Writing for my gynecologist friend has included a lot of Aha! moments. I admit some of this learning makes me blush. It's not just because I blush when talking about sex—though I do. It's because I’m embarrassed when I’m caught not knowing things I think I should have known a long, long time ago.
So, I’m reading along in Dr. Barb’s enormous textbooks on female sexuality, when I come across an illustration of the clitoris, sort of like the one below. I nearly passed it over, because, what’s to know at my age? I've lived with this equipment for 50 years. I'd like to think I know my way around it.
But this illustration colored in the entire structure of the clitoris. Not just the glans, but also the shaft and the crus clitoris, or crura.
Excuse me… the shaft?... and the crura?
No.. please picture me picking my head up like a prairie dog, looking around my office, and asking the air...
"And the crura!?!”
Somehow in all my curious, bookish, research-happy past, I never learned more about the clitoris than about the little button—the glans—the part that sticks out from the prepuce at the top of the labia.
Who knew my clitoris had legs? And a shaft, even?
But yes, indeed. It's practically a little penis under that hood. With long, long legs that extend waaay back toward the perineum, which fill with blood when I’m aroused.
Now, of course, the cool, rational part of my mind tells me I have enjoyed my crura—and possibly even the shaft—because they’ve been there all along. But I would have liked to know about them from the start. I can’t help but wish for a few years back in which I could quite clearly visualize my long, leggy crura.
What can we do with this information? Well, with age, the clitoris loses some sensitivity. We may find it useful to use warming oils and gels or vibrating sex aids to increase stimulation to the clitoris as we prepare for or engage in sex.
And of course, to do that, it really does help to know where it is.
Back to the books...
...and why you should care too!
It began when I partnered with the local hospital in my hometown to evaluate local women's health services, looking for any gaps where additional services were needed. In the process, it became clear that our community needed and could support a healthcare practice devoted to the special needs and care of women who were past their child-bearing years—these special needs were largely ignored by existing providers.
I decided to transform my practice. That was 4 years ago. I studied and became certified by the North American Menopause Society as a menopause care provider, and while welcoming patients into my practice, used their questionaire—a thorough document that makes it easy for new patients to give me a comprehensive view of their symptoms and health histories. On that eight-page-long form there are just a few questions for women to answer about their current and past sexual experiences:
Well, I was amazed by the responses from my new patients. 60 percent of my patients have experienced a loss of interest in sexual activities, 45 percent have a loss of arousal, and 45 percent a loss of sexual response. And when I talked to them, they were:
And when you carry those numbers from my practice to the rest of the country—well, more than 44 million women are aged 40 to 65 in the US alone. Some 6,000 of us reach menopause every day. And at least half of us experience sexual problems with menopause. Probably more.
That’s a lot of disappointed women. And a lot of disappointed men too… I believe there can be more, and women don’t have to just accept the changes if they don’t want to. I see MiddlesexMD as a real caregiving opportunity: Make it easy for women over 40 to gather the information and products they need to sustain their sexuality after menopause.
And that could make everyone happier!
Menopause brings a drop in circulating estrogen. And a drop in circulating estrogen often (but not always!) brings a drop in sexual response. So at midlife, for many of us, sexual satisfaction takes more—more time, more moisture, more sensation.
I like to use the reading glasses analogy. When you reach 40, suddenly it’s not easy to read the fine print. When that happened, did you give up reading? Of course not. You got reading glasses and went on. Or bifocal contacts. You adjusted.
Many of my patients have little to no experience using sexual aids. I may recommend that they consider using a vibrator or a lubricant or a positioning pillow—but they have to actually purchase these things. I can just picture my patients walking out of my office and shaking their heads at the thought.
A majority of my patients are not going to visit a sex shop. They are not likely to be comfortable or happy visiting the sex shops online either. I looked and looked for a good place to send my patients, where the focus is on sexual health, on sustaining our sexuality. We need a safe place to shop, where the products are durable and made of safe materials. And frankly, we need a place that doesn’t cast women as sexual toys, and that acknowledges a healthy sexuality for people over 40.
My patients are from a generation of women who have redefined female sexuality, and are now redefining menopause. As pioneers, we all had a lot to learn, and still do. Many of us have never used sex toys or lubricants at all. The language of these products is completely foreign to many of us. We can learn from and teach each other.
So I'm trying to build a sexual support site for us. And that includes a product store for us. A store that’s comfortable, private, but has the advantage of including guidance that will help women who are new to this language choose products that will make sense for their own sexuality, their conditions, their goals.
