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…)

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?

If you’ve been a faithful reader, you know that I frequently comment on upcoming developments in the area of sexual medicine and pharmaceutical interventions.  Get ready for a new one:  A prescribed topical spray that will numb the penis and delay ejaculation for men that have premature ejaculation.

An article in the NY Times reports that this new spray will help men that ejaculate early–on average, 36 seconds–to last another 2 minutes or so.  And the pharmaceutical company is betting that men will line up around the block for this medication–especially with the proper marketing.

The whole issue of how long intercourse “should” be is at stake.  Most men only last a few minutes, so that indicates that’s pretty much normal.  But men feel embarrassed because they know it’s possible to last longer.  And women complain, because they think that if their partner lasts longer, they will be able to have vaginal orgasm.

The fact is that a man’s lasting longer won’t necessarily lead a woman to have vaginal orgasms.  Only about 20% of women have orgasm this way; clitoral stimulation is needed instead.

Also, there are lots of ways a man can learn to last at least as long as what they’d be able to achieve with a topical spray.  (Other topical sprays exist, but they tend to numb a woman’s genitals as well; this new one isn’t supposed to have that side effect.)  Men that want more self-control can learn some methods of awareness that can help them during intercourse.  Also, couples can learn to change their sexual “script” so that both partners have more satisfying sex, regardless of who lasts how long for whatever activity.

In addition, men that have this issue often also have chronic anxiety that has gone undiagnosed and untreated.  In therapy, we can work on both issues so that a man has more overall confidence and control in various aspects of his life.

Yes, therapy costs money.  Yes, it takes effort.  But you don’t learn a skill from a pill–or a spray.  Besides, with our paltry sex education–plumbing + prevention–coming to sex therapy may give you a whole different perspective on sexuality and pleasure that you’ll never get from a visit to the pharmacy.

I wanted to share this interview with a sexual medicine specialist in the Bay area, which I think is an excellent introduction to the common problem of painful intercourse.  I especially liked that they started out the segment by letting women know that if they have painful sex, they are not alone; about 10% of women have discomfort with intercourse.  They talked about three conditions:  vulvodynia, dyspareunia, and vaginismus.

As stated in the interview, there are treatments for painful sex, and they vary by condition.  What is not stated in the interview is that even if you do find a physician that understands and treats sexual pain disorders, it is sometimes tough to get as good an outcome as hoped.  For example, some women learn that they may have to live with some degree of discomfort.  Other women may be given a course of treatment, such as using graduated dilators, but may have psychological difficulties that preclude them from following the prescribed behavior.

The role of the sex therapist as part of the treatment team is an important one.  Many women that have sexual pain disorders balk at seeing a therapist because of the stigma and because of the lack of understanding of how seeing a sex therapist can be helpful.  Not all women may need the help of a sex therapist, but for those that may benefit, here’s how.

Because sex becomes associated with pain, motivation to stick with a treatment plan can wane.  Also, the woman’s partner can become discouraged and withdraw support.  There may be relationship difficulties that impede progress.  Also, a small percentage of women with these problems have had negative sexual experience such as molest and date rape.

A sex therapist can often spend more time with a woman understanding how the condition developed.  Again, the condition is not in the woman’s head, but there may be psychological factors that contributed to its development.  For example, sometimes a woman is in a bad relationship and has repeated yeast or other chronic infections at the same time.  She then develops vulvodynia, which is pain in the vulvar area surrounding the vagina.  The stress of the infection and the relationship may have simultaneously helped to manifest the vulvodynia.  Understanding and processing this can be very helpful for some women.

Also, sometimes women have developed negative attitudes about sex, or what is called a sexual aversion.  As you might imagine, this can have an impact on a woman’s relationship.  Sometimes, this gets in the way of healing.  A sex therapist can help a woman overcome her aversion and discover, or rediscover, a healthy attitude toward her sexuality and her sexual partner.

Just a few days ago I posted about persistent genital arousal disorder (PGAD) aka restless genital syndrome. Then SNL did a tasteless skit about it.  What if this was a character portraying someone with Tourette’s disorder?  Would that be funny?  I don’t think so.

If you watch the skit you’ll see that the actress says that pretty much anything can cause PGAD.  Not so.  It seems to have to do with damage to the pudendal nerve.  Although it can have a psychological component, there is also a biological basis for its manifestation.  And even if it was purely psychological, why should PGAD or any other psychological disorder be a target for stigmatization?

Anyway, I left a comment.  Maybe you will, too.

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.

Two researchers have published a book entitled Why Women Have Sex.  I admit I haven’t read the book, but I found it discussed and excerpted on the ABC website.  The excerpts demonstrate that women have sex for all kinds of sneaky, underhanded reasons:  revenge, pity, to get money or favors, to prove a point, to try sex with someone different, boredom, etc., etc.

Anything new here?  Despite what the researchers say, I don’t think so.  Aren’t these reasons the plot for scores of novels, plays, and films?  I was an English major, but I don’t think you have to have much expertise to come up with a list of at a bazillion familiar works of art that deal with all kinds of reasons that women have sex:  Women in Love, Lolita, The French Lieutenant’s Woman, Gone with the Wind, The Thornbirds, The Postman Always Rings Twice, Fear of Flying, The Group–and those just the classics.

Another problem with the excerpts, as some of the commentators point out, is that it promotes the stereotype that women don’t enjoy sex for the sake of sex–only men do that.   Conversely, it suggests that women are the sole gender that has sex for financial gain, increased status, curiosity, or pity.

Qualitative information isn’t always valuable (neither is quantitative data).  How will this information be useful to a woman that is reading the book?  To a partner?  To a clinician?  How surprising or new or groundbreaking is it that a woman wants to have sex with someone of a different race or socioeconomic class?  What is the model for understanding female sexual desire that comes out of this data?

Or is the real message simply, “Sex sells?”

It sounds like a dream, but it’s really a nightmare:  A woman complains of the sensation of being on the peak of orgasm all the time, or who has orgasm over and over again, never really feeling any sense of completion or relief.

Two items drew my attention to this condition.  The first was a recent article in the Journal of Sexual Medicine and highlighted on the Medscape site that discusses Restless Genital Syndrome.  The second was a woman’s story of having Persistent Genital Arousal Disorder on the site BoingBoing.  They are both the same problem, and they are both medical issues that may or may not have a psychological basis.

As with many female sexual pain problems, women that find themselves in this situation will go from physician to physician trying to find relief.  They may face being told that “it’s all in your head.”  They most likely will experience desperation.  And if they have a partner, they will face frustration because sexual activity may be limited, if it occurs at all.

Sex therapy can play a helpful role for women with this and other sexual pain problems in the following ways:

• Support.  Being able to talk about an intimate health problem with a helpful person who can offer insight and valuable suggestions can help take pressure off.
• Education.  Understanding how one’s emotional and mental state of being affect the experience of pain can begin the process of healing.
• Tools and techniques.  There are many tools that can be used for relaxation, which can decrease the subjective experience of pain.
• Counseling.  Couples affected by these problems often grow frustrated and angry.  Counseling can help couples learn how to communicate more effectively about difficult feelings and situations.

Not all sex therapists are well-versed in helping women (and men) that have sexual problems rooted in a medical condition; you need to ask if the therapist is, as I am, trained in health psychology as well as sex therapy.  You can visit AASECT to find a sex therapist, or the International Pelvic Pain Society to find a medical specialist that may be able to help you.

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.