Head over Heels: A Little Primer

In the last post, I ran up the flag for oral sex—mostly as a way of keeping our repertoire broad and deep as we and our partners face age-related issues with sexual sensitivity and/or function. After all, there are many ways to skin this particular cat.

But, as with any kind of sex, a little technique and creativity can put some spice into what too often devolves into a boring routine. All the tricks in the world, however, can’t take the place of communication and some interest and even excitement about the task at, um, hand.

Some level of communication is fundamental to sexual play and exploration. You can encourage: “I love it when you do that.” You can ask: “Does this feel good?” “What would you like better?” And you can pay attention to non-verbal cues: breathing, muscle tension, sounds, movement.

I’d also like to emphasize that, while it’s good to push your boundaries, if any part of sexual exploration feels really uncomfortable or off-putting, you don’t have to go there. We all have lines, and it’s important for both partners both to draw them and to respect them. But don’t just draw lines, continue to look for ways to keep the intimacy alive.

I’ve had women tell me that fellatio (oral sex on men) gave them a sense of empowerment, because they were controlling the action. By the same token, it gives the guy a break—he’s not in charge, plus he still has a good view of the action, which can be its own kind of turn-on.

With loving attention and communication on the front burner, here are some ways to change up your oral sex technique.

  • Take it slow. Don’t go for broke right away—let momentum build. Start with sensitive areas at the periphery—belly, inner thighs, buttocks. Use light touch, blow, kiss, lick. Take your time.
  • Move in. When you get to the genitals, keep the action soft and slow at first. Cup his testicles in your hand or mouth. Slide your tongue up the shaft of his penis. The frenulum is a particularly sensitive spot on the underside of the penis where the shaft meets the head. Tease a little before you commit.
  • Take a break. If your jaw gets tired, use your hands or your tongue to keep the action going.
  • Cool off. For a surprising change of pace, take a drink of ice water. The change of temperature is startling.
  • Heat and spice. Don’t keep doing the same old thing while you’re in warm-up mode. Use different sensations, change the speed and the rhythm. Build up to a firm, steady rhythm. Even if he isn’t totally erect, he can still orgasm and ejaculate.
  • Avoid the gag. You don’t have to deep-throat. Use your hand on his shaft and only take the head of his penis in your mouth. Then, you can suck or use your tongue creatively while stroking the rest with your hand.
  • Swallow—or not. You’ve probably already settled this, but if you don’t want to swallow his ejaculate, you can tell him to warn you just before he comes.
  • Hold him gently afterward.

Of course, the need for skill and technique apply equally to cunnilingus (oral sex on female genitalia). If your partner could use some coaching, slip him the highly rated “essential guidebook to oral sex,” She Comes First: The Thinking Man’s Guide to Pleasuring a Woman by Ian Kerner.

Women whose men have taken it to heart (and to bed) give it rave reviews.

Kerner also has a female guide to men’s sexuality, which includes pointers on oral sex: Passionista: The Empowered Woman’s Guide to Pleasuring a Man.

Now that you have your required bedtime reading, maybe you want to give each other an occasional pop quiz.

"Eating at the Y": Why It's a Good Thing

I may be going out on a limb here, but I’d like to make a case for oral sex. It gives us another avenue to intimacy and pleasure, and as such, is an important component of a lusty love life. It’s a skill that couples should try to develop. Or at least keep an open mind toward.

Here’s why.

First, most women (70 percent. Did you get that number?) don’t climax with vaginal penetration alone. In my practice, postmenopausal women commonly tell me that the only way they can orgasm is through clitoral stimulation or oral sex.

For all women, no matter the age, the most dependable orgasm is clitoral—which, as we’ve said before, is a powerful organ with twice as many nerve endings as the penis.

Sure, the clitoris (and the penis) can be stimulated in many creative ways, but the mouth and tongue are darned effective.

Second, I know I sound like a broken record, but we lose sensitivity and the ability to lubricate vaginally as we age. And our partner’s ability to maintain an erection will eventually wane as well, despite the little blue pill. As the old penis-in-vagina sex becomes less dependable, it’s helpful to have other tricks up our sleeve.

