What is sexual grief? According to Edy Nathan (2023), sexual grief is a natural response to an unnatural sexually traumatic event or experience which can occur over the span of one’s life.

I recently took a webinar from Edy, who was talking about her book-in-the-works, Healing Sexual Grief and wanting to share her thoughts on sexual grief and how to heal from it.

Nathan says we don’t talk about sexual grief, and that we really didn’t have an accurate label for this experience that is felt by many, and spoken by none. Sexual grief is about the primal part of you that has a sexual self, a sexual birthright, and when that sexual self is harmed, traumatized, neglected, hurt, it results in
– self-loathing
-disgust
-shame
-hiding
– GRIEF

What’s left in the shattered soul is a lost sense of self.

Sexual grief can play “hide-and-seek”, or lay dormant and resurface throughout ones life. I describe grief and trauma as something that never quite goes away, even if you do the work, but it comes back around and around throughout your life. Each time it emerges, powerfully, triggered, activated, raw, its time to focus a new strategy on managing it.

Sexual grief can look like a lot of things, but I’ll share a few examples that I have come across in my work that I think does a good job of explaining what sexual grief actually is.

Sexual grief resulting from an interrupted sexual development. This results in the loss of sexual innocence, ones sexual “purity”, disrupts their entire sexual sense of self and beyond. Grief relates to what happened, what could have been, who the person could have been, sexually and beyond, had the incident(s) not occurred, the responses of others, and the loss of a life that was supposed to happen except for the traumatic event.

Sexual grief because of sexual dysfunction, injury, pain, medication side effects, just not being the sexual person that you thought you would be. Letting go of sexual myths, ideals, and expectations that cause grief around that. Not having sex or pleasure in the way that “everyone else does”. Feeling different or othered because of what is perceived as an abnormal difference in sexual functioning.

Sexual grief because of you are living a sexual life you didn’t expect to be living. Perhaps you are married and expected a blissful lifetime of sexual freedom and pleasure, but instead you or your partners expectations aren’t met. Sexual grief because of orientation issues, including asexuality. Sexual grief because decisions that you made lead to low sexual desire, drive, or pleasure.

Nathan describes sexual grief as a “hostage taker”. Edy presents six “hostage negotiation strategies” to tackle sexual grief. If you want to learn more about sexual grief and how to negotiate with the hostage of sexual grief, Edy Nathan has a 5 Part Video Series on YouTube on Sexual Grief. You can find the first part here: https://www.youtube.com/watch?v=udd50DhH9mc

If you would like to tackle sexual grief and start living a more healing and whole sexual life, please reach out using the form below or email info@sextherapy-online.com to get started on that journey.

If you or someone you love is concerned about their erectile control and are having issues with erectile dysfunction, early or premature ejaculation, or are having trouble ejaculating, it’s never too soon to reach out to a qualified sex therapist that can help you with the issue. In fact, the sooner the better. I see way too often that penis-owners will try to apply do-it-yourself fixes to erectile issues (stop masturbating, stop porn, start masturbating, start porn, Viagara/Cialis/Levitras, going off medication, fantasizing, etc.) that just wind up furthering the problem. In fact, men who have erectile functioning concerns have some of the most dedicated attempts to solving their sexual issue on their own and would rather try everything they can find that might be a solution before reaching out to a professional for help (kind of like not asking for directions when you are clearly lost!)

