Q: Should I be comfortable with anal sex?

Estimates say that up to a fifth of heterosexual couples have anal intercourse at least intermittently, more rarely exclusively.

The risk of sexually transmitted infections is the same or perhaps higher with anal than with vaginal penetration. There's more likelihood of trauma, since anal intercourse requires complete relaxation of the rectal sphincter muscles before penetration. Trauma or injury to those muscles can lead to loss of muscle tone or control. That makes this form of intimacy not entirely "safe," but, more importantly, consent freely given by both partners is an essential feature of sexual activity in a loving relationship.

You asked whether this was a new phenomenon and whether you were "too old" to adapt! I don’t think it's new (or, at less than 20 percent, a phenomenon), but our notions about sexuality and what's "typical" or even erotic are very complicated and influenced by many factors. You may never become comfortable with this form of intimacy, but you are never too old to explore options and be open to new sexual techniques.

Vibrators for Two

My conversations with patients, blog readers, and visitors to MiddlesexMD tell me that once a person’s gotten past her own discomfort with the idea of a vibrator, there can lurk another obstacle: How to introduce it to intimacy with a partner.

I’ve heard from both men and women on this topic: Both have asked how to introduce a vibrator into a relationship or how to overcome resistance. A recent study done at the Center for Sexual Health Promotion at Indiana University suggests some couples have figured it out. Half of both men and women have used a vibrator with a partner at least once. Slightly more men than women agree that vibrators can make sex with a partner more exciting, but for both the number is close to 60 percent.

And we know from other research that about two-thirds of women don’t experience orgasm with penetration alone; the IU study says half of women agree that a vibrator helps.

But in spite of that evidence that couples are using vibrators, and that women find them satisfying, there’s still resistance. I talked to Mary Jo Rapini, psychotherapist and one of the MiddlesexMD advisors, to learn more.

The first issue for some women is their preconceptions, Mary Jo says. “If you think of vibrators—or any other part of sex—as ‘creepy,’ you’re showing resistance. Resistance is a product of your own thoughts, which means you can change it and open yourself up to communication and growth. My first request would be that she use the word ‘uncomfortable.’ This opens up a wonderful conversation—if you’re uncomfortable with something, you can add something else to lovemaking, and not necessarily all at once. You might not be comfortable with a vibrator, but you may like being massaged during lovemaking with wonderful massage oil. Lovemaking is exciting and it’s so healthy for the heart, immune system, and hormone levels; I encourage women—and couples—to try new things, slowly, without rejecting the concept of lovemaking with new items.”

“Women are sometimes reluctant to own their own sexuality,” Mary Jo says, which works against introducing a vibrator—and other things—into a couple’s intimacy.

“Men are so visual in regards to sex,” Mary Jo says. “Many men enjoy watching their partner masturbate with a vibrator—especially if their partner is able to enjoy it. Men love watching the woman they love enjoy sex. They also want to please the woman. When the woman is able to let the man hold the vibrator for her, or use it gently on him, he begins to see the benefits.

“He may feel rejected if she prefers the vibrator to him, but including him and showing him what feels best being touched is a big turn-on for men. If she can talk about what feels good, how she likes to be touched, the intimacy will be a thousand times stronger.”

The IU study, by the way, confirms that seventy percent of men don’t find a vibrator intimidating during sex.

But that may be beside the point. The real focus, Mary Jo says, is something different: “Sex is not about the penis or vagina, but your ability to let go, explore, and broaden your awareness and understanding of your sexual self—and your partner. Being able to express yourself sexually and feeling safe and secure in that relationship heightens your health both physically and emotionally.”

We'd love to hear your experiences and questions!

Q: How can I increase our success using a vibrator?

I'm glad to hear that a vibrator has been helpful to you! Women our age often need extra stimulation for arousal and orgasm, and many find that a vibrator provides just what they need. If you're looking for more, here are some things you might consider:

  • A stronger motor: Not all vibrators are created equal. Check for motor strength, because it really does matter to midlife women: a stronger motor means more stimulation. You can also check for the number of pulse patterns offered; there's nothing magic about them, but they make experimentation easier.
  • Get versatile: If you've started with an external clitoral vibrator, you might want to try a vibrator that can be used inside the vagina, too.
  • Size differs: You'll notice I didn't say that size matters, but different sizes do offer different sensations. Models very in shape and dimension, the Raya for example is a slender model, while the Gigi 2 has a larger tip.
Finally, stay playful and stay connected to your partner when you're being intimate. While vibrators are great as both tools and toys, especially for us as women, the emotional connection is arousing, too!