Oral sex is one way to keep sexual pleasure alive as a couple. No less venerable an institution than the AARP says so in this article. It makes sense to give ourselves alternatives and room for compensation, so that when one capability diminishes, another can fill in the gap.

Now, I’m not for a minute suggesting that you haven’t tried oral sex. Sex coach Kathleen Baldwin, says that “It’s somewhat rare in my experience to find a woman over 40 who doesn’t enjoy oral sex.” She thinks that mature women are less influenced by cultural norms and are more familiar with how their bodies function, including their lady parts.

For many women, however, the “yuck” factor presents an impediment. Some women consider their genitalia “gross.” They worry about cleanliness or odor. They worry that it will take them too long to climax.

Funny thing is, most men really like oral sex—both giving and receiving it. I ran across an article by a man on the topic, who writes:

It’s an amazing feeling to satisfy a woman, and cunnilingus is the most foolproof way to do it. It also minimizes our own performance phobia. Women can’t see what we’re doing, our tongues will never need Viagra and we’ve all got a similarly sized piece of equipment. But most of all, [cunnilingus] is a five-sense experience that places us up close and personal in a way that no other act can. …most vaginas smell and taste pleasantly mild…

The pleasure you can give your partner (and ultimately yourself) may be worth getting over any squeamishness. And you can always address the cleanliness issue by showering (or a bath!) before sex.

Oral sex, whether cunnilingus (oral sex to a woman’s genitalia) or fellatio (oral sex to a man’s genitalia) works best with some technique, and like any other skill, practice makes perfect. The most direct path to improvement is communication. You have to let your partner know what feels good. (More on technique in the next post.)

One final consideration: if you aren’t sure about your partner’s status with regard to sexually transmitted disease (STDs): you can still transmit them with oral sex. Chances of infection are lower, but Chlamydia, gonorrhea, herpes, human papyllomavirus (HPV), even HIV can still be “caught” through oral sex. For example, one woman I know caught genital herpes from a cold sore on her husband’s mouth!

So, if you’re with a new partner and you aren’t completely knowledgeable about his or her sexual history, you need to use protection—a dental dam (piece of latex placed over the vulva) condom, or femidom (female condom).

Kind of takes away the sexy, but it sure beats the alternative.

Oral sex is just another way of expressing intimacy and sharing pleasure. And it’s a particularly nice option if more traditional forms of lovemaking become problematic. Well, heck. It’s a nice option any time.

September 22, 2014

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back pain ›   Condition News ›   sexual intimacy ›  


Common-Sense Tips to Ease Back Pain during Sex

Whether you have a little twinge or serious back pain during sex (and who doesn’t now and then?), these preventive measures can help ease the pain.

Explain the problem. Don’t leave your partner in the dark. Chances are, if you seem unwilling to have sex, your partner may interpret that as rejection. That’s almost as painful as back pain.

It’s hard to admit to physical limitations, especially in the sexual arena, but this is one of those topics that need airing. Then, it’s possible for your partner at least to understand the issue and more likely to become an ally in the search for solutions.

Medicate. Take an ibuprofen-type medication before sex. Or discuss using another pain-killer with your doctor.

Prepare. If your muscles tend to spasm, a hot shower before sex and cold compresses after could help. Or work a little massage with painkilling cream into your foreplay.

Innovate, don’t stress. Take your time. At this stage of the game, sex is more about connection than athletics. It’s more about enjoying the moment than setting off fireworks. Depending on the type of pain, try positions that support your back and reduce spinal movement. Experiment with support pillows to see what keeps you both comfortable. Or switch to other types of pleasuring if things get too gnarly.

September 18, 2014

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back pain ›   Condition News ›   sexual intimacy ›  


New Research Addresses Pain-in-the-Back Sex

Connect the dots for me here:
  • Research consistently ranks good sex as an important component of quality of life.
  • Back pain is a serious deal-breaker to good sex because when your back hurts, sex does too.
  • About 31 million people suffer from low-back pain in the US, according to the American Chiropractic Association.
  • From 34 to 84 percent of those people have sex less frequently, depending on what study you read.

