diminishing libido are there because of their husbands or long-time partners. These lucky women have a great relationship with a great person, and they don’t want anything, including their own lack of sexual desire, to jeopardize it.

I respect that. I think that the desire to keep a long and satisfying relationship intact is a good reason to want to want to have sex.

I also believe that a lot of women in this situation sell themselves short. They think that because their partners want to have sex more often than they do themselves, there is something “wrong” that they need to “fix.” Often, it’s just a matter of timing.

Being “in the mood” for sex comes more easily to men. A man who is physically healthy and capable of an erection is almost always in the mood. Men are wired to go from zero to sixty on nothing more than a flash of leg or a lingering kiss. Women, on the other hand, tend to rely more on emotional or intellectual stimuli to reach a state of physical desire. And that takes time.

My advice? Get out your trusty planner and schedule a date for sex. Think of it as extended foreplay. If you schedule a week in advance, you’ll have days to think about your date night--what you’ll wear, what he might say about what you’ll wear, how he will want to take whatever you’ll wear off you. You’ll have time to buy some candles, choose a new aromatic massage oil.

Most importantly, because you’ll have to synch your calendar with your lover’s, you’ll have time to anticipate and talk about sex with each other, to make the crucial emotional and intellectual connection that helps both of you get in the mood for physical intimacy.

Some people dismiss scheduled sex as unromantic or think that deep physical attraction has to be “spontaneous.” I think it’s important to distinguish between sex that happens spontaneously (which can be very nice!) and sex that includes creativity and spontaneity in the act of making love (also very nice!). Think of scheduling sex as a way of insuring that you and your partner have a space and time where spontaneous acts of love and erotic play can occur.

Connection: The Second Component of Great Sex

We’ve talked about how crucial mindfulness--being mentally and emotionally present in the moment--is to enjoying great sex, sex that is “better than good,” as reported in a study recently published in The Canadian Journal of Human Sexuality.

I like to think of “connection,“ the study’s second ingredient of optimal sex, as “mindfulness times two.” Connection is what happens when both partners are present together: in bed, in the moment, in each other. As one study participant describes it: “Inside my body I’m the other person’s body and we’re just all one together at that moment.”

This sense of merging, of “two becoming one,” was regularly cited as part of the experience of great sex, which has to involve “at least one moment,” as one woman said, “where I can’t tell where I stop and they start.”

I believe that this kind of intense sexual alignment is something that becomes more accessible to us as we get older. Part of our maturity is greater acceptance of self and others, which leaves us more open to making a deep physical and spiritual connection with another person. To experience the joy of merging, of temporarily letting go of the sense of any boundary between the self and the other, a person has to know herself well--and feel safe and respected by her partner.

Which brings me to two great impediments to sexual connection: unsafe relationships and sexual trauma. If you have reasons for not feeling completely safe with a particular partner, or if you have a history that leads you to feel unsafe whenever you are in a sexual situation, you’ll need to address these issues before you can experience intense connections in intimate relationships. There are resources that can help.

But for two self-aware people who respect and desire each other and who are capable of being completely present with each other in the moment, a deeply satisfying sexual connection can happen even without penetration or orgasm. The study’s authors report that great sex is often more about the level of energy between partners than about the actual physical act itself. (Check out our website’s alternatives to intercourse for imaginative techniques for increasing sexual energy and connection.)

Have you experienced these moments of sexual oneness? What were the circumstances? We’d love to hear your stories!

Sexual Satisfaction: All in Our Heads?

I saw a headline that irked me in Salon.com’s Broadsheet a week or two ago. I couldn’t quite put my finger on why it bothered me until I wrote a post about the cancelation of the flibanserin project last week.

The headline was “Forget the pink pill, try a placebo.” The article opened by saying that “Researchers are desperate to discover ‘female Viagra,’ but Cindy Meston says sugar pills might hold the key.”

Meston, a clinical psychology professor at the University of Texas at Austin, co-authored a study, published in the Journal of Sexual Medicine. Reviewing data from an earlier clinical trial of a drug treatment for low sexual arousal, she noted that about one-third of the test subjects who were given a placebo instead of the actual drug reported they had more “satisfying sexual encounters” during their “treatment.”

The Broadsheet reporter takes these findings as “a reminder that in the rush to ‘treat’ female desire, there is one organ researchers can’t forget: the brain.”

That’s a conclusion I certainly agree with: Mindfulness influences our sexual behavior. More simply, when we think about sex, we have more sex.

So let me get back to what bothered me about that headline: Yes, the brain is a critical and often under-estimated part of women’s sexual response. But it doesn’t function alone. It requires and interacts with hormones, which trigger physical responses that depend on our circulatory systems and tissue health. And the brain functions within the context of our histories and cultures and relationships.

Suggesting that a placebo is the answer for every woman’s sexuality oversimplifies and trivializes the issue. (In most clinical studies, by the way, placebos get about the same 30-percent response rate, so this study isn’t remarkable by that measure.)

Meston herself isn’t proposing that placebos are the answer: “Expecting to get better and trying to find a solution to a sexual problem by participating in a study seems to make couples feel closer, communicate more, and even act differently towards each other during sexual encounters.”

