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Help! I’m recently married and we can’t have sex!

I hear this concern at least once a week from young heterosexual women who have been recently married. Women will describe that penile vaginal penetration simply isn’t possible, it feels like “his penis is hitting a wall,” and penetration is incredibly painful. Typically, women in this position have seen several doctors and are told they need a surgery to remove their hymen, or they need to relax, or they just need to keep trying. However, for most of these women, these suggestions and even surgeries (!) haven’t helped. Why haven’t they helped? Because the problem is something called Vaginismus and vaginismus isn’t treated with surgery, it doesn’t just go away the more you try to have sex (it actually gets worse!), and if it was as simple as just relaxing, it wouldn’t be an issue in the first place.

What is vaginismus?

We have 26 muscles that group together in our pelvis to form our pelvic floor (check out this video on the Pelvic Floor by vaginismus expert, Laura Meihofer, DPT: Pelvic Floor Muscles. Vaginismus involves involuntary contractions and tightening of these muscles. Essentially, these muscles are so tight that when anything (a penis, a tampon) attempts to enter the vaginal canal, they clamp shut. This causes that “hitting a wall” experience, because the penis/tampon is hitting a wall of tense, tight muscles.

How do you treat vaginismus?

Vaginismus is very treatable. It’s actually my favorite issue to treat as a sex therapist because it is so treatable. Treatment requires a team of three specialists: 1. Sexual medicine specialist, 2. Pelvic physical therapist, and 3. Sex therapist.

The sexual medicine specialist, typically an MD, officially makes the diagnosis of vaginismus and rules out any other medical issues. One thing the doctor needs to rule out is something called vulvodynia. Often vaginismus and vulvodynia go hand in hand. And if vulvodynia is an issue, it needs to be treated before the vaginismus can be addressed.

Side note: Vulvodynia is pain of the vulva. It’s external pain, whereas vaginismus is internal pain (pain from the tense muscles). Vuldodynia is diagnosed with a “Q-tip test.” Basically, your doctor takes a q-tip and touches different areas of your vulva to assess for pain. If simply being touched by a q-tip is painful, this is a sign that you have vulvodynia. There isn’t much research on the cause of vulvodynia, but we believe it’s an issue with nerves. Imagine the nerves of the vulvar area have an alarm, and it takes the tiniest thing (like a q-tip) to set the alarm off. The nerves are constantly on high alert and easily startled.

The pelvic physical therapist teaches deep breathing, how to relax the body, and exercises to relax and stretch the pelvic floor muscles. They also teach how to use dilators.

Dilators are a series of silicone or acrylic cylinders, that go from small (like the size of your pinky) to large, and are used for vaginal insertion in order to help the pelvic floor muscles relax and stretch. I recommend the dilators made by SoulSource: Silicone Vaginal Dilators. The goal is to be able to vaginally “contain” the dilator that is one size larger than your partner’s penis without any pain.

The sex therapist teaches how to mentally disconnect sex from pain. After so many experiences where sex and pain have gone hand in hand, over time, when you even think about sex, the first thing in your mind is likely pain. Using a type of therapy called Cognitive Behavioral Therapy and exercises called Sensate Focus, the therapist teaches how to separate sex from pain and reduce sexual anxiety. Sex therapy may also include learning accurate sexual health information, increasing comfort with your body image, and learning healthy sexual communication with your partner.

I think I have vaginismus, what do I do?

  1. Stop having/attempting to have painful sex. The more you have painful sex, the more you are strengthening the connection between pain and sex.
  2. Give me a call to schedule an appointment. If you don’t already have a sexual medicine physician or physical therapist, I’ll get you connected to a great team. Then I’ll work with that team to get you started in treatment. Treating vaginismus is not quick. On average, treatment is 6 months to 1 year. However, the results will be worth the hard work!

Why do I desire sex more frequently than my partner?

When one partner has a higher sex drive than the other, this is called a desire discrepancy. Desire discrepancies are one of the most common sexual complaints seen by sex therapists. Actually, some sex researchers argue that a discrepancy in sexual desire between partners should be expected and is just one feature of a long-term relationship, not an indicator that something is broken in the relationship.

For many heterosexual couples, one partner simply just has a higher sex drive due in large part to biological reasons. That is, we know that testosterone is a major player in driving sexual desire and men have substantially more testosterone than women. Women have about 1/10th the amount of testosterone than men and as they get older, this gradually declines. If you’re in a heterosexual relationship, then perhaps for biological reasons (hormones) you and your partner have different levels of desire.

Then why didn’t we have a desire discrepancy in the beginning of our relationship?

The first 12-36 months of a relationship is called the Limerence phase or the honeymoon phase. This is the period when you and your partner can’t get enough of each other and sex is no exception. This Limerence phase is wonderful, but the wonder typically lasts no longer than 12-36 months. Actually, most couples I work with identify that this honeymoon period declines around 6 months. It’s in this honeymoon phase that both partners typically have similar levels of sexual desire. The relationship is novel, the sex/physical connection is exciting, the chemistry is powerful. This doesn’t last and soon the couple enters what I call the Sweatpants phase. During this phase, novelty wears off and the discrepancy in desire starts to become apparent.

