Delighted to Have Sex Again

Whether in person in my office or by email from the MiddlesexMD website, I hear variations on this story more often than you might think: A woman who’s been without a partner for years—often as many as 10—has found someone new. While she’s happy to have found a partner with whom to be intimate, she finds that sex is uncomfortable or even painful.

I celebrate the new relationship with each woman! While it’s perfectly possible to be happy on our own, it’s also lovely when we find a “right person” with whom we can share our lives and experiences—and intimacy, too.

When we find that right person after menopause, sometimes physical changes take us by surprise. Pain with intercourse is typically associated with vulvovaginal atrophy, which is the effect of the loss of estrogen. Women notice that they have less natural lubrication, and vaginal dryness makes friction painful. And the vaginal tissues are less elastic; the vaginal actually can shrink.

Both dryness and loss of elasticity can be addressed most simply with a lubricant. Silicone lubricants (our most popular is Pink) provide the most glide and last longest. Vaginal dilators can be helpful if, after a period of sexual inactivity, tissues need some gentle stretching.

Providing estrogen to the tissues is another option. There are prescription products that supply estrogen only to the vaginal tissues: Estrace cream, Premarin vaginal cream, Estring, and Vagifem are all localized options. Osphena is a non-hormonal option for treatment of vaginal and vulvar pain.

Some women describe a burning sensation on penetration, which may be caused by vulvodynia. Estrogen is part of the solution then, too, and a thorough medical exam would be helpful to determine exactly what treatment is needed.

Women who are sexually active after a hiatus also sometimes report the first urinary tract infections of their lives! There’s a movement to replace the term “vulvovaginal atrophy” with “genitourinary syndrome of menopause.” Both terms are a little clumsy, but the latter more accurately represents the reality of the effects of menopause: that there is a urinary as well as a genital component. Again, anything that improves vaginal health is a plus for the urinary tract; adding localized estrogen may be necessary. If bladder infections are recurring, using an antibiotic each time you have sex can be helpful to preventing them.

And! If you’re not in a relationship right now, whether or not you’re looking for one, be mindful of your body’s changes. If you’d like to keep your options open for the future, create your own maintenance plan; with some ongoing care, you can avoid the need to undo the effects of time.

Eve Ensler: In the Body of the World

While reflecting on our anniversary, we were reminded of how many women have come before us, paving the way for straightforward conversations about women’s sexuality. This is the third in a series (read the first and second) launching our sixth year with gratitude to them!

Eve Ensler was an obscure New York playwright until she debuted her one-woman play, The Vagina Monologues. The very title was electrifying. Suddenly, audiences were being asked to say the word “vagina” out loud.

Ensler got the idea for the play when a woman she knew said “really hideous, demeaning things about her vagina.” That spurred her to interview more than 200 women. “It’s the easiest thing I’ve ever done in my life. People long to talk about their vaginas. It’s like a secret code between women.”

“Once they got going, you couldn’t stop them,” she said in a 2004 TED talk. “No one’s ever asked them before.”

She assembled some of their stories into a series of short monologues, ranging from humor (“Hurry, nurse, bring me the vagina”), to tragedy (gang rape as a weapon of war); from the birth of her own grandchild, to a fake orgasm more stupendous than the one in When Harry Met Sally.

In 1996, The Vagina Monologues won an Obie for best new play. There were other effects that Ensler had never anticipated. “Women would literally line up after the show because they wanted to tell me their story.” She had thought they would want to talk about sex. Instead, many told heart-rending tales of rape, incest, and violence. She found out that the UN estimates 1 in 3 women worldwide are beaten or raped. That number enraged her.

On Valentine’s Day of 1998, she began a new campaign: performances of The Vagina Monologues to raise money to stop the violence. The first year, she enlisted high-profile actresses like Whoopi Goldberg, Lily Tomlin, Glenn Close, and Susan Sarandon. Sony and ABC were corporate sponsors.

The V-Day movement has continued ever since. The money raised has gone to safe houses in Kenya for girls escaping genital mutilation; to the City of Joy in Congo for victims of rape; to Juarez, Mexico, where bones of murdered women were washing up on the beach. Money has gone to Haiti, Afghanistan, Egypt, and Iraq.

Women in the U.S. have also benefited. During the month of February, local productions pay nothing for the rights to the play, provided that all proceeds go to organizations working to stop violence against women.