We won’t offer hundreds of items. We will keep the information informative, tasteful, and clear. We’ve been working hard (no, really) shopping, testing, choosing, sorting—pulling together a portfolio of products specifically for midlife women who want to enjoy sexuality for life.
I can’t wait for you to see the selection. And when you do, please share your thoughts. I very much want our product selections to be influenced by our customers and the menopause community.
Hi everybody. My name is Julie. I’m a writer here at MiddlesexMD. My credentials for writing about sex at midlife are… Well… I have reached midlife. And I enjoy sex.
Despite almost 30 years of togetherness with the same guy. Despite aches and pains, stress and too little time, and all the physical surprises of menopause. Despite all of that, we are nowhere near ready to hang up our sheets.
So when my own friend (we served undergraduate years together) and doctor (my own menopause doctor, because I’m lucky), Dr. Barb, asked me to help her develop her website, I jumped at the chance. I needed to learn about this myself. What better way?
I’ve been writing for years and years, and for many years researching and writing on health topics. But I have never written about sexual health. Barb is teaching me—you would not believe the size and density of these textbooks.
So, day one, lesson one, Basson’s Model. I had no idea that there is a difference between Sexual Desire and Sexual Arousal. I really always thought they were the same thing, or flip sides of the same impulse, or something. Because that’s the way I’d experienced it for most of my life. Arousal and Desire arrived on my doorstep, it seemed, instantaneously.
But they are considered distinct aspects of the sexual experience. And now that menopause has slowed me down a bit, I understand better.
We can achieve arousal with or without desire. We can have comfortable, enjoyable, emotionally satisfying sex with or without desire. That is, we need arousal for sex. But we don’t need desire. We like it. We want it. We enjoy it. But we don’t need it to engage in sex or get a lot out of our sexual experiences.
The easiest way for me to tease these ideas apart is this way: Desire happens in your head. It’s an idea. Arousal happens all over. It’s physical. Certainly the idea can spark a physical response. But it works the other way more often for women. Sexual stimuli—physical sensations, emotional feelings, sights, sounds, smells—arouse us physically. Our arousal readies our bodies for sex and can breed desire.
So, when we start talking about the kinds of sexual problems women may experience with menopause, the distinction becomes very important. Are we having difficulty with arousal or with desire? Or both?
What used to follow automatically from sexual stimuli—the arousal part—may now take more time and more stimulation. We may have to ask for and give ourselves more help and support to become aroused. This isn’t a lack of desire, but a greater need for stimulation.
We may be receiving all the same sexual stimuli that we always have, that always worked before, but we don’t respond to it as readily. We love our partners just as much or more. But our bodies just don't respond as quickly now. Or we may now have physical or emotional limitations or illness or medications that muffle the effect of sexual stimulation.
This was lesson one for me. A real eye opener. I used to worry that I didn't feel the same desire as I did when I was in my 20s and 30s. Worry isn't the word. It upset me. I am much more relaxed about it now. I'm learning to tune in to stimulation, to appreciate and notice my body's response more. And that helps a lot. Well, I suppose writing about sex every day doesn't hurt either...
There have been and will be many more lessons. Some embarrassingly basic. Some I wish I’d known 30 years ago. I will always be willing to show my ignorance in these matters, followed by Dr. Barb’s patient teachings.
Meantime, I’m gathering up all my favorite stimulants: I’m with Reka, a visitor from the last post, on the potency of Dr. Gregory House. And Dr. Andrew Weil too (his relaxation tapes have an opposite, unadvertised effect on me). I have a thing for David Strathairn. Indian food. Tango/dance movies. And I have this special drawer in my bedroom…. And you? Care to share?
(Anonymous sharing is always welcome. Or make up a name, if you like!)
Rosemary Basson's model of female sexual response
The science of human sexuality is young. For most of the last century, we assumed that men and women approach sex in roughly the same way.
I know: Crazy. But as I said, the science is young.
Older models (Masters & Johnson, Kaplan) theorized that sex for people happens in a few neat, linear stages, beginning with desire, proceeding next to arousal, then orgasm, and finally satisfaction.
But it doesn’t always work that way, particularly for women, and especially for women over 40.
More recent researchers who focus on women’s sexuality, confirm that really, women do not experience sex in this simple, linear way. We sometimes skip phases. Our reasons to have sex are many and often complex.
