Every once in awhile I like to write a bit about my experience of being a sex therapist in Orange County.  The end of the year seems like a good time to reflect on my experience.

My practice is definitely a microcosm of the macrocosm.  As the economy slowed down, so did my practice.  Whereas I used to have lots of people in the real estate industry, they now rarely cross my threshold.  And where I used to see some people that were fishing around for answers, I now see mostly clients that are in more dire straits–and that’s the way, frankly, I like it, because then I’m not so much just an actor in someone else’s drama, but working with people paying for a real service.  (I apologize if that sounds a bit callous, but I’m just writing it as I experience it.)

Having my practice slow down has been a good thing.  I have had time to work on a book that’s already been purchased by a publisher.  The book has required a great deal of reading and reflecting, which has in turn informed my practice, making me a stronger therapist in various areas of my work.

Orange County is such a diverse place, and is becoming more so all the time.  This past year I have, once again, seen people who have moved here from all over the globe or who are visiting here from another country or state.  It isn’t easy to find a sex therapist in many places, and Orange County is a cultural and business center, and people do seek help here.  Since I worked as a teacher in Los Angeles for a decade, I thrive when I get an opportunity to learn about different cultures and religions.  The LGBT population also seems to be growing, and I have worked with more gay people that are sorting out various issues.

What will happen in 2010?  First, I am already seeing signs that my practice is picking up, so I think the economy as a whole must be improving, albeit slowly.  Second, I think I will see more people that are looking for non-medical interventions for their sexual problems.  No one really likes to think they are so bad off that their only recourse is a pill!  (Of course, sometimes medication is an important part of treatment, but at least the person will know that they have made an informed choice.)

Third, I will be attending at least two conferences, one on how to better help men that have been sexually abused, and one for AASECT, an organization for which I serve as the Western Regional Representative.  That, too, has been a positive part of 2009, because I have met and networked with plenty of other AASECT member, people that I think of as not just colleagues but friends.

Fourth, I am some plans for providing continuing education, but I’m keeping that under wraps until they’re ready for debut.

As for the blog:  It will still be here.  And, if you are reading this and haven’t yet done so, you can also sign up to receive my newsletter.  You’ll get a free ebook, “Sexual Discoveries: 25 Secrets for Incredible Sex,” plus a monthly article from me.  I also include “Really Weird Sex Stories,” for which I scan the Internet.

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.

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.

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.

Looking for some quick answers about women’s sexual health?  Here’s a new resource, Sex & a Healthier You, from the National Women’s Health Resource Center and the Association of Reproductive Health Professionals.  It looks like the site is in its infancy stages with potential to grow.  I’d recommend signing up for the free newsletter to get on-going information from these two excellent organizations.

Many of the articles recommend talking to your healthcare provider, which makes sense–it’s the first stop for a lot of men and women looking for help with a problem.  But you can also make a sex therapist your first stop.  Most good sex therapists can refer you to a physician that has a special interest in sexual medicine.  If you live outside the SoCal area, visit AASECT to find a sex therapist.

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!

Wouldn’t it be fascinating to see a study of couples in sexless marriages that make lifestyle changes?  I wonder what would happen if, for example, partners managed their stress, exercised, and ate a healthful diet.  Would there be less fighting because they were less tense?  Would they feel better about their bodies?  Have more energy?  Feel more confident?

What if some sexual problems could be fixed by eating more leafy green veggies?

A recent article in the Journal of Sexual Medicine reports that, just as men may have trouble with erections if they have high cholesterol, women might, too.  The study found that women who complained of difficulty with arousal and orgasm and high cholesterol might have blocked blood flow to the pelvic area and genitals.  Because there is no medical treatment for women like Viagra, the researchers suggested that changes in lifestyle might help mature women experience more sexual pleasure.

More and more, we are learning that sexual enjoyment is tied to lifestyle.  A study in Brazil showed that just smoking just 2 cigarettes affects erections in men.  Obesity in both men and women can cause hormonal imbalances that affect sexual health.  Lack of exercise and decreased muscle tone can make it tough to find the stamina or energy to have good sex.

Can you think of a better reason to live a good, clean life, at least outside the bedroom?

Tonight was historic for sufferers of vulvodynia and their partners as ABC’s news show, 20/20 highlighted sexual pain.  Dr. Timothy Johnson interviewed my colleagues (urogynecologist Dr. Andrew Goldstein, physical therapist Amy Stein, and vulvodynia advocate Chris Veasley of the National Vulvodynia Association) plus 2 women who have experienced sexual pain disorders.  Those 2 women, plus Chris, were able to cure their vulvodynia and go on to have normal sexual intercourse with their partners.

I was, of course, very happy to see this common but misunderstood set of conditions covered on national television.  I was a bit disappointed, though, that the segment did not include the perspective of a health psychologist or sex therapist.  There are researchers and clinicians that work with women that have pelvic pain disorders and their partners.

Here’s why a sex therapist can be helpful.  The women in the program complained of psychological problems such as feeling inadequate as a female, lacking support from a partner, embarrassment about the condition, and fears about ever being able to have normal sex again.  All of these problems are things that a few sessions with a psychologist can help.  Not only that, but a sex therapist with a background in health psychology can help women with sexual pain to relax and cope better with discomfort.

The fact is, of course, that if women are steered in the right direction by organizations like the NVA, their gynecologist, or an online search, they can find medical help for the problem of sexual pain.  There are surgery, topical solutions, and medications available.  However, in my clinical experience, some women achieve partial relief.  They are able to have more comfortable sex, but not necessarily pain free.  They also are sometimes left with damaged self-esteem.

Also, a study just released in JAMA confirms that chronic pelvic pain is sometimes associated with past childhood sexual abuse.  It isn’t that the pain is in the woman’s head; it’s that past abuse makes her susceptible to this and other health problems.  Physicians and physical therapists, therefore, need to assess their patients in this regard.

Aside from myself, there are definitely other sex therapists that are willing and able to help women with sexual pain; the best resource I know of is AASECT.

Kind regards,

Dr. Stephanie Buehler

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