Eve Ensler herself suffered abuse as a child. “I left my body at a very young age . . . I wasn’t informed by the intelligence of my body.” Living without connection to the body means “we are not living in our full creativity and intelligence.”

Her body received a shattering challenge in the form of stage 3 uterine cancer, but she never lost sight of the suffering of other women. In a 2010 Guardian article, she wrote with fury about the world’s indifference to the plight of women in the Congo, while she herself received excellent, curative care for her cancer. She remained, as the title of her 2013 memoir has it, In the Body of the World.

Dr. Ruth: A Passionate Life

While reflecting on our anniversary, we were reminded of how many women have come before us, paving the way for straightforward conversations about women's sexuality. This is the second in a series (read the first here) launching our sixth year with gratitude to them!

The name of the world-renowned sex expert Dr. Ruth immediately brings to mind her warm, German-accented voice. Dr. Ruth Westheimer, 88 years old, has her own YouTube channel, where you can find clips of her answers to important questions such as I’m over 65—can I still have sex?, her frisky report on a kiss from President Obama, and even her thoughts on Fifty Shades of Grey.

Though only four foot seven in her prime, she’s been a huge figure in sex education since the early ’80s, when she started a fifteen-minute radio show,“Sexually Speaking,” on a local New York station. At first, the station was so wary of the subject that her show aired Sundays at midnight, and Dr. Ruth answered written questions only. Soon that evolved to an hour-long live call-in show with a seven-second delay. Live TV was next. She made several appearances on the David Letterman show, her radio and TV shows were syndicated, and she was on the cover of TV Guide and People magazine. She taught the nation that sex can be talked about, and on live TV!

She was reassuring and compassionate on-air with nervous people, especially the young—asking questions, putting them at ease. Even in her younger days, she exuded a grandmotherly air. It’s hard to imagine that, tiny as she was, she’d been trained as a sniper in Palestine.

She had a narrow escape from the Nazi horror. When she was 10 years old, her mother and grandmother sent her to safety in Switzerland. She spent the war in an orphanage with many other Jewish children, refugees from Germany. After learning in 1945 that her parents had been murdered in the Holocaust, she went to Palestine and trained in the army. She relates, “When I was in my routine training for the Israeli army as a teenager, they discovered completely by chance that I was a lethal sniper. I could hit the target smack in the center further away than anyone could believe.” But, she says, she never killed anyone. “Even today I can load a Sten automatic rifle in a single minute, blindfolded.”

She went on to study psychology in Paris, then immigrated to the United States, where she made her home in Manhattan. She earned advanced degrees from the New School and Teachers College, Columbia University, then did post-graduate work in sexuality with Helen Singer Kaplan from Vienna, a psychiatrist who pioneered scientific research about sex.

She retains a close association with Israel and Judaism. “For years, I wondered why I could talk about the things I talk about so openly. Now I know. For us Jews, sex was never a sin.” In her book Heavenly Sex: Sexuality in the Jewish Tradition, she writes, “The great rabbi Simeon ben-Halafta called the penis the great peacemaker of the home.”

In addition to her many books and recorded programs, Dr. Ruth’s Family Encyclopedia of Sex & Sexuality is available on-line. Those who helped her escape from Nazi Germany made possible a well-lived life, with a great legacy.

Dell Williams: Celebrating Sexuality

We saw the obituary for Dell Williams while we were gearing up for our MiddlesexMD anniversary. Realizing how many women have come before us, paving the way for straightforward conversations about women's sexuality, we decided to start our sixth year with a series on those women pioneers. This is the first in that series.

The courageous pioneer Dell Williams died in March at the age of 92. She spent the second half of her life on a crusade to help women “define, explore, and celebrate” their sexuality. Back in 1974, she founded Eve’s Garden, the first store in America where women could buy vibrators and other sexual aids in a safe, private environment. All these years later, it’s still going strong.

Dell Williams grew up in the Bronx. After thriving as a WAC, in show business, and as a New York advertising executive, she made an unexpected career move, precipitated by a march. As she put it, “I stepped into the Women’s March for Equality in 1970 like a lamb and I walked out like a lion.” She joined the New York chapter of NOW, and “another chapter in [her] life began.” It was an intoxicating time, when women were giving each other the strength to redefine what their lives could be.