If this sounds like you or someone(s) you love, then reading this blog can help point a lost ship in the ocean towards a safe harbor of erectile control and confidence. I’ll break it down in a few easy pointers that can help:

1. Accept that there isn’t just ONE cause of your erectile concerns, even if you are convinced that it started because of X. All sexual issues are multi-causal, meaning there are many different reasons why the sexual issue is occurring. When clients come to me, I am interested in not only what you think the origin is of the issue, but also the issues that are maintaining the concern as well. There are likely a LOT of things going into this issue and part of my job is to help figure out what those things are and minimize the impact they have on your erectile control or remove them all together.
2. Your body is not designed to be sexual if it is in a state of stress, fear, anxiety, or relationship conflict. We are mammals, and if our body is in any state of fear, we are really not designed to be sexual. So if you have underlying anxiety or anxiety related disorders (OCD, panic issues, mood issues, hoarding, body focused repetitive behavior, etc.), that is likely a big cause of the problem- where your erection is a SYMPTOM of a bigger, greater issue.
3. Your erection might be telling you something else that is wrong. We have high expectations on an erection. It should just be ready to go, at all times, rain, snow, gloom of the night. But the erection has an opinion about things and often can be the first alarm bell that something isn’t right- physiologically, relationally, psychologically, neurologically, or other. It’s important that we listen to the erection and really make sure we are looking at anything that may be effecting it. Sex is so often a symptom to a bigger, more obvious problem and our bodies, and the erection, often speaks loudly so that we will listen to it.
4. Partners play a huge role in the development and maintenance of erectile and ejaculation issues. If your partner gets disappointed, frustrated, sad, or questions their self-worth, attractiveness, sexual skill when your erection doesn’t do exactly what they or you expect it to do, your partner is part of the problem too. Many people just want to “send” their partner to sex therapy to “fix your issue”, but this is exactly the attitude and perspective that created and/or maintained this problem to begin with. When partners play a role in a problem, they also need to play a role in the solution and likely will be invited into sex therapy to work on how they are contributing to the issue.
5. Certain personality characteristics are more likely to have erectile and ejaculatory issues. If you are “Type A” or a perfectionist, you might have been rewarded for these characteristics in your professional and personal life. But this type of personality or thinking is terrible for your sexual functioning and sexual satisfaction. Sex, by nature, is extremely imperfect. And your sexual self does NOT appreciate being held to any standard but acceptance and positivity. Perfectionists are chronically unhappy and need to do some therapeutic work to deconstruct their values.

If you need more information, I recommend you to a few resources:

Coping with Premature Ejaculation

Coping with Erectile Dysfunction

Hard Conversations Podcast

Have you ever heard of vaginal rejuvenation?

Recently, at the 2018 AASECT Conference, I attended a presentation entitled “Vaginal Rejuvenation: A New Technology for Vaginal Health and Improved Intimacy” presented by my fellow online sex therapist colleague Lisa Thomas, LCSW, LMFT, CST-S and Susan Schroeder, M.D.

This technology has been around for several years but about two years ago, we started using it in the vaginal area and have been finding impressive results.  While more short and long-studies need to be done, this might be a helpful option for some women as long as they consult their health care professional and do the research necessary to understand all the risks, benefits, and unknowns.

What is vaginal rejuvenation?

Vaginal Rejuvenation consists of interventions (surgical and nonsurgical) aimed at improving vaginal laxity, stress urinary incontinence, vaginal lubrication, erotic sensation and/or external appearance.

The field of non-surgical female genital rejuvenation is growing as the changes women experience with age are receiving greater attention.

This is a newer technology that can be LIFE CHANGING for women and many people aren’t aware of this technology.

Three Reasons Why Women Choose Vaginal Rejuvenation

1. It’s not just about better sex.  There are numerous reasons women choose to undergo vaginal rejuvenation which can include loose tampons, scar tissue in the vaginal, experience a “popping’ sound during yoga class or when walking, urinary stress incontinence and problems passing bowel movements.
2. But the sex will be better.  Because surgical vaginal rejuvenation results in vaginal tightening, friction during intercourse is increased which means greater stimulation and pleasure during sex.  Studies report that 83% – 90% of vaginal rejuvenation patients experience successful results and an improved sex life following surgery.  It has been reported to increase sensation and the patient sex life is enhanced by resulting self confidence and increasing libido.
3. It’s a long lasting investment.  Thought it’s normal that all parts of the body relax slightly as we age, the vaginal areas should never return to the degree of relaxation experienced after the intervention.