That’s definitely the first step—to be intentional about taking control of and improving our own sexual experience, involving our partners when we can. Any pattern at all that helps to focus our attention will help—whether it’s a before-bed routine with a partner, a sensual lotion that’s part of our self-care, or even taking a sugar pill.

But if that’s not enough, it’s because while it’s in our heads, it’s also not in our heads.

Warming Up to Foreplay

I’m a recreational runner, and before a run, I always spend a few minutes warming up. I’ll run in place and do some stretches, especially of my calves and ankles. Experts no longer say this is a must, but I do it anyway because I know that as I’ve grown older, I have tighter muscles and less range of motion in my joints. And I’ve learned that if I exercise and end up hurting, I’ll be more likely to postpone my next outing.

This cycle can also be true of sex. If you rush past the warm-up—foreplay—you may not have enough lubrication to make penetration comfortable. If sex hurts, you’re less likely to initiate it or to respond to your partner. The more time that passes without having sex, the more difficult it is.

Many couples have a long habit of foreplay, but If the women I talk to are representative of the larger population (and I believe they are), men don’t always get the connection. They are happy to skip the foreplay and sprint to the finish line. Early in the relationship, that might work even for women, who are more sexually complex than men, because excitement is high all the way around and it’s easier to get aroused. It might even fly during the “thirsty thirties,” when women’s sexuality peaks.

But during menopause and after, hormones work against us. Estrogen declines, vaginal tissues become thinner and more fragile, and circulation to those tissues decreases. The less stimulation your vagina receives—from sex with a partner or your own self-care—the faster those changes happen.We’re not kidding when we say, “use it or lose it!”

So after menopause, we need more to warm up. More real intimacy, more talk, more titillation. In short, more time.  The stakes are higher now. If we don’t warm up, it hurts. If it hurts, we don’t want it. If we avoid it for too long, it’s more and more difficult to have it. If any of this sounds familiar, it’s probably time to talk about it.

Because a little foreplay has gone a long way in the past, your partner might be puzzled when you suggest your lovemaking include more foreplay. He might worry he’s losing his sexual prowess. This is a great opportunity to explain how changing hormones affect your response to sex. If there’s something you’ve secretly been longing to suggest to him lo these many years, you can slip that into the discussion, too. It’s never too late for your partner to learn, and telling him what you need and why is a great first step.

How about you? Have you been able to change the patterns of sex with your partner? How did you approach it? How did your partner respond? We’d love to hear!

October 22, 2010

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Another Dead End for “Pink Viagra”

It’s official. Boehringer Engelheim, the German pharmaceutical company, has shelved its plans to develop flibanserin. They’ve decided to focus on other drugs that “have better potential to make it to market.”

The pill’s been called “pink Viagra” because it was hoped it would do for women what other drugs have done for men with erectile dysfunction. I know flibanserin has been controversial. The drug was rejected by both an advisory panel and FDA staff, and much of the discussion about the project cancellation has focused on the negatives.

I don’t argue with concerns about Boehringer Ingelheim’s research or focus on marketing instead of fact-finding. But I do know that some of my patients who struggle with a loss of desire are desperate for more options that offer hope. They’re well-informed about their condition and their choices, and they’re fully capable of making decisions about the trade-offs between side effects and a return to a more complete sexuality.

The broader issue for me is the lack of focus on pharmaceutical options for women. Pfizer, makers of Viagra, canceled research into a female counterpart in 2004. Boehringer Ingelheim appears to be saying that it’s just too hard to follow through on a drug for women. What are the barriers? Are they cultural? Is male sexual satisfaction easier to talk about? To measure? To “monetize”?

As a physician, I want the most possible options to explore with my patients. Sometimes mindfulness, information, localized hormones, and tools like vaginal dilators are enough to change a woman’s life. Sometimes they’re not. I’m optimistic about ongoing research about testosterone for women’s sexual health, but I’d like to know that pharmaceutical companies see the issues we face as clearly and as important as I do.

Have you found a drug treatment that’s helped? Are you with me in thinking more options to consider is a good thing? Or would you rather pharmaceutical companies keep their focus elsewhere? Lots of voices will help them set their agendas.

What Do Breasts Do for Us?

Recently I treated a patient who’d had elective breast reduction surgery. Nerve damage during the procedure had caused her to lose all sensation in her nipples. She found herself unable to have an orgasm without the extra stimulation those nerves had provided. That was a consequence she hadn't thought to ask about!

Changes in nipple sensation are possible side effects of any type of breast surgery, including elective surgery to increase or reduce breast size. Sometimes the effects are temporary, but they can be permanent. It’s important to understand these risks -- and the role your breasts play in sexual arousal and satisfaction -- when choosing breast surgery for cosmetic reasons. I don't know if my patient would have made a different choice, but she may have.

How do breasts contribute to orgasm? Some women (not most) can reach orgasm through nipple stimulation alone. Others rely on intense breast and nipple fondling to “put them over the top” during oral sex or vaginal penetration.