In 1972 she helped to organize the Women’s Sexuality Congress, which set her on the path of her life’s work. More than a thousand women gathered at a New York high school to talk about sex in a brand-new way. About the sex educator Betty Dodson, Williams said, “Her forthright talk transformed women from body-shy to body-proud.” Dodson recommended the Hitachi Magic Wand, which was supposedly for muscle massage but was highly functional as a vibrator. Inspired, Dell Williams went to Macy’s to buy one. The male sales clerk asked what she was going to use it for. The embarrassing encounter led her to think, “Somebody really ought to open up a store where a woman can buy one of these things without some kid asking her what she’s going to do with it.”

So she founded Eve’s Garden, first as a mail-order business in her kitchen, then as a store nearby on West 57th Street, discreetly upstairs. She wanted it to be a place where women could “celebrate the joy of their own sexuality” in comfort, at first with no men allowed. The mission was “to encourage women to take responsibility for their own sexuality, honor the sacredness of sex, and clearly understand that bodily pleasure and spiritual joy are one, and an inalienable right.” Kim Ibricevic, the current manager of Eve’s Garden, said that Williams “wanted to focus on the spiritual side of sex and felt that if every woman had an orgasm, there would be peace in this world.”

In a video made when she was well into her 80s, she is as warm and enthusiastic as ever. Flanked by two doctors, women whom she was introducing as sex counselors, she exclaims that “Eve’s Garden is just a garden of delights.” She describes how empowering it was for her to learn that she could take responsibility for her own pleasure, and how she had spent decades fighting for “women’s awareness that they had a right to enjoy themselves.”

As she put it, after so many years of studying the subject, “Sexuality is the biggest mystery of them all.”

Just a Perfect Day

If you could plan out a perfect day, what would it look like?

Two researchers explored that question in a study, “Developing a Happiness-Optimized Day Schedule,” published in the Journal of Economic Psychology. The researchers, Christian Kroll and Sebastian Pokutta, took data on how a large number of women spent a typical day and how much they enjoyed each activity. Then they had some fun with the numbers.

Subtracting 8 hours for sleep, they were left with 16 hours to divide up, minute by minute, into a day that would offer the most pleasure and satisfaction. Here is what they came up with:

  • 106 minutes “intimate relations”
  • 82 minutes socializing
  • 78 minutes relaxing
  • 75 minutes eating
  • 73 minutes praying or meditating
  • 68 minutes exercising
  • 57 minutes talking on the phone
  • 56 minutes shopping
  • 55 minutes watching TV
  • 50 minutes cooking
  • 48 minutes using a computer
  • 47 minutes doing housework
  • 46 minutes taking a nap
  • 46 minutes childcare
  • 36 minutes working
  • 33 minutes commuting

Some journalists joked about these oddly precise numbers. Simon Kelner asks whether a perfect day is different for men (likely answer: yes) and recalls Lou Reed drinking sangria in the park in his classic song.

But the researchers’ method actually makes sense. They write, “Our research asks what a perfect day would look like if we take into account the crucial fact that even the most pleasurable activities are usually less enjoyable the longer they last and the more often we do them.”

Imagine doing a jigsaw puzzle for twelve hours straight. If you like jigsaw puzzles, you would enjoy the first hour or two, especially if you don’t do jigsaws every day. But over time it would get way less fun.

Using that idea, the researchers took 16 common activities and allotted a number of minutes to each one, so that the last minute of each offered an equal amount of happiness. The more pleasurable the activity, the longer it took for the pleasure to diminish enough to match the others.

True, anyone who tried to follow the suggested schedule would go berserk. That wasn’t the authors’ intention! It’s a thought experiment: a way to think about what’s most important for an individual or a society. As the researchers point out, their computation “differs considerably from how people usually spend their time.”

If I use myself as a test case, I ask: Only 36 minutes of working? Fortunately, I love my work. I hope my perception of pleasure throughout a whole day of seeing patients is not an illusion. And 56 minutes of shopping? That’s not at all attractive to me as a daily activity.

But the study encourages us to be intentional with what we do with our precious time. The six activities at the top of the list, which the women enjoyed the most—intimacy, socializing, relaxing, eating (eating well, we hope), praying or meditating, exercising—are all vital to health in body or mind. We can think of each one as a different color thread, and make sure to weave them all through our days—with intentional planning of time for our relationships, for example.

We will be happier, and so will the people we love.

