Vaginismus happens for many reasons.  A woman may be highly nervous about having intercourse, particularly for the first time; she may feel shame or guilt about sex, or she may have performance anxiety.  Or, past trauma such as date rape may be to blame.  Repeat infections, such as yeast infections, or dryness during menopause uncomfortable intercourse can also cause vaginismus.  Finally, treatments for gynecological cancers, such as cervical cancer, can also cause vaginal atrophy.

Because it can be so embarrassing, many women fail to talk to a physician about treatment.  Unfortunately, even women that do mention the problem to a doctor often receive a pat on the knee and advice to “just relax.”  Of course, that is much more easily said than done.  There is much more that can be done to help a woman and her partner overcome vaginismus, including the following steps:

1. Find a physician that specializes in sexual medicine.  This is usually a gynecologist or a urogynecologist (a urologist that specializes in women’s problems).  You can ask your own gynecologist or general physician for a referral.
2. Work with a psychotherapist who specializes in problems of a sexual nature.  This may be a sex therapist, or it may be a marriage therapist who has some training in sexual dysfunction.  Identify what makes you fearful, guilty, or shameful about sex, process it, and let it go.
3. Consider a program of dilator use.  A dilator is a cylinder-shaped object that is inserted into the vagina to desensitize a woman to having something “in there.”  Dilators start with a small size and increase to something comparable to a man’s penis.  The physician or sex therapist can give you guidance on how to use them.
4. Try a program of overall physical relaxation.  You can find many relaxation recordings online.  Or do yoga, meditation, or other form of regular relaxation.  Listening to relaxing music can also be helpful.
5. Learn more about sexual pleasure.  You can learn a lot about your own body through self-massage.  Let your partner know what you do and do not like when it comes to touch.
6. Always use lubricant for any type of genital contact.  Water-based lubricants tend to dry out and need to be reapplied, but they can be used with condoms.
7. Don’t give up on sex altogether.  There are definitely couples that have a rich sex life that just doesn’t include intercourse.  (Often it is the wish to become pregnant that brings them into treatment.)

Women with vaginismus shouldn’t give up on the desire to have “normal” sex with their partner.  It may take some time and lots of encouragement, but with the right assistance most every woman can resolve the problem and enjoy sex.

In my view, women who have a problem with orgasm often have one or more of the following issues:

1. They don’t understand their own bodies.  They never masturbate, which is unusual, especially in these times when you can buy a sex toy and a bottle of lubricant at many local pharmacies.  Since they don’t know their own bodies, they can’t communicate to a partner what it is that arouses them and might bring them to orgasm.
2. If they do masturbate, they focus exclusively on their genitals.  They don’t realize that orgasm requires arousal.  They don’t explore their bodies to see what feels good and gets them excited.
3. They often come from a very religious background which puts the breaks on sexual pleasure, so much so that even when married and in a safe relationship, they cannot let go and allow themselves to experience orgasm.
4. They are in denial about stress in their lives or relationship.  Women may not allow themselves to believe that being with a partner who belittles them or abuses them in anyway, who is neglectful, or who has unacceptable behaviors like frequently drinking to excess, can have any effect on their ability to get turned on.

All of these barriers to sexual pleasure can be overcome.  There are many books available on how to achieve orgasm.  The basic approach is the same.  A woman begins by understanding her own body, both how it is made for pleasure and how to generate sexual energy and excitement.  Next, she begins exploring her body.  She needs to become comfortable with sexual touch and to discover what areas of her body bring her pleasure.

Then she begins to explore her genitals.  She can experiment to find out what kind of pressure, where she needs it to be applied, and how sensations travel through her body and mind.  She needs to overcome fears and anxiety about what will happen if she has an orgasm, because she will know that the answer will simply be she will have a sense of release and a warm glow.

If a woman is unable to experiment with these steps on her own, then a qualified psychotherapist with training in sex therapy can help.  Together with the therapist, a woman can discover her mental blocks to feeling pleasure.  She can learn how to relax during sex, not just with her partner, but with herself.  She can gain confidence in her ability to experience her body and learn to communicate her discoveries. And if there are relationship problems or other stress that get in the way, she can work those through and make changes.

Most of all, what she may learn is that orgasm is only a small part of sex.  A woman’s relationship with her own body and an understanding of her mental attitudes about sex are what can make a true difference between being non-orgasmic and orgasmic.

It is a myth that it is always the male partner that has higher sexual desire.  In my sex therapy practice, it is about 50/50 men to women that have higher desire than their partner.  Another myth is that most partners stop having sex once children have arrived.  If couples had a decent sex life before pregnancy, they will figure out a way to regain their sex life.