Sex and Cancer: The Body

Here is the second part of our talk with Mary Jo Rapini, a therapist who specializes in intimacy counseling (the first part focused on the mind). She often receives referrals from oncologists who have treated women and men for cancers that, post-treatment, require a re-thinking, re-learning, re-framing of their intimate life. Says Mary Jo:

When a couple is referred to me, it’s usually because the cancer part of their life is now under control. That is, they have their diagnosis, understand staging, and have been receiving treatments, with some evidence that treatments are working. Until that point, survival is the critical concern for most couples.

This time of diagnosis and sheer survival can actually bring couples closer — they realize that what they used to argue about is petty. On the other hand, really bad relationships will many times get worse. Women who are sick might ask themselves what they're doing, what happened in their relationship. When that’s the case, my first step is figuring out the emotional environment. Where is this couple now, at this moment in time?

When we do come around to talking about intimacy in the relationship, my first concern is with pain. Painful sex is a really common problem for survivors. Low energy is another problem. People receiving treatments or recovering from extensive treatments have very low stores of energy.

Women recovering from surgery and radiation for any kind of cancer, including breast or uterine cancers, may be adjusting to new losses and scars that affect body image, sensation, mobility, or all three.

And while thinking about restoring sexuality may be pretty far from her mind, the truth is that reengaging with a lover has been shown to really help with recovery. Sex is very healthy—for our bodies and our minds—and a loving intimacy is certainly one of the best things we have to live for.

Get help. Your intimate life may have been perfect your whole lives, your relationship sound, your commitment to one another unshakable, but still a good counselor can give you things to think about, assignments and exercises that can help you to re-engage after harrowing course of treatment. Consider it a gift to yourselves, a reward for surviving.

Planning is everything. Spontaneous sex was great when you were teenagers, but now things are different. Intimacy is best now when it is anticipated and planned. Choose a day of the week when nothing much else is going on. Choose a time in that day when you are likely to have less pain. Be sure you have an hour of pain medication in your body before engaging in cuddling and caressing.

Set a new goal. Sexuality is often so goal-oriented we forget that sex is good for more than just orgasm. When orgasm is difficult to reach—for either of you—why not take it off the table and enjoy the benefits of sexual intimacy without it? Massaging erogenous zones is extremely pleasurable—provided there is no pain—whether we achieve orgasm or not. It still circulates blood, increases healthy hormone production, and helps couples bond to one another. Set a new goal: bonding and intimacy. Use that vibrator to make one another purr, and let purring be enough for a while.

Become a prop master. Pillows, pillows, pillows. If you spend any time in a hospital, you will notice that nurses really know how to use pillows to prop people into comfort in bed. Well, we can use them too, to prop us into comfortable positions for intimate caressing and lovemaking. We may not have needed them before surgeries or treatment, but may really need them now, when a slight change in position or angle may make a huge difference in comfort and painless lovemaking.

Patient exploration is the key. Most of us don’t know how our bodies will respond to treatment. Our mileage varies. So patiently exploring how treatment may have changed our sense of touch and taste and smell, in addition to pain and pleasure—this takes time. Be a scientist about it. Experiment, experiment, with all the patience of a field biologist!

Use a light touch. When we get chemo, our skin can become very sensitive. Chemo changes the epidermis of the skin. Our sense of touch shifts. That’s where things like feathers, mitts, and lotions become so important as tools for exploration, because your body is different on chemo. Figuring out those changes is the work ahead for both of you.

Some of the chemos are so toxic any intercourse would be too rough on fragile tissues. That’s a good time to think about a different form of expression, beyond intercourse. Find new ways to connect.

Wetness now, more than ever. Most women can’t handle intercourse during treatment. Chemotherapy can be very drying, and our skin, our vaginal tissues, are just too fragile. But if you are going to try intercourse during treatment, lubrication is extremely important. Try a lube that has a trace of silicone. I especially like Yes for this purpose. A little bit of silicone can give that lube sticking power. Too much is hard for a dry vagina to clear on its own.

Slow down. Pretend you are new lovers, virgins, even. Go very slowly. Be prepared to relearn everything about to make love to each other. Kissing can change. Taste can change. Relax, take interest, explore, report, and learn.