Sex and the Sharper Mind

A recent Wall Street Journal headline read, “Sex in Old Age May Lead to a Sharper Mind.” The article describes a study in which Dutch researchers looked into the way cognitive function and attitudes toward sexuality might be related among older people. Nearly 2,000 adults, with an average age of 71, were given a variety of cognitive tests. They were also asked a series of questions about sex—whether it was important for older people generally or themselves personally, whether they found it pleasant or unpleasant. They were asked whether they still benefited from intimacy and touching.

Quite a few—41 percent—said that their current sexuality wasn’t important, but 42 percent said it was important for older people in general. A quarter considered sex important or very important. Only 6 percent found sexual activity unpleasant. More than two-thirds believed that intimacy and touching were still vital.

The results of these questions and the cognitive tests were correlated. Both men and women who thought sex was important and were satisfied with their current sex lives tended to do better on the cognitive tests.

The Wall Street Journal article points out that the study made no claim that sex improves brain function, or vice versa: only that the two are associated. It can be difficult to disentangle cause and effect.

Another study looked at how cognitive function affects sexual behavior interest and sexual behavior among the elderly. The 352 Italians studied were between 65 and 105 years old. They were asked, “Are you interested in sex?” and “Do you have sexual relations?” They were also given two tests of cognitive functioning. One third were still having sex and 40 percent were still interested. This study suggested that a sharper mind might help keep a sex life going.

It could be that older people who are healthy enough to have sex are also healthy enough to do well on cognitive tests. Generally, whatever is good for the brain is also good for sex. That’s a good reason to keep on exercising, or to start.

Dusting Off the New Year’s Resolution

It’s March 1: Do you know where your New Year’s resolution is? You may be thinking, “It’s here, somewhere.”

I have a guess about where it is—collecting dust in a corner, where you left it when you “failed.” I’ve left a few there, myself.

Making a resolution is a positive step that makes it more likely we’ll change a behavior. But when we don’t follow through in the way we envisioned, that resolution becomes something that makes us feel worse about ourselves. When we don’t meet whatever goal we’ve set—whether it’s doing Kegels every day, ramping up a moisturizer habit, or setting aside time for intimacy—the easiest thing to do is give up altogether. “I don’t know why I even bother to make a resolution,” you might say. “I never keep them.”

I’d like to suggest that that’s a story you tell yourself. And the great thing about stories is that you can change them. In fact, research shows that telling yourself a different story has a lasting effect on performance. The researcher had students who thought of themselves as “bad at school” do a story editing exercise that included the idea “everyone fails at first.” Those students went on to get better grades and were more likely to stay in college.

So if you’re telling yourself that old story about your lack of self-discipline or your complete inability to follow through, stop. Retire that old story. Get yourself a new one. Tell yourself you’re learning how to integrate that new thing into your life, and learning takes time. Congratulate yourself on the effort. Look to the past for a time when you did follow through and change something about yourself or your life, and draw inspiration from it.

Then dust off that resolution—yes now!—and try again. Haven’t you heard? March is the new New Year.

Vibrator Myth-Busting

Recently, I joined with two colleagues to produce a “continuing medical education” unit for the American College of Obstetricians and Gynecologists (ACOG). Our topic was “Vibrators and Other Devices in Gynecologic Practices” (if you’re a health care practitioner, you can investigate the CME offer here).

I was joined by Mary Jo Rapini, a sex psychotherapist and long-time friend of MiddlesexMD, and Debra Wickman, a gynecologist who teaches at the Banner Good Samaritan Medical Center in Phoenix. We talked about a 2009 study in the Journal of Sexual Medicine that says that 52.5 percent of women have used a vibrator; that led us to talk about the roughly half who have not.

A number of myths might get in their way, and we hope we made some progress in busting them.

Myth #1: Vibrators are for people whose relationships are in trouble. Based on what the three of us have seen, the opposite is true. As Mary Jo explains, “Vibrators are for couples who want to explore, who want to try new things, who want to play and have fun in their sex life.” Couples who share that desire are typically interested, trusting, and care about each other.

Myth #2: Vibrators make it hard to have an orgasm any other way. I’m happy to debunk this one with a medical reality: As the muscles involved in orgasm grow stronger, orgasm becomes easier and more intense. Vibrators are good at stimulating—and they don’t get tired or fumble, as we sometimes do as we lose a little strength and dexterity. Staying sexually active with a vibrator will increase your responsiveness to manual stimulation—that’s just the way we work.