Photo by Internet Archive Book Images

What Causes Vaginal Change?

• Aging (Atrophy, decreased lubrication, vaginal laxity)
• Childbearing (urinary stress incontinence, decreased sensation, laxity, and trauma)
• Hormonal Changes
• Chronic Inflammatory Disease (Vulvar Lichen Planus)

Do you have any of the above related concerns?  Here are some of the options:

What are some Behavioral Options if I have some of the above issues?

• Kegel Exercises- minimally effective but often recommended
• Pelvic Floor Therapy- Ben Wa Balls or working with Pelvic Floor Physical Therapist
• Biofeedback- a treatment to help patients learn to strengthen or relax their muscles in order to improve bowel or bladder function

What are some of the short-term fixes if I have some of the above issues?

• Vaginal Tighteners (topical): V-Tight Gel, Acano Essential Oil (non prescription)
• Lubricants and Moisturizers (topical): Replens or KY Liquid Beads (non prescription)
• Topical hormones- estrogen (prescription)

What are some of the Surgical Procedures if I have some of the above issues?
Vaginoplasty, Labiaplasty, Perineoplasty

• Vaginoplasty- any surgical procedure that results in the construction or reconstruction of the vagina
• Labiaplasty- a plastic surgery procedure designed to alter the appearance of the labia
• Perineoplasty- a plastic surgery procedure used to correct clinical conditions to the perineum

What are some Emerging Options if I have some of the above issues?

Lasers

• not new technology, just new applications
• Definition of a laser: single wavelength of light absorbed by a specific target or chromophore (color).  Laser energy is converted to heat energy when absorbed by the target
• Mechanism of Action: Tissue Remodeling
• Three types of laser Technology: Radiofrequency, noablative lasers (Erb: YAG), Ablativ Lasers (Fractional COS)

Some Current Lasers on the Market

• FemTouch
• MonaLisaTouch
• Thermiva
• femilift
• Diva: Laser Vaginal Therapy
• Juliet
• Intmalase

According to Dr. Schroeder, the average patient will do 3 treatments, one to start, then the second one month after the first, then 6 weeks after that.  She states that the companies often advise an annual treatment but Dr. Schroeder doesn’t see evidence for the need for this.  Down time varies on the laser technology that is used, but Dr. Schroeder says that the laser she uses frequently (CO2) is 3-days without intercourse with minimal pain or discomfort.

External Treatments using Lasers

Medical Indication: Lichen Sclerosus et Atrophicus (inflammatory condition that causes tissue paper like quality of the skin)
Labia Minora Remodeling: Shrinkage
Hyperpigmentation (Dyschromia)

Platelet Rich Plasma (PRP)

A different procedure but something to note and learn more about that can be an effective treatment for:
Women with decreased libido.
Women who are anorgasmic or struggle to orgasm.
women who desire a heightened sexual experience.

Where to go for treatment: 

Photo by Walt Stoneburner

Board Certified: Dermatologist, Gynecologists, and Urologists.  Do your research, this is a new technology and doesn’t have a lot of information about the long-term effects over.

Costs

If you are doing it in a package of 3, depending on the part of the country that you are in, it can cost between $2000-$4000.  Insurance does not cover the treatment at this time.

A few caveats:

There aren’t long-term studies on the effects of this procedure so we don’t know EXACTLY the long term effects of this so do your research and speak to your doctor(s) and sexual health team.  We DO know the long term effects of this technology on other areas of the body which may inform your decision.

When this was presented, it activated some of the members in the audience, showing that there might be some controversy around the technology.  But as a sex therapist, it is important that I have as much information as possible about possible treatment options for clients that come to me for a myriad of issues.

If you are struggling with this issue, or other sexual issues, please do not hesitate to reach out to me and we can set up a time to meet to discuss this in further.