We can be perfectly satisfied with sex that does not include orgasm, and we can reach orgasm without desire. We are flexible that way.
Enter Rosemary Basson, MB, FRCP, of the University of British Columbia. Basson formalized a new model of female sexuality that is now widely accepted.
She offers two key insights. First: Female sexual desire is generally more responsive than spontaneous. That is, we are more likely to respond to sexual stimuli — thoughts, sights, smells, and sounds — than we are to spark an interest in sex out of thin air (Men, on the other hand, specialize in this).
Another key insight: emotional intimacy matters to women. I know, that doesn’t sound like a news flash, but in the realm of the biological sciences, it’s news, trust me.
So Basson drew a new model – not a linear series of steps, but a circle that includes both sexual stimuli — the thoughts that trigger a woman to take an interest in sex, and emotional intimacy — the emotional payoffs of the experience that lead her to want to come back for more.
I love Basson’s model and use it every day in my practice to help my patients understand how sex really works for us.
We need to understand that it’s okay and it’s normal that we don’t always start with desire. And as we enter menopause, and our hormone levels drop, spontaneous thoughts about sex, and responsiveness to opportunities for sex diminish for most of us. That’s natural and normal too.
If you don’t like the situation, and you want to feel more sexual, more responsive, Basson’s model gives us the hint: We need to stimulate our minds. The more sexual stimuli we receive, the more sexual we feel.
So, this is worth thinking about today, a worthy discussion to have with your partner: What makes you feel sexy? A juicy romance novel? A James Bond movie? Erotic art? Pretty underpinnings? A romantic dinner? Having your partner empty the dishwasher? Spend some time thinking about that. Maybe make a list. And then provide for these things. Sexy is as sexy does, friends.
And, hey, if you’d like to help a sister find some sexual motivation, use the comment field below to share. What sights, sounds, scents, scenes help you get in the mood?
A big bouquet of roses waited for me at the front desk of my clinic.
It wasn’t my anniversary or my birthday. And doctors just don’t get a lot of flowers. When I saw who sent them, I smiled that special “good sex” smile, even though the sex I was smiling about wasn’t my own.
I've been a women's health doctor for more than 20 years, focused on midlife women for the past four. These flowers were not from a new mom or a patient with a difficult disease. These came from a patient who got her sex life back.
That may not seem like a big win in the scheme of things, but it was a wake-up call for me. My patient, now in menopause, was distraught that her sex life seemed to be over so soon—too soon. Sex was effortless for most of her life. It had been very satisfying. And suddenly, it wasn't any more.
We talked about sexual response with her hormonal changes, all of the many factors that could be influencing her experience. Then we talked about her options for managing these changes. She tried different routes, but when I introduced her to a device—she had not used them before—that made the difference for her. With the help of a simple tool, she was able to adapt to her new reality, and enjoy sex again.
It was a fairly straightforward doctor-patient exchange, but not a common one. Women rarely talk to their doctors about sex. As a menopause practitioner, though, I know that changes in sexual response are a key source of distress for a lot of women and their partners at this age.
Is it a doctor's job to help their patients have good sex? I think it is, absolutely. A healthy sex life sustains our overall health and well-being. Sex is good for us, and helps us to remain vibrant and strong. Menopause isn't a disease. It's a natural process. The more we understand this process, and discuss it openly, the easier it will be for us to make adjustments to accommodate our bodies' changes.
The roses were evidence that my patient's sex life had been restored. How many women like her have never raised the question with their doctors. Their gynecologists? Or sisters? Or friends?
Natural changes during meopause can make it feel like the door is closing on your sex life. For some of us, that’s not a huge loss. For others, it’s seriously distressing.
But these changes don't have to stop your sex life. They will certainly change things a bit. They may require learning some new things, trying some new techniques, experimenting with a few products.
I'm working with my friends to launch MiddlesexMD. We will reach out to women like my patient, women at midlife who aren’t ready to close the door on sex, and who aren’t sure how or when to talk with their doctors about their experiences. My partners and I want to build a trustworthy (and bouquet-worthy!) sexual health resource for midlife women, combining helpful advice, clinical expertise and a carefully selected set of products with a record of helping women continue to enjoy a satisfying sexual life as they age.
By launching our blog first, we're starting the conversation. We'd love to hear what you think, need, want. What do you think about a website devoted to midlife sex? Can you relate to the changes in your sex life? Please leave a comment to join the discussion, and/or sign up to receive the posts by email.