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The Fullness of Midlife

“I will listen without judgment about this important aspect of your life.”

“I will listen without judgment about this important aspect of your life.”

by Dr. Barb DePree MD

Nurse Barb DehnBarbara Dehn RN, MS, NP is a practicing Nurse Practitioner and a health educator known as Nurse Barb. She is the award-winning author of the Personal Guides to Health used by over five million women in the U.S. and contributes content to HealthyWomen, Huffington Post, NurseBarb, KevinMDm, and The Patch; she has an active and engaged Facebook following and 34,000 Twitter followers. Barb is the author of The Hot Guide to a Cool Sexy MenopauseNurse Barb's Guide to Breastfeeding and Nurse Barb's Guide to Pregnancy.

Barb earned a masters degree from UCSF and a BS from Boston College. She is certified by the North American Menopause Society and is a Fellow in the American Association of Nurse Practitioners. Over the last several years, she has been an active participant in Global Health Initiatives at FAME Hospital in Karatu, Tanzania. Barb lives in the San Francisco Bay area.

Dr. Barb: I’m fortunate to welcome back Nurse Barb Dehn. She and I share an interest in women’s health, and we both actively practice, write, and speak to educate women about how they can manage their health to live their best lives. I don’t want to miss an opportunity to talk about sexual health with Nurse Barb, so I invited her back for a second episode. 


Nurse Barb: Oh, Barb, it's so great, and I’m so excited we’re going to talk about sexual health.

Dr. Barb: [laughs] You know my guests who share an interest in this and speak about this probably all say that very same thing. I think the exciting thing about this topic is it’s emerging from behind the curtains.

Nurse Barb: Mmhm, it is. And I think those of us who talk about it, don’t you think there’s like a little sign on our foreheads that says, “I will listen to you talk to me about sex.” And it like blinks on and off. So do you have this happen, people on an airplane or somewhere else, they’re telling you their deepest secrets, and they’re asking your advice, you know, besides the patients we see?

Dr. Barb: You know, I have had that, yes. I have had that. And I don’t know how you emit a sense honestly, but it's funny that you say that, because I’m not sure I’ve had an awareness of that happening outside of my practice, but it certainly happens. And I welcome it.

Nurse Barb: Oh, my gosh, I think you do have that light; it blinks on. It's like, “I’m open, yes. I’ll listen without judgment, and I’ll be very positive about things that you might do to improve this aspect—this so so important aspect— of your life.”

Dr. Barb: And so while we’ve talked about sexual health generally on this podcast, I don’t think we’ve talked about it more in the context of the pandemic, and how things may or may not have changed as a result of the pandemic. But, I’m wondering what you’re seeing with single women? I mean this is always kind of a unique time for women who are widowed or become single, they’re transitioning, perimenopause, menopause, sexual health-related things are changing. How does a pandemic have an overlay into that? What have you seen?

Nurse Barb: It's a great question. I’ve seen a lot of women be very, very hesitant to meet someone in person. And what’s happening is that they are still meeting people, and they’re getting to know them virtually or with social distance, so there’s more dating. And they’re sort of getting to know someone’s core and developing more emotional intimacy before there’s physical intimacy. And then people are saying, “Well, I’d like to take this to the next level.” And they’re taking their time. And that has been lovely for many of my patients. 

Now the other part, though, is giving women permission who are solo for whatever reason, to be self-stimulating, and to really honor their sexual health because they are masturbating; they’re using toys, and they’re making sure that they’re taking care of their sexual health with or without a partner. And Barb, you and I both know, gosh, there’s a lot of women in long-term relationships that are not happy. There’s a lot of issues there, emotional issues, but then sometimes it’s where the partner is not able to or not willing to have an intimate relationship. Giving women permission saying, “It’s okay, it’s normal to be using a lot of self-pleasuring right now.” It's a great way to fall asleep. It's a great way to have more joy in your life and after all, when we’re sexual, no matter if it's partnered or solo, we’re getting a ton of endorphins that help us feel better; those are those feel-good hormones in our bodies.

Dr. Barb: And sleep better, I think I’ve heard you say.

Nurse Barb: That’s what I’ve been thinking about during the pandemic.

Dr. Barb: Yeah. There’s no downside to it. But I think not every woman recognizes the health benefits that go along with maintaining sexual activity. And so I feel like I spend time helping women understand why not, only outside of pleasure, but just the importance of pelvic floor health and general health, blood supply, etc. I think this is an area that women just didn’t have awareness of. Would you agree?

Nurse Barb: I would, and I wonder if we could do something kind of fun here. Can you pretend that I’m one of your patients? Can you tell me what you say to your patients, because I would love to know. What are the benefits, like, ahhh, you know I’m not that interested, but I could be if I watched “Outlander,” I could probably be interested. What do you tell your patients?

