One of the benefits of my work with MiddlesexMD is the networking that makes it more likely that I’ll run into medical information, over-the-counter products, articles and books that could be helpful to my patients, and, of course, the interesting conversations that turned into our podcast, The Fullness of Life.
I received an advance copy of Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship, by Stephen Snyder, MD, a month or so ago. Steve is a couples therapist, psychiatrist, and writer, as well as associate clinical professor of Psychiatry at the Icahn School of Medicine at Mt. Sinai in New York City. While I’ve met him—so far—only via email and his written words, I know we share some perspectives: that intimacy remains important to us no matter what our age, that men and women do have some differences in their approaches to love-making, and that there’s nothing wrong—and lots that’s right—about seeking tools that help us!
I think it’s useful to hear men’s perspective on sexuality, too, so when Steve offered to contribute to this blog, I accepted! Read on for more from Stephen Snyder, “sex therapist in the ‘hood.”
Several years ago, a merchant in my neighborhood learned that I was both an MD and a sex therapist. The next time I was in his shop, he asked me if I could get him some Viagra.
“How long have you had erection problems?” I asked.
“I don’t,” he answered. “But my wife and I have been married for 30 years. To tell you the truth, sometimes I’m too tired or preoccupied to get hard without the Viagra.”
What was this man’s problem, exactly? He wanted to have sex with his wife, even though he wasn’t feeling that strongly turned on. Evidently there were other reasons he wanted to do it.
Sound familiar? Of course: He wanted to make love like a woman.
Women can have sex with their partners any time they want. They don’t have to be very excited. Sure, some lubricant might be required, especially over 50. But the absence of peak excitement isn’t necessarily a deal-breaker.
A woman can make love for other reasons besides strong desire. To feel close or emotionally connected to her partner. To promote loving feelings. Or just for the simple pleasure of the experience. Even occasionally to keep a partner happy, even though she might be too tired or preoccupied to be really into it. A useful book on the subject calls it “good-enough sex.”
One wouldn’t want all one’s sex experiences to be like this. But once in a while it’s okay. Especially if the alternative is not to make love at all. If there’s one thing that sex research repeatedly shows about successful long-term couples, it’s that they keep having sex even when if the sex isn’t always earth-shaking. The ritual itself is important.
Men traditionally haven’t been able to do sex very easily under conditions of lower arousal. Especially over 50, when it ordinarily takes more stimulation to stay hard than it did at 20. If a man, for whatever reason, hasn’t been strongly turned on, conventional sex hasn’t usually been an option for him.
Viagra changed all that. Since the blue pill came on the market in 1998, a man can take Viagra and have sex even if he’s tired or preoccupied and just wants some loving and affirmation but isn’t feeling peak excitement. In fact, just having a good erection can help a man feel more in the mood.
There is often strong partner resistance to a man’s boosting his erection through chemistry, though. Women especially are used to the affirmation that occurs when a man gets hard (as Mae West famously put it) simply because he’s “happy to see her.” It’s worth it for a man to communicate that he needs sex for closeness and affirmation and pleasure as well. Just like she does. And that worrying about his erection just gets in the way.
Some couples worry whether taking Viagra under such conditions is a wholesome or natural thing to do. If it just takes more sexual stimulation now to keep him hard, wouldn’t it be more natural to simply intensify the excitement?
Maybe, but not necessarily. Intensifying excitement sounds like a great idea. But in practice, having to do things to get the man hard enough can be a bit of a burden. And it can take time, sometimes so much time that the moment is lost.
Sound familiar? Of course. It’s the same predicament that women find themselves in when they can’t get lubricated or can’t climax. Deliberate efforts to manufacture excitement often backfire. They usually aren’t very erotic.
My advice? It depends on the couple and the situation. But sometimes Eros is best served by taking the Viagra. Then a man can stop worrying about his erection, and get back to making love.
Sometimes it’s best for a man once in awhile to make love like a woman.