Crank Up the Heat

It’s the third Friday of the month, and you know the script by heart—half-hearted foreplay, missionary position, a quick (or not-so-quick) denouement, and your partner’s already snoring while you’re thinking about tomorrow’s chores. Routine is inevitable in long-term relationships. Routine can feel secure and orderly, but too much routine in the bedroom just feels boring. When you can anticipate every move, when you stay up late to avoid sex, when you wish your partner would just hurry up and get it over with, it’s time to hit “reset,” and crank up the heat with your honey. It’s worth putting the effort into a good sexual relationship for all the reasons I mentioned in the last post. You’ll probably be spending your golden years with this person, and sexual intimacy (which includes kissing and cuddling) is at the heart of a healthy relationship outside the bedroom. Regular sex is also good for your health, and it’s good for your mental frame of mind. Besides, if you’re going to have sex, you might as well make it good. But you can’t just jump in bed with sex toys in hand—lay the groundwork I discussed in the last post. Communicate. Try to understand your partner’s needs. Does he or she feel vulnerable? Uncertain? Inadequate? Bored? Share fantasies. And keep an open mind. Anything new seems awkward and weird at first, but neither your mother nor your pastor is in the bedroom. This is sacred space for just the two of you. Once you’ve both agreed to sweeten the honey pot, here are some ideas to heat things up:
  • Create a boudoir. Your bedroom should be a place for sleeping and for sex. It’s not the junk room, not the den, not the family photo gallery. Take out the distractions—including the television. Create a private, comfortable, beautiful space for the two of you to be together.
  • Write love letters. Leave notes for each other throughout the day. Make them more lusty as the day goes on. (We found some postcards you can use if you like.)
  • Fantasize. Talk about sexual things you’ve always wanted to do. Write down three for each of you. Put them in a hat and draw one. The other has to at least try. (Not sure where to start? We found these vows when we were looking for postcards!)
  • Focus on foreplay. Forget about scoring a home run. Get creative with the many ways of getting around the bases, from sexy undressing to intimate touching.
  • Focus on skin. Remember that big sex organ? Use that powerful sense of touch to explore your partner’s erogenous spots. Use textured objects, such as feathers or silk, to create new sensations and to stimulate sensitive nerves.
  • Swap roles. One of you is the “giver,” whose sole task is to pleasure the other. Pay attention to what feels good to your partner, how he or she responds to certain touch in certain places. Then switch roles—you get to be the receiver.
  • Change places. Make love in a different room, a different house, outdoors, in front of a mirror. “[Sex] is about the stimulation of your surroundings,” said Jane Seddon, author of Daily Sex in an interview with Cosmopolitan. “Doing it somewhere out of the norm adds an element of fun and makes you feel a little deviant.”
  • Stay healthy. Stress is a sex-killer, and it isn’t good for your health, either. Eat healthfully. Keep your weight under control. Exercise to maintain flexibility and to keep your joints healthy. You’ll be able to make love and do a whole lot more.
The goal, of course, isn’t to become sexual superstars, but simply to reestablish the connection and intimacy that was undoubtedly there in the beginning of your relationship. With decades of life experience behind you, the best is yet to come.

Try a Little Forgiveness

By the time women reach midlife, we’ve experienced all kinds of things in our relationships, some good, some bad. It’s great to think back on the positive experiences once in a while, maybe even relive them from time to time.

For the negative experiences, that’s not such a good idea.

And the more serious the situation, the harder it is to not think about it. Maybe you’ve had to deal with an infidelity or some other kind of betrayal by your partner. If so, its lingering effects may very well be interfering with your ability to fully embrace your partner in a healthy--and even in a literal--way.

If you’re harboring resentment or anger over some past wrong, you need to address it. As psychotherapist and our relationship coach Mary Jo Rapini has said, “When your relationship struggles with resentment, it can feel like you are sleeping with the enemy. The resentment is felt deeply by one of the partners, and although it is rarely discussed openly, the tension can be felt by anyone close to the couple.”

So how do you let go of it? Well, it’s forgiveness. Dr. Fred Luskin, a psychologist affiliated with Stanford University, has made the study of forgiveness his life’s work; he’s written several books on it. The first, Forgive for Good, is based on the successful workshops he conducts using a step-by-step process to teach people how to forgive.

His second book, Forgive for Love, was written specifically for husbands and wives, and came about, he explains, because so many of his workshop participants were women trying to forgive current or ex-husbands.

Dr. Luskin has done studies that show harboring feelings of resentment and anger is not good for us physically or emotionally. It means we’re in a constant state of stress and negativity. In lectures he often quotes Nelson Mandela: “Harboring resentment is liking drinking poison to kill your enemy.” In other words, it’s doing a lot more harm to you than it is to the person who hurt you.

His methods of letting go of anger are similar to stress management and include mind-over-matter techniques like visualization and focusing on positive thoughts rather than negative ones.

Mary Jo, too, advises those who are angry to “make a peace with your past. Tell whoever hurt you how you feel about what happened.” She also says that “letting go of your ego and learning to forgive your partner for their flaws and weaknesses—as well as forgiving yourself for holding on to that anger—are two of the biggest obstacles to overcome when working through resentment.”