There are two common issues I see in my sex therapy practice: sex and anxiety issues and sex and attachment issues.  Generally all clients that I see come to me with one or both of these issues, and often times they are the core and fundamental route of other sexual and relationship issues that I see in my work.

I recently attended a training presented by David S. Elliot, PhD on “Healing Adult Attachment: The Three Pillars of Integrative Treatment”.  He is one of the authors of Attachment Disturbances in Adults: Treatment for Comprehensive Repair which details in depth a lot of the concepts presented here around attachment issues in adults.   A lot of this blog comes from the information in his book as well as the presentation and information along the way of being at sex therapist for over 10 years.   I will specifically attend to the issue of how I am seeing SEX and attachment present itself in my therapy practice.  Attachment concerns aren’t a DIY fix- it requires a skilled and trained therapist to take clients to a depth of repair that needs care, nurturance and support.  This book is a big one, thick and cerebral, and something that presents as an invaluable amount of information and resources for the type of therapy that I do.

What is adult attachment?

Watch this brief video on modern adult attachment to learn more about adult attachment.

Attachment affects everything that we do.  Attachment insecurities underlie a lot of mental health problems.  If we treat the attachment issue, we can treat the underlying issue for a lot of mental health issues.

Characteristics of Adult Attachment Patterns

Here are a list based on Elliot’s (2018) presentation handouts of the four main types of attachment styles.  Read through the description and see where you fall.

Have you ever thought about consensual non-monogamy as an option for yourself and/or your relationship(s)?  When we say consensual “non-monogamy”, what do you know or think of?  What do you feel?  Are their strong feelings for or against?  Have you ever considered what your relationship orientation is in terms of monogamy and non-monogamy?  Have you ever thought about having a CHOICE in whether you identify as monogamous or non-monogamous or some different shades instead of just black or white? Further, can you consider that monogamy/non-monogamy isn’t necessarily a CHOICE but rather an orientation and identity factor of fundamentally who you are?

Photo by Abhishek Singh Bailoo

This blog aims to help explain some basic information on consensual non-monogamy.  Much of this information comes from a recent presentation of the Southwest Sexual Health Alliance where Dr. Elisabeth Sheff and Dr. David Ley presented on “Flexible Relationships: Monogamish to Poly” but also includes a lot of information from my own experience as a sex therapist that has worked with non-monogamous individuals, relationships, and couples for many years.

We will get our conversation started by just discussing some basic terms you may or may not know.  We begin with:

Compulsory monogamy is the cultural construct that presents monogamy as the the assumed path for everyone rather than simply one relationship option. Compulsory monogamy as an ideology tends to hold up the heterosexual, married couple as the ideal.  Compulsory monogamy can be marginalizing for not only the non-monogamous but also for people of different sexual orientations (Kinkly, 2018).

Consensual non-monogamy, also called ethical non-monogamy or responsible non-monogamy, is an umbrella term describing relationships in which all parties choose, with full communication and consent, to have the option of engaging in sexual and/or romantic connections with multiple people. This can mean swinging, multi-person relationships, a “monogamish” open relationship in which two people are still each other’s primary partners, or infinite other variations (Baurer, 2016).

Types of Consensual Non-Monogamy

There are a variety of different types of consensual non-monogamy and many variances within these categories.  I will try to offer just a general overview of each of these types of consensual non-monogamy so we have an idea of what we are talking about and possibly give you some ideas for your own life?

Polygamy– Literally means marriage of multiples.  Polygamy is marriage of multiple spouses.  Polygyny is one husband with multiple wives.  Polyandry is one wife with multiple husbands.

Open– Open relationships tend to be the broadest category and is a broad umbrella category for non-monogamy in relationships.  Open relationships simply implies non-monogamy without much detail.