Sounds like you’ve been doing a number of the right things: You’ve been using dilators, a vibrator, lubricant, and vaginal moisturizer. It sounds like you’re at a point where localized estrogen, Osphena, or Intrarosa would be helpful for you to achieve your desired outcome.
Any of these prescription drugs will provide elasticity, a critical factor for getting the “stretch” needed with the dilators. Take your dilators in to your health care provider and have this conversation, too. He or she can help you determine whether you can get further capacity with the methods you’re using or whether, as I suspect, you need to take the next step and add a prescription to your routine to restore health to the vaginal tissues.
It’s hard to get to the final goal without that option--and that final goal is definitely one worth working for! Good luck.
I’m so sorry that you’re experiencing this loss in your relationship. Both depression and the medications used to treat it can be culprits in a loss of desire, and given the relatively short time frame in which you noted the change (one or two weeks), the antidepressant is the likely explanation for your husband.
The situation that you describe is probably best addressed with the help of a therapist; someone who does sex therapy would be most helpful (you can find one certified by the American Association of Sexuality Educators, Counselors, and Therapists through their website).
As you’ve begun to experience, the longer this dynamic goes on, the more anger and resentment builds. Having a therapist to help you navigate the conversations is extremely helpful. And your suggestion of a therapist sends your partner the clear message that intimacy is really, really important for you and your relationship.
There’s some evidence that Stronvivo, a nutritional supplement for cardiovascular health, can improve both libido and function in both men and women; that could be a consideration as well.
Here’s an idea to spice up a holiday evening: Gather your coffee klatch girlfriends, or your BFFs, or even your sisters and/or daughters, make popcorn and margaritas, and watch “Love, Sweat, and Tears,” the new documentary about menopause.
Even better, snuggle up and watch it with your partner, because the red thread running through all the information about hot flashes and mood swings is that our sex lives don’t have to be disrupted or put on the shelf forever because of menopause. We can still be sexual beings; we can still be attractive; we darned well can still have sex.
The movie was a labor of love for Dr. Pam Gaudry, an ob/gyn who specializes in treating older women. After years of consulting with patients in the throes of menopause, Dr. Pam came to realize that of all the difficulties accompanying menopause, the most disturbing to many of her patients was the disruption of their sex lives. Losing this deep and intimate connection with loved partners was the most distressing part of menopause. And she knew that losing sexual intimacy is completely unnecessary.
Dr. Pam wants to educate women about menopause, about how to stay vital, healthy, and sexually fulfilled. She wants to blow up the social stigma surrounding menopause (that we’re dried-up old crones). “Women should look forward to this transition,” she says. “I want them to know what to do to protect their vaginas so they can have exciting, comfortable, and worry free sexual intercourse for the rest of their lives.”
In the film, Dr. Pam travels across America interviewing actors, comedians, clergy, medical professionals, as well as ordinary men and women about love and menopause. Joan Rivers is the headliner, in what turned out to be her last interview before her death in 2014. “I’m on a mission,” says Dr. Pam in her interview with Rivers, “to save menopausal vaginas in America.”
“Well, sign me up,” says Rivers.
Basically, Dr. Pam covers the same ground that we do here at MiddlesexMD because we have the same mission and message. She does it holistically, with humor and a lot of sage advice. “I want women to know why they must protect their vaginas,” she says. “I want estrogen in their vaginas when they’re going into the ground. And no woman should die without using a vibrator.”
Do not hesitate to gather selected friends and family and watch this movie together. For you and your honey, it’s required viewing. A pop quiz will follow.
I wish there were an exact “science of measurement” that would answer your question definitively. The vagina is typically elastic--especially when we’re younger--and will stretch to accommodate any (or nearly any) size required, but there can be male/female matches that are outside of that range.
As we get older, our vaginas become less distensible and less elastic. The tissue itself becomes less elastic as we lose estrogen, and we lose the “pleating” we had when we were younger (I’ve used the analogy of going from a pleated skirt to a pencil skirt). Dilators work by gently and gradually stretching the vaginal walls, making them open enough (called patency) to allow for comfortable intercourse.