Myth #3: There’s something sinful about a vibrator. Again, it’s Mary Jo who addresses this most directly. She’s had a number of conversations with faith leaders on her patients’ behalf, when religious concerns weighed on their minds. The ministers she’s talked to are invariably in favor of keeping marriages strong, and maintaining physical intimacy is a natural part of those relationships.

Myth #4: Vibrators are only for self-stimulation. Vibrators are good for self-stimulation, and that’s a good option for women who want to maintain their sexual health when they’re without a partner. But they’re also part of intimacy for couples. They’re especially good for couples who see a need to slow down and spend more time in foreplay. Which, now that I think about it, could be any of us who’ve achieved midlife!

If you’re among those who haven’t tried a vibrator, I support your right to decide for yourself. Here’s hoping, though, that none of these myths is what’s standing in your way.

Think Outside the Heart-Shaped Box

If you don’t already have that perfect gift for your significant other, don’t despair. There are other ways to show your love. The most important thing is to be thoughtful about choosing the way that you show it. Try to set aside the traditional idea of Valentine’s Day. When you wipe away all those images of roses, chocolate, and candlelight, what’s left? You and your beloved, alone for an evening.

You may think you know where I’m headed with this, but not so fast! Take a few minutes to consider what you know about your partner. You might be familiar with the concept of emotional love languages: words of affirmation, quality time, gifts, acts of service, and physical touch. Keep your partner’s love language in mind as you plan the evening.

Also think about what your partner enjoys. A recipe that you don’t normally make because it’s too much work (or you don’t like it yourself)? Make it for him. Ice fishing? Go with him (pack hot drinks and hand warmers!). A certain junk food? Buy it, put a big red bow on it—and let him enjoy it, guilt free. Whatever it is, give it with love.

If you want to take your gift to the next level (nope, not yet), look to your shared history. What did you enjoy doing together when you were first dating or right after you got married? Maybe you can find a way to revisit that interest. It could be as simple as putting together a play list of music that was popular when you were first together and dancing to it.

And yes, of course you can think of all of this as leading to intimacy. Valentine’s Day is a great time to be intentional about working on foreplay, which many of us need more at midlife, whether or not it was important to us before. You could be sensual with a scented massage oil (Just Love is an all-natural and organic addition to our collection) or playful with something like flavored body paint. Remember the lubricant to be sure you’re comfortable, and consider its frivolous possibilities, too (Just Love is formulated for both massage and “intimate glide”). Maybe you just don’t have the energy for any of this.

Maybe you and your partner have been “running on empty” for a while. If that’s the case, then try spending the evening asking each other these 36 questions, which can result in falling in love, according to one study. (And it seems to have worked for this woman.) Can it work for falling in love again? I don’t know, but what have you got to lose?

A New Way to a Better You

As we mentioned last time, 47 percent of New Year’s resolutions are related to self-improvement—losing weight, quitting smoking, getting organized, or saving money. “Improving sexual health and wellbeing” doesn’t make the list (at least not the one in this study) but we think they should.

Because—let’s face it—chances are, they won’t magically get better on their own.

They used to, though, didn’t they? Or it seemed like it. Over the course of our relationships, all of us have probably experienced sexual desire come and go, as we went through things like pregnancy, health-related issues (for us or our partners), and times of stress. Looking back, we remember that desire always bounced back, as it does for most people who are generally healthy and on the young side of middle aged.

But at this stage of the game, how long should you let it go, hoping it will self-correct, before resolving to do something about it? Our take: Not long. Start now. You’ve got nothing to lose and so much to gain in the area of self-improvement.

Although we may not think of intimacy and sex falling into the “self improvement” category, it actually does. Do you want to lose weight? Be healthier? Feel better about yourself? Then get busy, sister, because having sex can help in all those ways. Equally as important is that when sex is good, as you’ll recall, it adds 15 – 20 percent additional value to a relationship; when it’s bad or nonexistent, it drains the relationship of positive value by 50 to 70 percent.

Make 2015 the year that you make a concerted effort at doing what it takes—kegels for better muscle tone, a vaginal moisturizer as part of your skin-care routine, lubricants or a vibrator to add some spice, an honest conversation about foreplay with your partner—to get your game on in the bedroom. Don’t just say you will; make it your New Year’s resolution. Research shows that if you make a resolution, you’re 10 times more likely to have been “continuously successful” at six months than if you don’t. Good luck and Happy New Year!

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