Swinging– Swinging is the most widespread form of CNM.  It is heterosexually focused and used to be called wife swapping and some people call it spouse swapping.  People engage in swinging behavior and “the lifestyle”online, in clubs, at conventions, on cruises, at resorts, and at parties.  Peoples participation in swinging activities can be affected by age, social class, race, and locale and is focused on cis-gender people.  Swinging is usually a dydadic focus (usually two people) and can be sexist (focuses on women participating, and single men often are not allowed unless accompanied by a woman or a couple).  Swinging allows sexual diversity and exploration with no strings from others.   There is not a lot of openness to transgender or queer sexuality in swinging culture and lifestyle.

Polyamory– Polyamory allows/encourages love among more than two people.  Polyamory varies tremendously by relationship, from group sex with others at same time (less common) to independent relationships (more common).  It’s the Double Black Diamond of the consensual non-monogamy community because of the emotional demand that occurs in polyamorous relationships.

• Polyfidelity is a closed/sexually exclusive relationship among more than two people.
• Polyaffectivity is the emotional relationship among people who are connected via a polyamourous relationship but do not have a sexual relationship themselves

Monogamish– More common among younger people.  “Monogamish” tends to be a couple who has a connection to each other, and there is flexibility and “wiggle room” in the relationship: sexually, emotionally, or both.  It varies tremendously by relationship, from group sex with others at the same time to independent flings with others when out of town or with an ex. When monogamish, activities are often embedded in social life and is less event-oriented than swinging.

Photo by rtilden

Relationship Anarchy– Relationship anarchy is the rejection of hierarchy in relationship.  There is a refusal to prioritize sexual monogamy over other forms of relationships.  This is highly specific to each person.  Relationship anarchy can be difficult to define.  This often includes refusal to make, apply, or live by rules or norms and instead relationship anarchists guide life by ethics.

Why is cheating or infidelity NOT consensual non-monogamy?

Infidelity, or cheating, or “having an affair” is not the same as consensual non-monogamy.  The key is that with infidelity, there is generally NOT consent between all parties and some times the act of it being illicit, secretive, and not honest is part of the behavior and the pleasure associated with the behavior.  There is also usually an implicit inequality within the power dynamics of the relationship, a hierarchy, in cheating where one person has a lower level of social and relationship power because that person is being “duped” or is not in the “know” about the affair.  Lack of communication and dishonesty are essential components of cheating, affairs, and infidelity.  In consensual non-monogamy, honesty and communication are essential components.

Therapy with Non-Monogamous Clients

Therapy with clients who are non-monogamous looks very similar to therapy with clients who do not identify as non-monogamous and often deal with issues like finances, sex, parenting, logistics, and COMMUNICATION.   While there are tremendous benefits for individuals, relationships, couples, and families in non-monogamous relationships, in therapy, we often don’t see the clients who say “this is great and working SO WELL for us” but rather we see the clients that are distress over their relationships and these issues.  I want to be clear my clients know that the benefits in non-monogamy often outweigh any risks or discomforts and that clients who are non-monogamous live rich and fulfilled and satisfied lives and that it is a lifestyle and an orientation I strongly support.  BUT it does have some unique challenges in therapy which will be the main focus of this blog.

According to Sheff (2018) the most common issues that non-monogamous clients present with in therapy are as follows:

• Communication
• Negotiation
• Time-sharing
• Types of jealousy
• Indiviualization
• Customizability
• Children, friends, relatives

While non-monogamous couples might have unique presentations of many of these issues, take a look at the list. Does it look much different than issues that most couples struggle with?  Another factor in presentation depends on developmental issues within a non-monogamous relationship.  Often times, I see clients who are struggling with non-monogamy after they have hastily gone into some sort of non-monogamous relationship and it wasn’t going well or had aspects of infidelity or the boundaries weren’t sorted out properly.  Or I’ll see clients that have been in long-term poly- or non-monogamous relationships and new developments around polyaffectivity and emotionality in the relationships have emerged.  I often support relationships as they move through the exciting and pleasurable world of non-monogamy and navigate all the twists and turns this fantastic orientation can provide.  Another way I can support non-monogamous individuals and relationships is by discussing how we might propose the idea of non-monogamy to a partner in a supportive and loving way in efforts to reach our maximum identity integration and minimize feelings of insecurity or fear.

