Sex addict.  Those two words conjure up an image of a wild-eyed man hell-bent on getting his sexual needs met, cheating on his wife, and exploiting other women.  Nothing can stop him in his search for the ultimate sex high.  Like an alcoholic on a bender, the sex addict has no control over himself or his urges.  His need for sex grows without limit.  He can never be sated.  He must have sex or his body will cry out with need.

Really?  That’s not what I see.  When a so-called sex addict comes into my practice, I usually have before me a man who:

• Was exposed to pornography at a young age

• Learned to cope with many adolescent challenges by looking at porn
• Used porn to “self-medicate” stress, anxiety, and depression
• Has difficulty sustaining an intimate connection with his partner
• Doesn’t readily share what will turn him on
• If not yet partnered, may have social anxiety or feel unlovable
• Has a partner that doesn’t understand his sexual needs
• May have been sexually abused and is now trying to figure out how sex is supposed to work
• Is confused by his own secretive nature about sex
• May use porn to satisfy a need for sexual arousal that his partner doesn’t understand

My preferred label, if one must used, is “problematic sexual behavior.”  Usually, what makes the sexual behavior a problem is that it interferes with a person’s relationships or ability to function in other ways.

A man that pays a prostitute instead of (more…)

I had an interesting discussion recently with a couple about the value of foreplay for men, since the husband didn’t seem to think it was necessary for him.  Most people think that foreplay is for women, to help them relax and get prepared for intercourse or orgasm.  But foreplay is for men, too.  Foreplay can also help a man relax, which can make orgasm more pleasurable.

But foreplay isn’t just about orgasms.  It is also a way to connect with your partner.  You can take turns giving one another pleasure.  You can choose to be passive and let your partner give to you, or to be active and please your partner.  Or, you can have mutual foreplay, both giving and receiving pleasure at the same time.  It’s more about sharing an intimate, fun experience than about preparation for intercourse.

If foreplay is imaginative, there may be no need for intercourse; orgasms may be experienced in other ways.  Foreplay can also allow you to explore one another’s bodies, to understand what is erotic for each of you.  It is a time to free yourself and be creative, to try out scenarios that turn you on.  You may find out that you enjoy some of the same things, or that you need to make adjustments so that your fantasy is fun for both of you.

Foreplay builds a sense of connection and intimacy.  When someone doesn’t want foreplay, for me as a therapist, I am always curious about whether they are able to be truly intimate with a partner, to let a partner get into what they are really about in the bedroom and to get into their partner’s thoughts and feelings.  Foreplay is one of life’s great free experiences, right there in the privacy of your own home.

A devoted husband can be truly puzzled when his wife either seems uninterested or tells him flat out that she has no sex drive.  He remembers a time when his wife made love freely, when her drive seemed to match his own.  Now he still feels attracted to her, but she turns him down more frequently than she agrees.

Women’s sexual desire is more complex than a man’s.  Especially for women in long term relationships, sexual desire is less driven by hormones, though they do play a role.  What seems to be more important is the quality of the relationship between a woman and her partner; her mood, energy, and stress level; her feelings about herself and her body; and her overall enjoyment of sexual activity.

Also, while men feel horny and then want sex, women in long terms relationships often need some loving before they feel horny.  If a man approaches his wife or partner with his motor on “idle” and gives her some time to warm up without pressure, letting her tune in to her own needs to see if a “no” might become a “yes.”

Another way to help a woman enjoy sex more is to take the time to find out what she enjoys.  If she can’t communicate it verbally, ask if she can show you by guiding your hand with her own.  Encourage her to explore her own body (more…)

When most people think of sex, they naturally think of intercourse.  Remember Bill Clinton saying, “I did not have sex with that woman!”  Ahem, he most certainly did.   But even a “zipless” encounter can be quite passionate and can quite definitely be counted as a sexual act.  Just watch “The Young Victoria” to see that people have sex all the time without having intercourse.

It isn’t just men that feel sex is only about intercourse and resulting orgasm.  Women often say that it’s the only part of sex they enjoy.  Perhaps it’s because it’s the only part of sex that has an official stamp of approval as being sex.  After all, most people are taught that “Sex is for after you get married
because it can result in pregnancy.  Since pregnancy nearly always occurs as the result of intercourse, it only makes sense that sex means such an act has occurred.

Of course, there’s nothing wrong with intercourse.  It’s just that it’s very limited.  It requires that both partners be aroused, that the genitals are in good working condition, that the participants have the strength and stamina to follow through with the act.  That is, I think, part of the reason that people think of “sex” as being for young people.