What causes differences of sexual desire?  The reasons are as varied as what causes differences in participating in different sports or liking different kinds of food.  Some people have a hormonal profile that makes them naturally more interest in sex.  Other people find that sex is a good way to relax, or feel connected, though their partner may not find sex as effective.  Some partners find that their desire to be with their partner never fades, while others discover that their desire diminishes over time.  People differ in how they were raised to view sex.  They also differ in how important it is to them personally.

Differences in sexual desire can cause a lot of friction in a relationship.  What never works is to nag, harass, beg, argue, or avoid the issue.  If you accept that it is okay, even normal, to have those differences and not read too much into them, then you can calmly and kindly discuss how you can both be happy.  Most couples find that simply compromising on how often they will have sex works well enough, while others prefer scheduling so that both know what to expect.  Some couples find that if the high desire partner has his or her needs met regularly, they are happy, whether or not the encounter is romantic or matter-of-fact.

If you can’t seem to resolve your differences, then you might benefit from the services of a sex therapist.  A sex therapist is a psychotherapist with specialized training in sexuality and human relationships.  The sex therapist can help you understand why you are stuck, give you each an opportunity to voice your concerns, and help you work toward a satisfactory solution.  This involves good communication, compassion for your partner, and a willingness to accept differences.

Asperger’s seems to be current vogue disorder.  HBO recently had a documentary on Temple Grandin, the fascinating woman agriculturalist who has written books about her own experience of Asperger’s.  Last year, three movies were released that featured characters with Asperger’s.  Asperger’s, it seems, is everywhere.

But is it? Asperger’s has a short history, because it was only first diagnosed in 1994 by Viennese pediatrician Hans Asperger, the number of people in the U.S. who have Asperger’s is actually unknown.  Many adults may have Asperger’s without knowledge of the disorder.   Today, however, many children are diagnosed sometime in their early childhood.  In any case, Asperger’s is

How does someone know that they or someone they know has Asperger’s, anyway?  People with Asperger’s usually have poor social skills, obsessions, odd speech patterns, unusual posture, and other peculiar mannerisms.  In an adult, the person may have difficulty understanding social behavior that others take for granted, for example, laughing loudly or at inappropriate times.  (One male client with Asperger’s, horribly embarrassed when he told me about his Peyronie’s disease, then went out to the reception area after his appointment and confided so loudly to the receptionist that the entire clinic heard him.)  They may have strange collections, such as one physician with whom I’m familiar who collected all things having to do with bees; even his office was decorated in black and yellow.

When people with Asperger’s speak, they may not make sense, not because they speak gibberish but because they don’t know how to segue into normal conversation.  Generally, they learn how to get along socially by observing and copying others.  Since they don’t do well with change in any case, this only contributes to behavior that may appear strange or robotic.  A common myth about Asperger’s is that everyone who has it is a “genius.”  Not true.  There are people with average intelligence that also have Asperger’s.

Because people with Asperger’s don’t fit in socially, they often apply themselves in school or in their careers.  This makes them stable and dependable, which can be attractive to a partner that is looking to settle down.  Many people who partner with someone with Asperger’s will marry in the belief that feelings and intimacy will grow over time.  While this can happen, more often than not the non-Asperger’s partner becomes disappointed and frustrated.

Sometimes this disappointment and frustration becomes focused in the couple’s bedroom.  While adults with Asperger’s vary, many non-Asperger’s partners find the lover with Asperger’s mechanical and emotionally disconnected during sex.  Even if they have sexual experience, they may not understand what is expected of them, e.g., mutual pleasuring, vocalization, or emotional expression.

Besides misunderstanding social cues and lacking in empathy, the partner with Asperger’s may also be overwhelmed by the sensory experiences of sex.  One man, for example, disliked the smell and feel of his partner’s hair.  Another couldn’t stand the little bumps and irregularities of his partner’s skin and asked her to wear a body stocking when they had sex.  A woman with Asperger’s complained that she felt “completely smothered” by her husband during lovemaking and decided it was better to divorce than to put up with having to have sex.

Is there any hope for couples in which one partner has Asperger’s?  Yes, of course.  If both partners are motivated to change, then they can have a more satisfying sex life, one that makes each partner feel wanted and accepted.  But a satisfying sex life generally starts outside the bedroom.  Partners first need to educate themselves about Asperger’s so that they can understand how it is affecting their intimate relationship.  They need to be able to communicate to each other; both need to develop some empathy for the other’s position.

Sensate focus activities may also be helpful in slowing down both partners so that they can concentrate on what feels good, instead of on performance.  Learning to give verbal feedback about sex without creating defensiveness is another valuable skill.  Being realistic about what may or may not change in the bedroom is another facet of acceptance of the diagnosis of Asperger’s.