Learning to forgive may not be easy, but it’s worth a try. In fact, it can be a life-changing experience. Because it’s never too late to take action. And you’ll feel much better when you do.

Your House Is Not Your Own?

Today, more and more women over age 50 are finding themselves sharing their households with parents and/or grown children. A recent article in the Atlantic magazine, “Grandma's in the Attic, Junior's in the Basement,” talks about the big jump in multi-generations living under one roof, from grandpa or grandma who move in to adult kids who move back.

The article cites a recent Pew Foundation study estimating that 16 percent of the U.S. population now lives in multi-generational households—the largest share since the 1950s. Reasons range from economics to caring for elderly parents.

These findings made me think about how complicated it can be for women in that situation to keep their sex lives alive and kicking. If you’re married, having a romantic evening (let alone having sex) presents all kinds of logistical problems. Knowing that your 78-year old mother is in the next room is not exactly an aphrodisiac.

If you’ve got grown children around, they can be even worse: Even a hint of parental romance can still gross them out (although they should know better!)—and curtail any action on your part.

To make matters worse, this multi-generational living may not have been your first choice; it may be happening just when you were starting to really enjoy being alone with your partner again, comfortably settling in as empty nesters.

So what’s a sexually active, post-menopausal woman to do? Make an effort, that’s what.

Go on an overnighter every few months, even if it’s just to the hotel downtown. Or ask friends if you could borrow their cabin in the woods some weekend.

Yes, it might take some planning ahead, but that in itself could be exciting (as those Viagra ads imply). So when grandma goes to visit your sister and your kids are out on their dates, make your own date to “meet in the bedroom” once the coast is clear.

Or be spontaneous and grab any moment that presents itself. Make a game out of it.

The point is, if you have a healthy sex life, don’t let these new circumstances ruin it for you. Good sex is not something to let casually slip away. And the way to keep it is to keep at it, making a commitment to get together in spite of your situation. Make it a priority; put it at the top of your “Things to do” list once in awhile!

Because, remember, having a good sex life is good not just for your relationship but for your overall health. If you do get caught by an older or younger resident, tell them you were just “exercising”!

Taking Care of Yourself. Intimately.

As a medical doctor, I try to provide a place where uncomfortable or unfamiliar topics can be discussed in an open, honest way, without inhibitions or worries about “what people might think.” For lots of people, both men and women, self-stimulation or masturbation falls into that “uncomfortable” category. Some of the myths surrounding masturbation—like it causing blindness or hair to grow on the practitioner’s hands—have faded, thank heavens! But there’s still a lingering perception, I find, that self-stimulation is somehow less acceptable for women than for men. MiddlesexMD_OnlyBody

For post-menopausal women, self-stimulation is especially helpful, whether or not they have partners. It can solve problems with vaginal dryness or tightness: Stimulation causes your clitoris to swell, helping to maintain healthy blood flow to the walls of the vagina, which in turn can help keep your vagina open, strong and responsive. (It’s the old “use or it lose it” rule.)

If vaginal dryness or tightness is a problem, self-stimulation can also be a way to temporarily feel sexually satiated if intercourse is too painful. I say “temporarily” because I don’t recommend that you think of it as the solution to painful intercourse. Always seek medical attention if you’re experiencing any kind of vaginal pain, because there are lots of remedies.

Another benefit of stimulating yourself is the way it helps you to get to know your own body and what satisfies you best. As hormone levels decrease and effect other changes in your body, what’s worked in the past may not be as satisfying now. It’s great to be able to experiment with your partner to find your new best experience, but that’s not always possible, for all kinds of complicated reasons. Old habits die hard, and either you or your partner may feel tense or intimidated about changing things up. You can experiment to see what works for you and then share that knowledge with your partner to make your sex lives more mutually satisfying.

If you don’t currently have a sex partner, self-stimulation is a great way to enjoy the side benefits of sex, like tension and stress release and the feeling of calm and relaxation that immediately follows a sexual session. Fantasy can be a fun part of it; picture yourself with a former lover—or George Clooney (or Dean Martin… or… you tell us!). And taking care of yourself in this way keeps open the possibilities in case you do find yourself in a relationship again. In my decades of practice, I’ve learned never to say never!

If your sex life is suffering from other issues—a rough time in your relationship or it seems to hard to get your love life back on the right track—I caution patients against replacing intimacy with a partner with self-stimulation. It may be the “easy” thing to do, but it can compound problems if you turn to self-stimulation instead of your partner for satisfaction.

Self-stimulation is a normal part of a healthy sex life. At this point in our lives, the last person we need to be shy with is ourselves. Who knows what we’ll learn?