Ergo, if you suffer from back pain—and a whole lot of people do—you’re probably having sex less and enjoying it less, as well.

That’s a lot of lost quality of life.

Now, for the first time, a group of researchers from the University of Waterloo in Canada actually studied how the back moves during sex, adding some hard data to support, and in some cases, debunk, the common advice doctors give their patients.

The first phase of this research focused on how the spine moves in a normal, healthy male during sex. To do this, lead researchers, Natalie Sidorkewicz, MSc, and Stuart McGill, M. PhD, recruited 10 heterosexual couples who did not have back pain.

Then they wired them with reflective sensors and told them to “move as naturally as possible” in five different sexual positions: two versions of the missionary position, two versions of the “doggy-style” position, and “spooning” or side-lying (the most common position recommended for people with back pain).

The researchers analyzed the data and identified the positions that were most “spine-sparing”—involving less movement—for different types of back pain.

Some people—and this is more common with age—experience back pain when they sit or bend forward. This is “flexion-intolerant” back pain. The best position for the flexion-intolerant is the quadruped or a missionary position with the male on his hands.

A second type of back pain is called “extension-intolerant,” which means that lying on the back or stomach is painful. For this type of back pain, spooning may be a better position.

For some people, any movement causes back pain, and for these “motion-intolerant” types, sex remains challenging. In general, however, movement (and pain) is lessened when it is shifted to the hip and knee, as in the quadruped position when the female is on her elbows.

With any of these positions, small adjustments—whether a person is on elbows or hands, for example—significantly changes the amount of back movement involved.

The best option for the person not controlling the movement (the females in this study) is to keep the spine in a neutral position, by supporting the small of the back with a pillow in the missionary position, for example.

A chart illustrating the best position for different types of pain is here.

Future research will focus on female back movement during sex and how the spine is affected by orgasm. The researchers also want to study the effect of various positions for actual back pain sufferers.

All this is the beginning of good news for people with back pain. Previously, medical recommendations have relied on “conjecture, clinical experience, or popular media resources,” according to the University of Waterloo study. Hard data is a welcome addition.

Researchers also hope their work will spark more dialog between patients and health care providers about sex, now that practitioners have real research to refer to in discussion with patients with back pain.

Women Suffer from Erectile Dysfunction, Too

We received this submission from UK-based kindred spirits, looking to maintain intimacy for women--and their partners--just as long as they choose.

Erectile dysfunction affects millions of men in the UK and there is often embarrassment surrounding the issue. Erectile dysfunction is when a man cannot get or maintain an erection which makes engagement in intercourse impossible. In fact, the NHS estimate that 50 percent of men aged between 40 and 70 will suffer from erectile dysfunction at least once in their life.

The main causes of erectile dysfunction are both psychological and physical. Sometimes hormones can be the problem, as can high blood pressure and high cholesterol which cause the blood vessels to narrow and sometimes erectile dysfunction can occur as a result of surgery or an injury. Not only can erectile dysfunction be a symptom of other health problems, it can also be the cause of psychological effects. Erectile dysfunction can have a serious effect on a man's mental well-being, because it can damage his self-esteem. However, the relationship between erectile dysfunction and psychological issue can be seen as a vicious circle; not only can erectile dysfunction be the cause for reduced self-esteem and depression, but anxiety and depression are also listed as common causes of erectile dysfunction.

It's not just men who are psychologically affected by erectile dysfunction, either. Women can get emotionally hurt when their partner is unable to get an erection or maintain one, because they blame themselves and think they could be doing something differently to help their partner. Sometimes women feel rejected when their partner suffers from erectile dysfunction, assuming that their partner can't get an erection because they are not adequately aroused.

Of course this does not help make the situation any less stressful for the male suffering from erectile dysfunction and the situation is often made worse. Relationship problems can often occur as a result, because tense situations arise and couples are too embarrassed to talk about the issue.

According to clinical psychologist Mark L. Held, PhD, the best thing to do is talk about erectile dysfunction before it becomes a strain on the relationship. Held says discussing the issue is crucial because:

“Almost all men have erectile dysfunction at some point... it’s how they deal with it that counts.”