Special Considerations around Communication, Negotiations, and Boundaries

Communication and negotiations are key in consensual non-monogamous relationships and fundamental in healthy relationships.  If your relationship struggles with communication, it is likely a good indicator that your communication skills need work in order to be successful in any relationship, monogamous or non-monogamous.

While there are many popular communication techniques for couples out there to assist with developing good communication skills (IMAGO Couples Dialogue, Gottman Communication, etc.).  One communication technique that is increasingly becoming more popular is Rosenberg’s Nonviolent Communication.  Some basic tenets of nonviolent communication include:

• Emphasis “I” Statements and Self-Responsibilitiy
• Listening with compassion instead of preparing rebuttal
• Four Parts
  • Observations: What I observe (see/hear/remember)
  • Feelings: How I feel
  • Needs: What I need or value
  • Requests: What concrete activities I would like

Here is a 3 hour YouTube video that can help provide you with the basic training in Non-Violent Communication and is worth a watch if you are interested in this communication model.

If you want to learn more about nonviolent communication, we suggest seeking out a workshop or training in the method in your area or feel free to reach out to Rhiannon C. Beauregard, MA, LMFT-S, CST, S-PSB using the form below to set up an appointment to learn the model and gain the skills to practice healthier and more productive non-violent communication.

Communication and Consent

Communication is important in order to ESTABLISH CONSENT FOR CONSENSUAL NON-MONOGAMY.  Consent is an ongoing and living agreement and is renegotiable over time or not truly consensual.  Coercion fouls consent and creates future problems or booby traps.  Consensual non-monogamy is often challenging even when all want to do it and if someone has been coerced it will inevitably explode in everyones face.  And while consent is ongoing, it is important that consent is confused with boundary settings or reassurance seeking.  I help couples establish initial consent and rituals for ongoing consent in non-monogamous relationships.

Communication and Boundaries

Communication is important in SETTING BOUNDARIES IN CONSENSUAL NON-MONOGAMY.  When you are setting boundaries, it’s also important to be flexible- are your boundaries more like a brick wall (no flexibility), a wire fence (boundary but lots of porosity), or elastic (flexible).  Boundaries come from the inside and grow outward into the world.  Rules are imposed on others.  It can be challenging to set boundaries in consensual non-monogamous relationships, especially since many non-monogamous relationships report not having a lot of resources or roadmaps on what boundaries to set and how to set them.  There are different types of boundaries: physical, intellectual, emotional, material, time, communication, sexual, relationship, and other boundaries and those boundaries might vary depending on the setting in which you are establishing your boundaries- work, family, friends, romantic partners, and members of the public.  When setting personal boundaries, its important to consider your individual boundaries, not in relationship to a specific relationship or other person, but just in relationship to oneself.  You can only make boundaries for yourself.

Consensual non-monogamy is a rich and beautiful experience for those that identify with some version of this orientation.  If you’d like to learn more and work with me, feel free to fill out the form below and I’ll get in touch with you to start exploring and healing within the context of consensual non-monogamy.

Desire and sex is one of the most common issues that people present with in my sex therapy practice.  Issues or concerns about desire and sex, “mismatched” desire, low desire, and lack of desire, are some of the most common concerns that clients are coming to me with and seeking out sex therapy for.

Recently, at the 2018 Texas Association for Marriage and Family Therapists (TAMFT) Conference in Irving, TX, I had the pleasure of hearing Esther Perel speak about fidelity, desire, sexuality, and relationships.  She is such an eloquent speaker, I wanted to bring home a few of her “one liners” and points around sex and desire that really impacted the audience and hopefully will impact you and contribute to your sexual desire.

If you like what you read, you should check out some of her books.  She is a leading expert on desire, intimacy, relationships and infidelity and is an incredible speaker and mind.