If sex included every act of pleasure, people–both individuals and couples–would be much better off.  Including self-, oral, and manual stimulation would take the pressure off of having intercourse.  It would decrease unwanted pregnancy and disease.  It would make it easier to imagine having sex as one ages, or sex if one is alone.  And if a woman had discomfort with intercourse or a man struggled with erectile dysfunction as the result of temporary illness or stress, then they could still be affectionate and comforting with one another.

If you are someone that balks at the idea of venturing beyond sex = intercourse, it might be interesting to think about why that is.  Is it due to stereotype?  Inhibitions about other types of sexual activities?  A belief that sex is only for procreation, so if one is going to have sex for recreation, it had better be a reasonable facsimile?  If going outside your sex = intercourse comfort zone is truly distasteful, well, so be it.  But it could be that you realize you are holding back from exploring all types of sex, starting with cuddling and kissing.  And then what would be the harm of exploring your sexual potential?

My last post was on a potential new medication that would help women with low desire feel a bit more like having sex.  And when I say “a bit,” I mean a bit; the data suggests a mean of about one more incidence of sexual activity a month, either masturbation or intercourse.

If you want to feel like having sex one more time a month, what else might you do besides taking an antidepressant?  Here are 10 ideas:

1. Get more sleep.  If you are always too tired for sex, then you need more rest.  Go to bed earlier instead of doing one more load of laundry or watching one more episode of CSI.
2. Eat a healthier diet.  Junk food affects mood and energy levels.  Eat a Mediterranean diet that includes fruits, vegetables, whole grains, and lean meat.
3. Get exercise.  Exercise gives you more energy to do the things you need and want to do, and improves mood.
4. Communicate with your partner.  Let your partner know that you are struggling (more…)

An Australian study confirms what I’ve seen clinically in my practice:  Men that chronically smoke pot can have sexual problems over time, including delayed or premature ejaculation.  Researcher Anthony Smith reported that some men seemed to be self-medicating to help retard ejaculation.

But since marijuana seems to have unpredictable effects, it’s probably not the best drug of choice.  Chronic marijuana use–usually defined as smoking pot 4 or more times a week–can affect a man’s sex drive and his ability to have an erection.  Some percentage of women that call my office about their partner’s lack of interest in sex actually have a partner that smokes pot–not just a few times a week but a few times a day.

With problems like marijuana addiction there is always a chicken-and-the-egg question of which came first, the sexual concern or the drug / alcohol escape mechanism.  In my experience, sometimes there is a lack of sexual knowledge, difficulties with self-esteem, or relationship / attachment problems that interfere with having a good sexual relationship with one’s partner.  Smoking marijuana or using other drugs can help a person deflect, rather reflect, on issues that consequently never get resolved.

Marijuana is a drug like any other.  It’s easy to minimize its effects, which actually seems to be part of the addiction.  Marijuana causes a myriad of changes.  If you’ve ever seen a SPECT scan of a pot smoker’s brain, you’ll see that the blood flow in the brain is really crummy.  And, it takes longer for pot to get out of the brain than almost any other drug.

So the next time you or your partner say, “Well, it’s just pot,” think again, especially when it comes to sexual health and relationship issues.

Yet another sexual myth to explode:  It’s always the woman in the relationship that doesn’t want sex.

Not true.  Not by a long shot.  It may not happen as often, but it happens more often than most people think.  And women are just as affected when their partner doesn’t want sex as men are when their partners turn them down over and over again.

Women in sexless marriages complain of feeling unloved, rejected, and unattractive.  In part because of the myth that “men always want sex,” they sometimes feel even more desperate than their male counterparts.  They experience intense sadness–and frustration.

When it comes to sex, even if you’re not talking about it, you’re communicating something.  When a man withholds sex from his partner, more often than not, he’s expressing displeasure with some aspect of the relationship.  What that is differs from situation from situation.  But getting a man to open up and talk about it directly can be difficult.  Quite often, he himself has no idea why he’s upset.  All he knows is that he doesn’t much feel like having sex, and there the story ends, leaving his partner frustrated.

I do frequently advise that physical problems be ruled out.  Unless you’re trained in medicine, you really can’t tell just by looking or studying someone’s behavior what might be going on in someone’s body.  Low testosterone and other medical problems can interfere with desire.

Also (and here I must admit I gave a big sigh), it can be difficult to convince a man to come into therapy, if a woman thinks this might be helpful.  He may call it “hocus pocus,” accuse the therapist of “just wanting to make money off of us,” or feel too embarrassed to talk about his problems.  Both male and female therapists, if they are worth their salt, understand this and know how to talk to men about their concerns.