Sex therapy can be an effective solution for couples whose relationship is suffering as a result of erectile dysfunction. A qualified therapist can help couples talk through the issues that have arisen, as well as help them identify and work through the psychological reasons that are causing it in the first place.

There is a plethora of medications that can help against erectile dysfunction. Perhaps the most famous one is Viagra, but there are now many more that work better for different patients. In any case, sufferers should discuss the issue with their doctors to determine if and which medication is appropriate for their case.

For some help in responding when ED's been countered, see our blog post, "He's Got His Groove Back. O Happy Day?"

Q: What is my "vaginal cuff"?

As you suspected, the "vaginal cuff" is the healed incision at the top of the vagina after the surgical removal of the cervix and other pelvic organs.

The vagina is just as functional as it was before surgery, but the depth is unpredictable. The tissue is somewhat elastic and stretchy–comparable to the inside of your cheek when you poke your tongue against it. If there seems to be less depth than you (and your partner) need, using dilators can gently and gradually stretch the tissue to a new capacity.

An intravaginal vibrator (like the Liv2) may be helpful to you as you determine what your needs and your new reality are. Sincere congratulations on achieving remission from the cancer for which you were treated, and best wishes as you rediscover your sexual self!

Good Sex, Grandma?

Perhaps you’ve seen reviews of a new book, called Sex After…: Women Share How Intimacy Changes as Life Changes. It’s definitely in my reading pile. The author, Iris Krasnow, interviewed 150 women from 20 to 90 about their sex lives.

The surprise—to Iris and some reviewers—was that the women in the later chapters were claiming some of the best sex of their lives. Among the comments:

We are so comfortable with each other that we will try anything to keep things hot.
When you’re younger, it’s all about the orgasm, then it’s over. I love this suspended feeling, the absolute intimacy we have been able to achieve.

Given my conversations with patients in my practice, I’m not surprised. There’s a whole lot of life after 50, and a whole lot of pleasure.

Two things typically get in our way: First, just as our kids never wanted to know we had sex (mine are adults and still don’t want to know!), we’re culturally just a little uneasy with grandparents having sex. Silly, but there it is.

And second, we could do a better job of sharing information about how to keep sex comfortable for just as long as we want it—and expanding our thinking about what “sex” means as intimacy beyond vaginal intercourse.

Most of the women I see are interested in being sexually active—I am, after all, a gynecologist. Every now and then, though, a woman will tell me, “We’re done with all that. And it’s okay.”

I think it’s awfully hard to tease out how we really feel about that “okay”: If it’s not cultural messages that we’re too old for sex, it's a cultural message that we need to keep at it to stay young. For many of us, the discomfort we may now experience with sex is enough to sway us toward that “too old” message.

But beyond the effect on relationships I’ve talked about before, what I hear from the women in this book echoes my own experience: Sex is part of feeling alive, powerful, energized, secure, blissed, refreshed. I’ll decide for myself when I’m ready to give that up.

And you can, too.

Q: Is emotional intimacy really necessary for good sex?

Let's first acknowledge that women—and men, too—come to sex with a host of different backgrounds, value sets, cultural expectations, emotional foundations, and experiences. It's very difficult, given that variety, to assert that anything is or should be true for every woman.

It is theoretically possible to have a strong physical attraction and enjoy sex with little emotional intimacy involved—whether we are men or women. There are differences between us, though: Research suggests that for women there are six neurotransmitters involved in sexual activity, and that the areas that "light up" in our brains with sex are completely different from men's responses. Women release oxytocin with sex, a very strong bonding hormone; men don't.

Cultural stereotypes may exaggerate the differences between men and women when it comes to sex, but the science is there to prove there are differences.

Among the women in my practice and in the rest of life, I observe that women often go into sexual experiences with an expected outcome that includes some emotional connection. Most of the women I see desire emotional intimacy as a cornerstone for their enjoyment of physical intimacy. And the study I recall that went the furthest in qualifying sexual enjoyment ("A Portrait of Great Sex") implied emotional intimacy as intertwined with physical intimacy.