Because of the variations in tissue elasticity, atrophy, a woman’s anatomy, and her partner’s anatomy, the goals are comfort and pleasure, not a specific dimension. Dilators come in sets of graduated sizes, so a user can move from one to the next-larger as she gains comfort with each. Some women will progress through the entire range of sizes; others will be satisfied before that.
We offer a variety of dilators, because women’s preferences vary. Our most popular, the Amielle kit, includes five sizes and a removable handle that provides more length for maneuvering. For those who prefer a solid dilator, we offer a six-inch-long option in a set of five or a set of seven, again depending on need. And for some women, the texture of silicone and its ability to be warmed makes the Sinclair Institute set of five their preference.
I hope this is helpful! I’ve very happy to hear that you’re still tending to your sexual health.
Getting old ain’t for sissies, and neither is menopause. For all you guys out there with menopausal partners, maybe you’ve noticed her, um, lack of patience. Maybe you’ve been caught in the crosshairs of her mood swings. Maybe you’ve been awoken at night to her tossing and night-sweat-induced turning.
And maybe she just isn’t interested in sex anymore.
In my practice, I usually hear the woman’s side, but I know you’re an uncomfortably intimate co-pilot on this journey. You may be feeling confused, hurt, rejected, and helpless. This person you thought you knew is changing before your eyes. You don’t know how to help; you don’t know what this means—and it seems to be going on forever.
You miss the sex, the intimacy, the person you used to know. You miss the way things used to be, and you don’t know if or when any of these things will ever come back.
You aren’t alone. Says 70-year-old Larry in this article: “When she got to about 65 it started to change. Intercourse became painful for her and she developed an allergy to semen. Now intercourse is out of the question and she has no desire for anything other than hugs.”
Life—and sex—does change during menopause, but that doesn’t mean you’re doomed to a relationship without intimacy forever. Shifting ground is treacherous, but with some work on both your parts, you’ll weather the storm, and emerge stronger than before.
Here’s what you can do:
Walk a mile in her shoes. Depending on the intensity of her symptoms, your partner is going through moods that may swing wildly without rhyme or reason, and over which she has no control. She may experience uncomfortable and embarrassing hot flashes frequently and unpredictably. She may toss and turn at night, waking soaked with sweat.
She may gain weight, lose her hair, and generally grow old before her own eyes. This can be particularly galling in a culture that is completely besotted with youth and beauty. “A woman’s self-esteem influences her sexuality, and low self-esteem is associated with sexual dysfunction,” according to this article.
What you can do: Educate yourself on menopause. Understand the trajectory and the tortuous path it takes. Read this blog. Learn about comfort measures and possible treatment options. There are many. She may be too embarrassed or miserable to do her own research or even to bring it up.
Armed with understanding, you can reassure and support. You can say, “You seem pretty down [or angry, or forgetful]. Are you okay? What can I do to help?” That alone may make an intimate connection, but this isn’t about sex right now. This is about reaching out to your lover who’s going through one of the most significant transitions in her life.
Now that you’ve asked, listen. And keep listening. Be an ally and a partner in this journey. Check in frequently to see how she’s feeling. Don’t advise unless you’re asked. Just listen. If she talks with her girlfriends, fine. But let her know you’re in her court. Most important—reassure her that she’s still beautiful to you. Girlfriends can’t do that.
Follow up with actions. Don’t sit on the couch while your partner makes dinner and then watch the game while she cleans up. Nothing says love like taking out the garbage or doing the dishes so she can take a bath. Once in a while, go out of your way. Cook a special, romantic meal. (You can order from one of those home-delivered meal plans, like Blue Apron or HelloFresh.) Send her flowers or plan a surprise getaway weekend. No expectations; no pressure—just an expression of your love and caring.