Dr. Barb: Well, number one, back to the question about in a relationship/not in a relationship, what does sexual activity look like? Because I think women want to give you the right answer, and so I also feel like—my initial interview—I get some nods and acknowledgement that I am “sexually active,” but when you share with women that you really want a better understand that, it's interesting how they will then open up and admittedly say, “Well it's been six months,” or “We sleep together, but you know there’s no sexual touch,” so to really try to get an understanding of what does it mean to be sexual in your relationship. But I also am fairly quick to say, “I’m not judging your relationship, I’m not suggesting that it has to be different, I just want you to know that if there’s a desire for it to be different, how could we talk about it and make that happen for you.” And then go into why it is important to consider continued sexual activity. 

I just saw a patient earlier this week. She happens to be on hormone therapy, and over the years we’ve talked about, do you continue it, do you discontinue it, what are the advantages? She became widowed about six years ago and she said to me, I think it was Monday morning I saw her, she said—she’s in a new relationship, a wonderful new relationship—she said, “I was telling my partner that I was coming in for my exam, and that he can thank you for your encouragement for me to stay on hormone therapy so when we initiated our sexual activity it was all great and pleasurable.”

So I think for the women who aren’t in a relationship, we want to talk about that future possibility—about maintaining some sexual activity—so that in the future it is possible. But what it means for improved blood supply to the pelvic floor, the contraction of pelvic floor muscles that results from orgasm, the release of endorphins, improved sleep, improved moods. There’s some evidence around heart disease incidence, not to mention overall quality of life satisfaction. There’s some evidence to say some of the autoimmune or anti-inflammatory factors might be improved by it. So off the top of my head, those are some of the things I talk about with women.

How about you?

Nurse Barb: Oh my God, I love this, I love how you say, what’s a sexual activity look like for you? Because it is different for everyone, and you know, I have a patient who is 92, and she said, “My husband, he’s not able to anymore, so I make sure that I take care of myself.” And I just validated that, and we talk about like, what are you able to have an orgasm? How long does it take? So of course, Barb, you and I both know, we take a full sexual history, we talk about everything under the sun, and then we dive a little bit deeper into what the issues are. And then we can help women who might be having sexual pain. 

And to your point, I have patients who haven’t had any kind of intimate penetrative intimacy in years, and then they find themselves in a new relationship and they are like, “Wait, you want to put what where? Does it fit?” And to your point, like is that even possible? So I have many patients, you know, we’re talking about this proactively to keep their vaginas moist, receptive, flexible, able to enjoy intimacy. And then I have others who come in and say, “Okay, I need some help because things don’t work, and things don’t fit.” And then we work on that in a variety of ways: wIth pelvic floor physical therapy, with vaginal dilators. I don’t want people to get overwhelmed by this. It's pretty straightforward how we can help. 

But don’t let fear or the feeling of overwhelm get in the way, because, yeah, we can help, and it's pretty simple to help you enjoy that part of your life again.

Dr. Barb: And it is for the most rewarding parts of the practice when women invest and almost always can see some successes come out of that.

Nurse Barb: Oh, yeah, absolutely. And they’re like, “Oh my God, thank you, I have my life back!” The other thing that happens for me is that sometimes I run into husbands and they’re like, “You’re Nurse Barb? Oh my God, I love you!” Right? “You gave me back this partner.” And that happens also with my patients who are lesbians and their partners—sometimes I see both partners in the relationship, and they’re like, “Oh my God, we’re back to having sex again, and it’s so nice.” Sometimes people say, “Gosh, I forgot how great this was.” That’s another aspect, just dip your toe in the water, and think about getting this started. Even, I know it sounds corny, but making a date for sex works! We’ve seen that in studies, right Barb?

Dr. Barb: Absolutely.

Nurse Barb: Right, when people make a date, they start to think about it. Because as women, we need to start having a little bit of arousal before we have desire. And so that’s been super helpful like, “Oh yeah, we’re staying connected physically,” and that helps with our emotional connection.”

Dr. Barb: You know I think about your earlier comments about single people entering into relationships in the time of the pandemic. I have heard the same thing, that I wonder if the success of those relationships is going to be improved, because people really are having to get to know each other more on a more personal level before entering the physical relationship. My patients who are out on the websites finding dates are saying date number one maybe men don’t want sex, but by date number two they want sex. For some women that works, for a lot of women, wow, that’s not at all where they are. And this idea of needing to establish a more personal knowledge of each other, to like them first, so to speak, and have a friendship before initiating the physical relationship. I would just be interested to know post-pandemic, how that played out for new relationships.

Nurse Barb: Oh, I think it's a great question. I’ve been looking at some of the data on this, about waiting to have sex. Actually the longer we wait to have sex, the more likely we are to have a long-term relationship, and there’s a lot of work now in studies using evolutionary biology to explain the behaviors between men and women. But there have been surveys of men—and I’m sorry, this is a heterosexual kind of conversation right now, and I apologize—but when we look at sexual couples in a new relationship, if a woman is like, “Yeah, I really want to get to know you,” she’s communicating, “I’m a high-status woman. This is an exclusive club, and not everybody gets access to this club.” Men actually want to pursue them more. And so when we think about evolutionary biology and how a man’s brain works, the pursuit is super important, and the more he has to pursue, the more he wants this and the more likely he is to stay in this relationship. So, you know, there’s no hard and fast rules of you know, three dates, ten dates, whatever. I think, trust your instincts. 