He’s Got His Groove Back. O Happy Day?

It’s been a long time since your partner’s been able to “get it up.” And truth be told, you’d grown accustomed to a platonic relationship. You haven’t missed the sex. Frankly, it was never all that great, anyway.

Now, thanks to the marvels of medical science, your man’s erectile dysfunction is a thing of the past. In fact, he may be more “vigorous” now than ever before—and more eager to test his newfound prowess. Which certainly presents you with a challenge. And some choices.

You can roll your eyes and sigh. You can respond in a way that communicates indifference or irritation and that perpetuates the status quo. And, indeed, if the lack of intimacy in your relationship reflects problems with trust or resentment, suddenly regaining the ability to have sex won’t mend the relationship—or make sex any more appealing.

But you could also analyze the reason for your mixed feelings. Maybe your lack of interest stems from remembering a former boring sexual rut. In all likelihood, you’re experiencing physical changes of your own that make it harder to respond to your partner’s new emotional and physical demands. Or maybe your own passivity contributed to the lackluster sex—you always took the passenger seat, never the driver’s seat.

But could it also be possible that your partner’s new ability could be the catalyst for a renaissance of romance in your golden years? For an unexpected reawakening of desire and intimacy? Stranger things have happened.

Embracing this new situation enthusiastically needs to take place at two levels: first, rekindling the emotional connection in the relationship and second, fine-tuning your body to be a sexual creature again. For women, sexual desire and arousal is part of a complex brew of intellectual belief and emotional feelings about yourself, your partner, and sex in general. You need to feel emotionally connected to your partner in order to respond well sexually. For men, it’s just the opposite: It’s the sex that creates intimacy.

Working on the intimacy that can rekindle desire can be as pleasurable and easy as spending time together, lingering over coffee in the morning, taking a walk, holding hands. Remember the romance? Even if you don’t, it isn’t too late to learn.

Second, you’ll need to recondition your body, especially if you’re dealing with menopausal changes. Consider yourself an athlete in training. Regular use of vaginal moisturizers may improve the overall health and condition of your vagina. Don’t overlook the use of lubricants during sex, which not only improve comfort, but can also make intercourse more exciting. You might benefit from a regimen of vaginal dilators to improve your “vaginal capacity.” Talk with your doctor about using a topical estrogen product in your vagina, which can improve elasticity and lubrication, or your doctor might recommend testosterone therapy to boost your libido. In fact, talk to your doctor about any sexual issue that arises; it’s his or her job to have resources to help.

While you’re working on rekindling intimacy and rebuilding your sexual muscle tone, you can also take an active role rebuilding your reinvigorated sex life. It’s too easy to write off sex as a nuisance when you haven’t done anything to change the script. You now have a second chance and the maturity to create the sex life you always wanted as a full and equal partner. Experiment. Play. Communicate.

In the end, your partner’s newfound prowess could be a catalyst for reenergizing your relationship and for rekindling passion. The process may be uncomfortable; it may be a little scary, even; and it will definitely take work. But doesn’t anything worthwhile?

Patience, patience!

So you arrive home from a hectic day at the office, and there's the box you've been waiting for, with your new lube, a vaginal moisturizer, and those dilators that have promised to return your sex life from painful to normal. "Oh boy!" you think. "Orgasm tonight!"

Please, please, please, slow down. I know it's hard to wait when you've been anxious to find an answer.

The conditions that cause painful intercourse in the first place can be comforted and in many cases reversed, but only with practice and time. Practice and time that are worth taking, when the result is the kind of sexual intimacy you want.

Picture a young athlete. She is powerful, flexible, supple, and graceful. She practices her sport every morning and night. Then she graduates, gets a desk job, has a couple of kids, spends nearly every waking hour sitting at her desk or in her mini-van, carpooling. Her fitness slowly drains away.

One day, she decides to get back into shape. If she tries to complete a workout at the level she did when she was in peak condition, she will get hurt. No doubt about it. She knows, or will soon realize, that she must start slowly. She'll get her fitness back, but only if she works within her comfort zone. When things start to hurt, she needs to back off. Keep moving, but slow down, decrease the intensity. Please approach your new sexual aids, your vibrator of course, your vaginal dilators, especially, with this same understanding. Pushing too hard, going too fast, will hurt you. You are trying to restore pleasure, and I recommend letting comfort and pleasure be your guide.

As always, if the pain just won't resolve, do discuss it with your doctors. Finding the real reason for the pain is the fastest way to resolve it.

Meantime, put the box down. Have a healthy dinner. Take a nice bath. Relax. Then begin, slowly.