Get healthy. I harp on this all the time, but both you and she will feel a whole lot better (and feel more like sex) if you’re eating healthfully, maintaining a good weight, and exercising. You can gently encourage walks together, healthy eating, and good sleep habits. Don’t be a drill sergeant, but your good example and attempt to make it a couple’s thing can’t hurt.
Shake things up. Boredom is a slow leak in the sex balloon. I’m not talking about having sex on the kitchen table. But just exploring the array of tools and props that can add sizzle and simple comfort to the routine. Since your partner is probably experiencing the common menopausal complaints of dry vaginal tissue, painful sex, loss of libido, you’ll have to shake up the routine anyway.
You’ll need lots of foreplay, lots of lube, and some toys. Try reading an erotic story or watching a sexy movie together to get your heads in the game. Don’t downplay the effect of a romantic ambiance—candles, incense, music. Use pillows to cushion joints and prop up the bits that matter. Try positions that might relieve pressure, offer a different kind of contact, or just be more comfortable.
Take your time and maybe forgo the literal act if the timing’s off. You can kiss, cuddle, spoon. You can use your tongue and mouth. You can masturbate together. Take the pressure off the performance and focus on trust and intimacy.
Don’t take it personally if she just doesn’t respond the way she used to. It isn’t about you, and it isn’t personal.
Find a counselor, if necessary. Generally, celibacy isn’t a healthy state in a marriage. If you’ve reached an impasse, and there’s no way out, you may have to get some help. This isn’t an admission of defeat; it’s a sign of maturity and wisdom to look for help when you need it. If your wife won’t go, you need to find a therapist for yourself to acquire the emotional tools to navigate your relationship.
I’ll leave you with the beautiful and encouraging counsel from the perspective of a 40-year marriage: “…we have found ways to enjoy sex with each other that do not need penetration. Mutual masturbation and oral and always with some nice foreplay, we still enjoy each other.
“I miss intercourse…but we make it work, and it’s usually fun! I hope some men will read this and decide there’s a way to stay happy with the woman of your youth.”
Lots of attention has focused on the finicky female orgasm in recent years, from Dr. Rosemary Basson’s model of the female sexual response cycle to the helpful finding of just how female anatomy influences the probability of vaginal orgasm.
A new study from Chapman University, Indiana University, and the Kinsey Institute colored in some details of female sexual response, in part by rounding up a wide net of participants. Over 52,000 men and women between the ages of 18 and 65 responded to an online survey, including a more robust sample of those who identify as gay, lesbian, and bisexual.
The take-away from all this analysis was the jaw-dropping finding (tongue in cheek) that men (95 percent) orgasm dependably, while women, not so much (65 percent). About 44 percent of women said they rarely or never reach orgasm with vaginal intercourse alone, a number that is quite low compared to other studies suggesting that fully 70 percent of women don’t orgasm with vaginal penetration. These numbers point (again) to some very significant differences in sexual response, which in turn, lead to significant misunderstanding between Venus and Mars.
“About 30 percent of men actually think that intercourse is the best way for women to have orgasm, and that is sort of a tragic figure because it couldn’t be more incorrect,” said Dr. Elisabeth Lloyd, a professor of biology at Indiana University and author of The Case of the Female Orgasm in this article.
Additionally, while 41 percent of men think their partner orgasms frequently, far fewer women (33 percent) say they actually do orgasm. The researchers note that this difference could be due to women faking orgasm for several reasons: “to protect their partner’s self-esteem, intoxication, or to bring the sexual encounter to an end.”
The researchers were particularly interested in the disparity between how dependably lesbian women orgasm (89 percent) versus heterosexual women (that 65 percent figure). They theorize that this is due, in part, to women having a better anatomical understanding of each other’s needs.
The headliner result of all those survey is a “Golden Trio” of sexual moves that the researchers say are almost guaranteed to induce the Meg Ryan-style “Yes! Yes! Yes!” in women: clitoral stimulation, deep kissing, and oral sex. Even without vaginal penetration, 80 percent of heterosexual woman and 91 percent of lesbian women were able to orgasm dependably with this magic trio. (Although deep kissing and oral sex seem either mutually exclusive or tremendously acrobatic.)