All of that said, I come back to the fact that women come to sex with enormous variety of experience and expectation. As long as she is caring for her own emotional and physical safety and health, each woman can choose, I hope, the right combination of emotional and physical intimacy.

What Subtracts More than It Adds?

That sounds like a bad riddle, right? Like one I heard on NPR last week: What goes up a hill and down a hill but doesn’t move? The answer to that one is a road. And the answer to what subtracts more than it adds is sex.

Sex after Sixty bookHere’s the disturbing—but not, when I think about it, surprising—statistic I ran across this week, courtesy of colleague Sheryl A. Kingsberg, a PhD and chief of the Division of Behavioral Medicine at the University Hospitals Case Medical Center: “When sex is good, it adds 15 to 20 percent additional value to a relationship. When sex is bad or nonexistent, it plays in inordinately powerful role draining the relationship of positive value—about 50 to 70 percent!” I was so struck by that statistical picture, I’m on the trail of the original research to understand more. But in the meantime, what I know from other studies—and my own experience and conversations with women—suggests that’s about right.

Let me first say that good sex doesn’t automatically make a relationship good. And a good, loving relationship doesn’t automatically mean that the sex will be good. But if I think back to a study done a couple of years ago, “The Components of Optimal Sexuality,” I’m reminded of how many of the characteristics of good sex are also characteristics of good relationships. I won’t revisit the whole list, because you can read the series of detailed blog posts we did on each of the components. But here are just a few that come to mind in this context:

  • Being present. It’s so easy to take our partners (and, of course, others in our lives) for granted. Truly paying attention to one another—today—is a great gift.
  • Connection. When we feel connected to our partners, intimacy comes naturally (especially when we’re overcoming obstacles together). If you’re feeling “together but alone,” there are steps you can take.
  • Authenticity. At this point in our lives, I find that many of us are more willing than ever to own what we think and feel. Whether we’re in longstanding or new relationships, this helps us to be ourselves—and to be open about what we like and need, in the bedroom and the rest of life.
  • Vulnerability. Having sex is perhaps the ultimate act of making yourselves vulnerable to each other. What a reinforcement of the bond that a couple has with each other!
If those parts of your relationship are important to you, too, you’ve got more reason to understand how to stay healthy and be intentional about nurturing this part of your life.

What Is a Happy Marriage?

A couple of weeks ago, I talked about an article I’d seen about how sexual intimacy is linked to marital happiness. The research, by Adena M. Galinsky and Linda J. Waite, found that continued healthy sex-lives help couples dealing with physical illness, especially chronic health problems.

Couples who had sex frequently (and sex was defined broadly—it didn’t need to include vaginal intercourse) were more likely to say they had a good relationship.

"Happiness, not in another place, but this place... this hour."This is, of course, a chicken and egg: More sex doesn’t automatically make a relationship good. It’s more likely—and perfectly reasonable—that an unsatisfying relationship will include less sex. And the women I meet through my practice as well as the rest of life show me that this is often a time when our relationships get some re-evaluation.

Sometimes it’s the empty nest, and the change in schedules and priorities that comes with it. Sometimes it’s retirement, for one or both partners, which means a lot more together time. Sometimes it’s the stress of caring for aging parents along with everything else. Whatever the prompt, when some of us look at our relationships, we say, “Is this really what I want?”

So it was interesting to me to read the details of the Galinsky Waite study, to see how they measured the quality of relationships. These are the questions they asked:

  • How close do you feel your relationship with your partner is?
  • How often can you open up with your partner if you want to talk about worries?
  • How often can you rely on your partner for help with a problem?
  • How often does your partner make too many demands?
  • How often does your partner criticize you?
  • How happy is your relationship with your partner?
  • Do you like to spend your free time together, separately, or some of both?
  • How emotionally satisfying is your relationship?
  • How often does your partner get on your nerves?

If you’re feeling some vague discontent, those questions might help you with a conversation with your partner—or with a couples therapist if you decide some outside perspective and coaching would be helpful. If you’re feeling angry, or resentful, or isolated in your relationship, it’s no surprise that you’re not feeling sexy.

And you deserve to.