You’ll have to wait until January 2011 to read a copy of my book, which discusses how various psychological problems, from addiction to learning disabilities, affect a couple’s sex life, but until then here are some links to resources about Asperger’s that may be helpful to you:

Asperger Adults

WEGO Health on Asperger’s

The National Autistic Society

A word about diagnosis and treatment:  Different people react to a diagnosis of Asperger’s in different ways.  Some people are relieved to discover an identity that answers questions for them.  Others are curious.  Still others are upset or go into denial.  No individual should ever be forced into being diagnosed or treated.  However, therapy can be helpful for people with Asperger’s and spouses or other family members who are trying to understand and give them support.

I understand that some women really do have trouble with blood flow to the genitals.  That’s because for women the brain needs to send a signal that the woman is excited about sex.  Of course, lots of women aren’t very excited about sex. So there’s no blood flow.  Hence, the pill.

Let me share with you some of the many reasons that women are uninterested in sex:

• they worry excessively about things that are unimportant, such as laundry and other chores
• they think of sex as an obligation, instead of a pleasure for themselves
• they don’t communicate what they want to their partner, so they don’t get aroused
• they feel guilty if sex feels good, so they suppress sexual thoughts and feelings
• they don’t take care of themselves–don’t exercise, eat right, or get enough sleep
• they lack education about their own bodies and don’t realize that they may need direct stimulation to the genitals to get blood flow going, leading to orgasm

How will a pill help with such things?  Imagine, if you will, the day that a man and a woman both need to take a pill to have sex with each other.  It’s a New Yorker cartoon waiting to happen.  Now imagine a couple pleasuring each other in a sensual way.  They know if they have intercourse, that’s great.  If that don’t, that’s okay, too.  No pressure, just pleasure.  Think you need a pill if you make love like that?

It’s different for men.  Men do have medical problems that cause erectile dysfunction, such as diabetes or chronic tobacco use.  And I suppose that there is a very small percentage of women that could use a medication to stimulate blood flow, perhaps a woman who has had cancer and radiation treatment.  But those women who commented on the story who are on antidepressants?  No, not likely.  What needs to happen is to get psychotherapy, get off the pills, and then see where things are at, because there are some people that never regain sexual function after antidepressant treatment. But why bother learning how to stop being depressed / anxious / stressed, when you can just take a pill?

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 talking to his partner about his real sexual needs is avoiding conflict or embarrassment.  If the secret behavior is revealed, the focus is on the fact that he had sex with another woman, and not on other, perhaps deeper problems that may exist.  A man that works at home and misses calls while looking on the computer may be underachieving at work; why is that?  A man that never dates despite his desire for companionship and hides behind his computer screen has another type of problem.

As a psychologist and AASECT-certified sex therapisty approach to treating problematic sexual behavior is unique to each individual.  I don’t sell a fancy program or follow a set course of therapy.  I want to work with someone to understand what function pornography or other types of sexual behavior serve in their life.  When do they look at porn?  What is the trigger?  What do they gain?  Lose?  If they weren’t looking at porn, what might they be doing instead that would make them feel better about themselves?  How is affecting their relationship, if they are in one?  If not in one, is using pornography holding them back?  If so, how?

Who comes in for help with problematic sexual behaviors?  All kinds of people, from high-powered executives to students, from newly weds to men in their 70s, from atheists to pastors.  Often they come in alone, forced by their partner.   For all of them, my goal is a better understanding of one’s sexual behaviors, one’s intimate needs, one’s relationships, and one’s choices when it comes to pursuing pleasure of all types.  If possible, I want to meet with the partner so that they can be part of the process of learning about sexual health, as well as help them process any feelings of anger, hurt, or betrayal.

If you have given yourself the label of “sex addict,” I’d ask you to look behind those words and give yourself the opportunity to learn how to get more of what you really need to be happy, without hurting yourself or your partner in the process.

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 so that she can share what she has discovered with you.

If your wife complains that she doesn’t have any energy, help her out.  If you are feeling amorous, take over a few chores so that she can put her feet up or take a warm bath.  Try doing this regularly, whether or not you are looking for an opportunity for sex.  It’s a fact:  Men that help out have sex more frequently.

There are some rather serious reasons that women may lack desire.  One is that they experience sexual trauma.  Another is that intercourse is painful.  A third would be medical problems, both gynecological and non-gynecological; a woman that has no drive should definitely seek a medical examination.  Problems with depression and anxiety can also interfere with drive.  Finally, changes such as the birth of a child or menopause can have an effect on libido.  These experiences are real and need to be addressed; they just don’t go away on their own.

There is nearly always a reason a woman’s drive goes missing.  Invite your wife to do some detective work with you and then work on the problem together.  If you solve it, great.  If not, perhaps you are both too close to the problem or haven’t considered some of the other many reasons this happens; try using the services of a AASECT certified sex therapist to help you.

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?

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.

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.