The research noted that women who orgasm more frequently also have sex more frequently and are more likely to be satisfied with their relationships. Whether satisfying sex is the chicken or the egg—a contributor to a satisfying relationship or an effect of a good relationship, it’s safe to say that the two go hand-in-hand. Good sex and good relationships are both enhanced when partners communicate about what works and include a healthy dollop of fun and flirtation.
“I would like [women] to take that home and think about it, and to think about it with their partners and talk about it with their partners,” said Lloyd. “If they are not fully experiencing their fullest sexual expression to the maximum of their ability, then I think our paper has something to contribute to their wellbeing.”
You say that you and your partner use manual and oral stimulation, since you’re no longer able to have intercourse. Your partner requires extended stimulation, and you’re wondering what might help.
Stronvivo is a nutritional supplement developed for men’s cardiovascular health; it’s been found to significantly improve sexual health--because circulation is integral to arousal and orgasm. It is used for both male and female sexual health, improving both desire and function (ability to arouse and orgasm). I’ve had many women report improved ability to orgasm, and the clinical trials report the same for men.
The other factor to consider is medications that may be interfering with orgasm, or hormonal factors, like low testosterone. I’d strongly recommend a conversation with his physician, if he hasn’t already had one, to see whether there are health factors to consider.
Not much is known about addiction to pornography, not the numbers of people affected; even the definition is hazy. There just isn’t a body of research surrounding the issue.
"There is a real dearth of good, evidence-based therapeutic literature," says Dr. Valerie Voon, a neuropsychiatrist at the University of Cambridge in this article.
The relatively recent advent of the Internet has revolutionized the world of porn, serving up raw, unfiltered, hard-core, and nonstop stimulation. The result is a cohort of (mostly) men who have become addicted and desensitized to the dopamine rush of a constant barrage of online porn. Occasional porn consumption is common, but therapists and doctors are seeing more relationship and sexual performance difficulties among heavy porn users—behavior that looks a lot like addiction.
Discovering that your partner uses porn addictively is a crushing, confusing experience. Women compare it to the betrayal of discovering an affair, except that the “other woman” is a computer screen that is available 24/7 and that doesn’t look or act like a normal woman.
A partner’s initial response is often denial: Is it really so bad? Doesn’t everyone view porn sometimes? Is this normal?
The morality or “normalcy” of porn use is a different conversation, but when a partner becomes secretive and withdrawn, when he can’t stop the behavior even at work or, as one woman discovered, during a weekend visit to her parents; when porn use creates difficulty in real-life sexual performance; when it causes pain and conflict, then it’s an addiction and it isn’t normal.
Porn addiction is socially anathema—people don’t talk about it or easily admit to having a problem with it. Support groups for partners of porn addicts are rare. And research-driven treatment for porn users themselves is also rare. The most common treatment is called a “reboot” in which porn users are counseled to stop masturbating to online porn until their brain chemistry and ability to engage in real-life sex is regained, which may take months.
The behavior of porn addicts is similar to other addictions. They minimize their porn consumption or outright lie about it. They may accuse the partner of causing the problem. They withdraw and hide what they’re doing. They may gaslight—a newly vogue term that refers to undermining the partner’s grasp on reality by lying, evading, bullying, and blaming.
This dynamic is devastating and toxic. Partners of porn addicts are often recognized as having symptoms of PTSD-like trauma.
The non-porn-using partner may try to control “the addict’s access to porn through anger, snooping, crying, guilt tactics, threatening, shaming and blaming the addict. This destructive behavior was once considered co-dependent, but those of us who work with partners of porn addicts now view these actions as symptoms of trauma,” writes Mari A Lee, sex addiction therapist and co-author of Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts.
As with any addiction, the path to recovery is difficult and riddled with relapse. The harrowing challenge to a partner of a porn addict is to maintain her own integrity and emotional health while offering her partner forgiveness and the space and support to manage his recovery, if he so chooses.