Like the clitoris, nipples are bundles of nerve endings that respond to touch by releasing certain hormones in the brain. One of these hormones, oxytocin, is sometimes referred to as the “cuddle hormone”: It makes us feel warm and open toward the person whose touch initiated its release in our bodies. Other hormones, including testosterone and endorphins, combine to create a surge of sexual arousal that increases blood flow to the clitoris and stimulates vaginal lubrication.

For most women, sexual foreplay is essential to getting us interested in and ready for intercourse or penetration. And for most women (82 percent in one study) breast and nipple stimulation are an essential ingredient of foreplay.  We talk a lot about clitoral stimulation and vaginal maintenance for maintaining our sexual satisfaction, but other parts of our bodies also play a part in arousal and orgasm, though.

For those of us fortunate enough to retain the pleasant sensations our breasts can provide, remembering these important sites of arousal during foreplay and intercourse (warming and massage oils can work wonders here) will enhance our readiness for and enjoyment of sex -- at any age. Let's not forget to raise our focus -- to our breasts.

Can We Talk? I’m Not Sure.

Maybe I was naïve. We ran into some issues with the launch of MiddlesexMD.com earlier this year: We couldn’t advertise on a popular social networking site. An article we submitted was rejected because of subject matter. We were “ineligible” for a medical site designation.

And I took all that in stride, with some disappointment, as an entrepreneur, and some concern, as a physician trying to get the word out to women that sex is good for you and still possible and pleasurable, well beyond menopause. But I’m a parent, too, and I understand that there’s adult content that can’t just go everywhere.

But in the last week I saw a couple of articles (one in the New York Times) about Zestra and the walls its makers were hitting in trying to advertise. If you’ve missed the story, a commercial for Zestra Essential Arousal Oils was turned down by TV networks, cable stations, radio stations, and web sites. When it was accepted at all, it was slated to run in the middle of the night. Rachel Braun Scherl, the president of the company that makes Zestra, says, “When it comes to talking about the realities of women’s lives, you always have some woman running in the field…. There’s a double standard when it comes to society’s comfort level with female sexual health and enjoyment.”

As evidence, Rachel points to the advertising for Viagra and Cialis. And that’s when I start to think I may have been naïve. I remember the first time Bob Dole came on my television, during prime time, when my daughters were in middle school and still watching TV with me. It was a little awkward, maybe, to explain to them what “erectile dysfunction” was, exactly. Now they’re old enough to snicker with me (in a compassionate way—I am a doctor) when we hear “in the event of an erection lasting more than four hours, seek medical attention.”

So this gets me thinking. Why can we be so public about an aid to a man’s sexual satisfaction, but not aids to a woman’s? Is it because Viagra and Cialis are prescription products for a condition that’s been named a medical problem? In the case of erectile dysfunction, have we successfully separated the erection from sexuality? Because women’s arousal and satisfaction are more complex (remember why we love Rosemary?), is it too difficult to make that same separation? Or is there really still a double standard, with men’s sexual satisfaction ranking higher then women’s?

I’ll keep thinking. And, I’m sure, gathering anecdotal evidence on both sides of my questions. I’d love for you to join the conversation.

Missing Orgasm: Is It Me or My SSRI?

Are the medications you're on behind your loss of interest in sex? Are they making it more difficult for you to reach orgasm? These are tough questions. On one hand, the answer is almost always "yes": So many of the medications we take--including pain meds and sleeping aids--list lower libido as a potential side effect. On the other hand, the answer is also usually "no": In my experience, the meds aren't usually the primary cause.

With one exception. If a patient reports a notable change in her ability to reach orgasm and is taking medication for depression or anxiety, I ask if she's on an SSRI.

The most commonly used antidepressants today, SSRIs--selective serotonin reuptake inhibitors (I know it's a tongue twister)--are very effective in treating depression and anxiety disorders. Unfortunately, they also tend to dampen a woman's ability to experience orgasm.

SSRIs--some of the most commonly prescribed are Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline)--work by raising levels of serotonin in the brain, enhancing neurotransmission and improving mood. The "selective" part of the name is because SSRIs affect only one type of neurotransmitter--serotonin. But higher serotonin can lead to lower libido--and missing orgasms.

Of course, depression and anxiety all by themselves often lead to reduced interest in sex, so it can be hard to tease out cause and effect. But when a patient tells me she has lost desire or orgasmic function since beginning antidepressants, I often suggest that she consider switching medications.

Other types of antidepressants, like Wellbutrin (buproprion), act on dopamine neurotransmitters and typically have fewer adverse sexual side effects. In fact, studies suggest that increased levels of dopamine in the brain may actually facilitate sexual functions including libido and orgasm.

Sometimes bupropion is prescribed in addition to an SSRI, sometimes as a replacement. Doctors can often try different combinations and dosages until they find the prescription that treats the depression without robbing patients of their orgasms.

If switching isn't an option or if changing the prescription doesn't do the trick, there are other options. Even on SSRIs, a sluggish libido or elusive orgasm will respond to increased lubrication and stimulation.

Dealing with depression is hard. We don't have to make it harder by accepting the loss of an important part of ourselves. If you've struggled with the trade-offs, let us know how it's worked out for you.