Sometimes the desire discrepancy doesn’t appear until after major life changes (job promotion, house renovation, or having kids). This suggests that whatever these life changes were, they hit the brake pedal on desire.

If biology plays a big role in desire, can’t my partner just take testosterone?

Some people take testosterone to increase desire and this could be an option, but there isn’t good research on how much is safe and for how long. There are even stories of women taking testosterone and they grow facial hair, have acne, experience balding, and their voice deepens. More importantly is that biology can’t explain a desire discrepancy entirely. Sexual desire is complex and it is driven by a combination of biological factors (hormones, medications, health), psychological factors (mood and anxiety), relationship factors (how much do you even like your partner?), and other sociocultural factors (culture, religion, values). Some of these factors hit the gas pedal and increase desire (for example, if you really find your partner attractive) and some of these factors hit the brake pedal and decrease desire (such as certain medications like antidepressants).

How do we get our desire on the same page?  

First off, you’re not going to get on the same page if you pressure or demand sex from your partner. In fact, that’s a major turn off for most people and will make the desire discrepancy even worse. If you’re pressuring your partner for sex or getting angry when sex is denied, stop! This is not helpful.

The best option is identifying what biological, psychological, relationship, and sociocultural factors are turns-ons (gas pedal) and what factors are turn-offs (brake pedal). The more turn-ons and the less turn-offs in your daily life, the better you can maximize the responsive desire of the lower desire partner. Responsive desire is a type of desire that isn’t there initially, but when the right ingredients are in place (more turn-ons than turn-offs), the desire will respond.

But let’s say the desire of the lower desire partner is as high as it’s ever going to be and there is still a discrepancy. If that’s the case, then it’s about finding ways to close the discrepancy gap that are acceptable to both partners, but perhaps not ideal to both (a compromise). This can include scheduling sex, finding ways for the lower desire partner to be engaged in the solo sex of the higher desire partner (for example, lower desire partner cuddles the higher desire partner while he self-stimulates), the higher desire partner masturbating as a sexual outlet, or finding alternative ways to be sexually/sensually intimate that feel good for both partners.

Sex therapy can help identify the turn-ons and turn-offs, facilitate communication between partners, and help couples come to compromises that can close the discrepancy gap.

October 14, 2018

What is Sex Addiction?

What is sex addiction?

Addiction is a disease. Thus, sex addiction is classified as a disease. There simply has not been adequate research to classify problematic sexual behavior as a disease. There is no solid research at this time to suggest that someone can be “addicted” to sex the way they are addicted to alcohol and drugs. In some ways, whether we label it an addiction or not doesn’t matter. It’s a problem that needs to be treated. But it many ways, it does matter.

The term addiction or disease suggests that this is a lifelong issue, that one is an “addict,” and there is a sense of powerlessness and stigma connected to this term. The term addiction also suggests that it should be treated in a specific way; the same way we treat other addictions (i.e., abstinence). Given that we are all sexual beings (to some degree), is abstinence from sex really a practical solution?

If it isn’t an addiction, then what is it?

More research is needed to identify what exactly it is. We do know that people who self-identify as “sex addicts” do have a few things in common. Research supports that they are more likely to have high sex drives, are highly religious, and experience moral disapproval of their porn use. Until we have more data, many researchers and sex therapists classify problematic sexual behavior as just that, a problem. Not a disease. Not an addiction. Problematic sexual behavior is often called Out of Control Sexual Behavior (OCSB). The hallmark of OCSB is that it feels out of control.

How is sex addiction or Out of Control Sexual Behavior (OCSB) treated?

If the research community can’t agree on what it is (an addiction, a problem, a disorder), that makes it quite difficult to do good research on how to treat it. Currently, treatment depends on how the therapist classifies the problematic sexual behavior. If the therapist sees it as an addiction, they’ll treat it like they treat addictions. If they see it as a problem, they’ll treat it like a problem. I treat it as a problem and follow the treatment protocols developed by Drs. Doug Braun-Harvey and Eli Coleman.

Treatment involves identifying your sexual cycles. In other words, what steps do you typically take to engage in the problematic sexual behavior? For many people their cycle starts with negative emotions (sad, anxious, angry) and to cope with those emotions they seek out sex or pornography use. Once we have an idea of your cycles, then we look for off-ramps (ways to get off the cycle once it starts). Off ramps might include learning to tolerate those negative emotions (distress tolerance), challenging irrational thoughts (cognitive behavioral therapy), setting boundaries (like a pornography filter on your phone), or simple distraction. When you have a few solid off-ramps in place, we spend time identifying your sexual values and assessing how these values fit with your sexual behaviors. Ultimately, the goal is to develop and maintain a healthy sexuality that is consistent with your sexual values.