I’m 62, and I want to speak to your patients who are over 50 and in that range. When we were growing up, at that time the idea was that you wait a while before you are sexual, and my question for my patients is, “Is this man worthy of your time? Is he worthy of your time, do you want to spend time with this person? Are they worthy of this kind of intimate relationship with you? Do they meet your standards? Are they kind? Are they just as interested in your sexual pleasure as their own sexual pleasure?” We talked about that way back in the day, right Barb? When we were talking about condoms to prevent HIV. Is a man willing to use a condom to protect his partner? And those are good questions to ask. 

And I also ask my younger patients, “Oh, you’re in a new relationship. Are you having an orgasm?” And if they’re not having orgasms, I say, “So tell me more about making these decisions to be intimate with someone if only one person’s having a good time. What is that really about?” And then of course, we talk about how to have orgasms, and I give them lots of resources—including your website—so they can buy books and get vibrators and other sexual toys. It's just amazing to me how we as women make decisions about being intimate with someone. 

Dr. Barb: Your comment about partner willingness to use a condom, I think that triggers me to think about this: We do want women to have the awareness of risks associated with new relationships, specifically around STI or sexually transmitted infections. Can you briefly talk about how you approach that with your patients? 

Nurse Barb: I love this question, and so I give them a script. And I say, please have this conversation not in a bedroom and not at night. Not when you are just about to have sex. Have this conversation separately.” And here’s the script that I use, I say, “Wow things are really heating up. You are smoking hot, and I can just see us getting together and having a lot of fun in the bedroom, but I’d also like to know what else we might be sharing besides a good time. I’d like to get tested for everything under the sun, and I’d like you to get tested, too, so that we can both be safe.” 

So that script works really well, because if you ask, you to get to know two things: a) is my partner willing to get tested? And b) do they care enough about me and my safety to get tested? And so that helps a lot of women have the script they need and so, so many have come in and their partners—or we do this via Skype now—and they’re like, “Oh my God, I had no idea I had genetal herpes.” And they had no idea they could transmit herpes without any symptoms. I’ve had patients come in who realized they have hepatitis C and they could give that to their partner. And especially for folks in our age group who are over 50, we’ve had a lot more time and a lot more opportunities to acquire STIs, so it’s really important to be tested and not assume, “Okay this person has a job. They pay taxes. They couldn’t possibly have an STI.” Oh yes, they could have an STI, and so it’s good to be tested I think ahead of time.

Dr. Barb: Yeah, I think that’s really perfect, and you hate to throw the wet blanket on the excitement of a new relationship, but you also want them to be healthy and safe and have realistic expectations.

Nurse Barb: I will tell you that, when a woman asks a partner to do this, her status increases in that man’s eyes. He’s like, “Whoa, she is amazing. Like, this is that exclusive club and not everybody has access.” It communicates, “Hey, I am someone who cares about myself, and I care about you, and I’m not just run-of-the-mill going to make these decisions in the moment, just because they feel good. I’m a thoughtful person.”

Dr. Barb: Hearing you talk about this reminds me of the conversations we’ve been having, just of who’s safe and who to have relationships with now [laughs]. You know in the pandemic, it's been, “Have you been in your small bubble?” “Have you been vaccinated?” “Have you traveled?” “Are you safe to come over for dinner?” So hopefully, we’ll be shedding that conversation soon, but we won’t be shedding the safe-sex conversation.

Nurse Barb: Yeah, I hope so.

Dr. Barb: Well thanks for your time, Barb, and your insight. I so appreciate you and what you do in our shared professional relationship. As I wrap up an interview with women, I also like to ask, so personally for you, at this time, where are you finding fulfillment?

Nurse Barb: I’m finding fulfillment now through connecting with people however I can. Whether it's phone calls, while I’m walking, or video conference calls. And it's been lovely to reconnect. I’m also writing more letters and cards. And that’s been lovely. So you know, through the pandemic, a lot of meditation, lots of walking, and then trying to cook some really cool recipes.

Dr. Barb: Well, that’s an inspiration. I wish I could share your cooking new healthy recipes with my to do list, but that unfortunately hasn’t been on it. But it will continue to be on the list of “maybe someday.” I’m glad you’re doing well and thriving at this difficult time.

Nurse Barb: Thanks so much. And you know, if people want to connect with me they can find me at and on all of the different social medias. I so appreciate talking to you. We are—both of us are named Barb, and we’re both providing amazing women’s health care, I think. It’s just such a pleasure to talk with you.

Dr. Barb: Thanks for your time today, Barb. 


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