Women who’ve been there say:
A partner’s addiction may be one of the most painful and difficult knuckle sandwiches that life can smack you with. It attacks the very foundation of trust, security, and intimacy that a relationship is built on.
However, there is hope, both for your own healing and the recovery of your partner. “When each person makes the choice to end the destructive dance of addiction, blame, shame and hurt, and instead chooses to move toward healing and recovery – miracles can happen and relationships can heal,” writes Lee.
A patient came to see me a few days ago. She had been in a sexless marriage for years—and she had recently discovered at least part of the reason. Her husband was addicted to pornography.
This is more common than you think. It’s also not a simple problem.
Lots of people—men and women—consume porn at least occasionally. Estimates range from 50 to 99 percent of men and 30 to 86 percent of women—numbers that are so broad and vague as to only suggest “a lot.” Women tend to watch porn with their partner and to consume softer types—erotica might be a better term. Women usually report feeling greater intimacy with their partner after viewing porn.
Men tend to consume porn alone, and it portrays sometimes aggressive and sometimes deviant forms of sex. A heavy diet of this can cause them to withdraw from intimacy and to feel "increased secrecy, less intimacy and also more depression," says Dr. Ana Bridges, a psychologist at the University of Arkansas in this article.
Porn has been around since time immemorial. What’s changed is the amount and type of porn that’s available online all the time. We aren’t talking about the Playboy or Hustler magazines from a previous generation. This is hard-core, porn-on-steroids content served up in any flavor to satisfy the wildest imagination. These aren’t normal bodies, it’s not real sex, and it’s available any time, day or night.
Although the scientific community has been hesitant to label such consumption as an addiction, and although many people, perhaps most, view porn occasionally without guilt or moral quandary, plenty of anecdotal evidence suggests that a problem is brewing.
Whatever you call it—addiction or compulsion—when an activity becomes uncontrollable and consumes many hours; when it affects performance at work, compromises intimate relationships, and physical or emotional health, then it’s a problem.
Therapists and doctors are increasingly seeing patients who report less interest in sex and sometimes an inability to have sex in real life. Erectile dysfunction is showing up in greater numbers, especially in young men who began viewing porn while still in their teens.
Or, like me, healthcare practitioners are hearing from confused, distraught partners who don’t understand what’s happening to their partner and to their relationship.
The mechanism that creates the problem is only beginning to be studied and understood. Consuming porn many times a week over a period of months (or years) is a solitary, alienating, guilt-inducing pastime. It frequently changes the way a person interacts sexually with a partner in real life—the person is often more impersonal, distant, and sometimes rough or demanding. Sometimes the person withdraws from the partner altogether.
Heavy porn viewing actually changes brain chemistry. In a small but carefully conducted study, a group of German researchers determined that high levels of porn consumption results in a shrinkage of gray matter in a specific region of the brain. Researchers were unsure whether this reduction was caused by the “wearing and downregulation of the underlying brain structure” due to hours of porn consumption or whether the subjects consumed porn because they had less gray matter in this area to begin with and needed more stimulation to experience pleasure.
Generally, however, the hypothesis is that heavy porn consumption desensitizes the viewer, so that more intense levels of consumption are required to reach the same level of satisfaction. “You need more and more stimulation as you build up this tolerance, and then comes your reality with a wife or partner, and you may not be able to perform,” said Dr. David Samadi, chairman of urology at Lenox Hill Hospital in this article. “It’s a problem in the brain, not the penis.” As such, drugs for erectile dysfunction, such as Viagra, aren’t effective. The penis may engorge, but orgasm doesn’t follow.
Obviously, ongoing porn consumption is problematic for a relationship. It can persist for years, with trust and sexual intimacy almost inevitably becoming collateral damage. The situation is confusing, hurtful, and debilitating to a partner, in part because the issue is so socially unsavory and so rarely discussed.
I’m thinking it’s time to crack open the door and begin talking about porn addiction, how to recognize it, and what a partner can do about it.