Even though this is a difficult situation, it can be important that a woman supports her partner with the understanding that this may be difficult for him, too.  Instead of making threats or saying things designed to hurt, work on the problem together to find a solution.

In about 15 minutes I’m leaving my office to give a talk to urologists about what sex therapists can do for men with erectile dysfunction and other common–and not so common–problems, so I thought I’d jot a few thoughts about when to visit a urologist, and when to visit a sex therapist.

If you are under 35 and are in good health, have morning erections, or can get erect when you’re by your lonesome, then you probably want to visit a sex therapist.  If you are under 30 and have health problems or don’t have erections much, spontaneously or not, then see a urologist first.

If you are over 35, then your best first stop is an urologist, who can determine if you have “plumbing problems” or hormonal issues such as low testosterone.  You don’t want to skip this step, because erectile dysfunction (ED) can be caused by various illnesses, including multiple sclerosis, diabetes, pituitary disorders, etc.

Sex therapists are trained to rule out medical problems first.  There’s no point in engaging in “talk therapy” if the problem is your health.  On the other hand, if you have a health problem such as diabetes or need to take medication that affects your ability to have erections, then you probably have a psychological problem, too.  After all, who wouldn’t be a little depressed or even paralyzed at the thought of a change in your sexual health?

Once you have ruled out medical problems, or you are in great health, then you can contact a sex therapist.  If you don’t live in the SoCal area, you can look on the AASECT website to find a sex therapist near you.  A sex therapist can help you overcome obstacles that prevent you from enjoying sex, and also counsel you and your partner about how to incorporate medical interventions into your sexual script, as in the case of someone who is recovering from prostate surgery and needs medication, shots, or other form of treatment.

Hope that’s helpful!

Poking around for blog ideas, I found a very good article on the Telegraph website on “The Sexuality of Middle Aged Men” that I thought I’d share with you.  The article isn’t earthshaking; by now, with all of the ads for meds for erectile dysfunction, you pretty much know that ED is the most common male sexual problem, and that it’s okay to talk about it with your doctor.

But what about with your therapist?  Can a pill solve every sexual problem that men have?   If you’re a regular reader, you know that my answer is no, because a pill can’t give you a skill.  And that’s where I think sexual medicine made a left turn at Albuquerque instead of a right.  Here are some of the skills that men can learn from a sex therapist that they can’t get from a pill:

1. You can’t learn how to be a better lover by taking a pill.
2. You can’t learn what will make you more aroused now that you’re older and may need more sexual stimulation.
3. You can’t learn how to talk about sex and communicate with your partner.
4. You can’t explore other types of sexual experiences that don’t require an erection.
5. You won’t learn that it’s okay not to have an erection sometimes and that snuggling isn’t just for women.
6. You may not learn that ED means that you need to relax, to stop and smell the roses.
7. You may not discover that there is more to your sensual life than is going on with your penis.
8. Your partner may never know that you need more direct stimulation to have an erection.
9. You may always wonder whether or not you are psychologically dependent on medication to have an erection.
10. If the pills don’t work, you may not realize that you have other options, or that your problem is more psychological than physical.

ED medications are marvelous for men that have medical issues that cause their problem, such as recovery from prostate cancer.  Other treatments, too, such as injection therapy, can be helpful.  But I fear that too many men are taking medication that really don’t need it.  Psychotherapy ain’t cheap, true, but neither are meds if the cost is missing out on understanding yourself and your sexuality a little better.

Kind regards,

Dr. Stephanie Buehler

It’s a question I get asked often: Can a sex therapist really help us with our problem?  And, in how many sessions?

In a recent comment, a woman wondered if a man’s low sexual desire was really more about no longer finding their partner attractive, not even a little bit.  She also wondered if the problem could be fixed, and if so, how long it would take.

First, as to the problem itself, low sexual desire can indicate many things, including the presence of out-of-kilter hormones and other biological problems, like an enlarged pituitary gland.  Also, in a study of people with depression, about 70% reported that they had low sexual desire.  Low desire may also occur when a person is struggling with another sexual problem, such as erectile dysfunction or, in either sex, lack of orgasm.

Of course, low desire can also be indicative of a problem in the relationship.  The person with low desire may be angry and unable to express their anger appropriately, so they withhold sex.  They may find that their partner’s lovemaking technique leaves something to be desired.  Rather than communicate, they avoid sex or make excuses.

And yes, as the person who commented said, sometimes it means that the person is so turned off by their partner that they no longer want to have sex with them.  It could be (more…)