FOUR WAYS PEOPLE ARE DRAWN TO THEIR PARTNER AND
SEX AND DESIRE BUILDS

People are drawn to their partners when their partner is doing something in their element. 

Esther says that people are most turned on and drawn to their partners when their partners are in their elements.  If you don’t need me, I can want you.  If you need me, I can take care of you.  That will be deeply loving, but not necessarily exciting.  Love and desire are related, but not the same.  When I see you do something when you are in your element, I see the otherness of you.  For a moment I am looking at you, in this space between you and me, this is where the erotic lies.  For a moment, someone I know very well is different, mysterious, and unknown.

People are drawn to their partners when their partner surprises them. 

This is the unknown and the mysterious- being surprised can improve sex and build desire.

People are drawn to their partners when they see their partner talking to other people.

Seeing your partner interact with other people builds desire- it is that otherness that is unknown, mysterious, and connects to sex and desire.

People are drawn to their partners when they are apart: when they are away from each other and when they reunite.  Desire is present in absences and longing. 

Desire can be built when your partner spends time away, is not available, and is absence and there is longing.

HOW CARING, LOVE, AND NURTURING CAN DISCONNECT DESIRE

If you need me to take care of you, that is loving and meaningful, but the woman leaves and the mother appears.  The mother in me, is not a sexual being.  The woman goes backstage and is not at the forefront. 

It’s hard to expect a woman to be mothering and be sexual, especially if she is mothering her children AND her partner.

As a sex therapist, I often hear “At the end of the day, I have nothing left to give” when it comes to desire, especially for mothers with children.    Esther offers a reframe, “that at the end of the day, there is nothing more I need.  I am satiated.”

I don’t want to nurture the little boy, and then have sex with him.

Men often say it’s a turn on to see women turned on.  Women rarely ever say that it is a turn on to see a man turned on.  It is irrelevant to her.  But nothing turns a woman on more than to BE the turn on.  

I’m not sure everyone would agree with the last statement. I have found that some women actually say they don’t want to be objectified, but objectification is sometimes strongly connected to the erotic.

When women say “All he wants is sex” what he really wants is what he has access to when he has sex.

Sex is the door in which he needs to pass to access vulnerability and the aspects of his own masculinity he cannot access unless through sex.  Sexuality is the place where he can go to feel these feelings.  When men are able to access those feelings sexually, they don’t have to worry about feeling like little boys, they can feel it and be a man at the same time.

There is no greater power than voluntary surrender.  It is the reclaiming of the power that has been robbed from us.  For people who have experienced trauma, abuse, and rape, this is actually how the erotic mind takes back control of the imagination. 

When we find someone who emotionally meets their needs, they don’t always meet their sexual needs.  

Esther Perel is the FUTURE of the way we think about monogamy, infidelity, desire in long-term relationships, love, and lust.  In 2018, she was the KEYNOTE speaker at South by Southwest, an annual festival that integrates technology, music, film, and current issues and is the most progressive and interesting festivals in the country.  The fact that ESTHER was the keynote shows the interest that our country and our culture has in this topic and she is a force.   Join me in celebrating her work and contributions on sexual desire

If desire is a concern for you, or if anything I wrote seems interesting and you think I might be a good fit for you in a therapeutic setting, please feel free to contact me using the form below and we can set up an appointment.

One of the most common problems I see in my sex therapy practice is people facing concerns about chronic illness and sex.  Chronic illness is defined as an illness that lasts longer than 3 months and according to the National Health Council (2018), chronic illness affects approximately 133 million people in the United States (which represents 40% of the population) and is projected to rise to 157 million, with 81 million people having multiple conditions.

I myself struggle with a couple chronic illnesses.  I had a back injury in 2011 that lead to a serious back surgery and while I am much improved, I still struggle with various pain and maintenance associated with the injury.  I also have polycystic ovary syndrome and some signs of adenomyosis (a condition when endometrial tissue, which normally lines the uterus, exists within and grows into the muscular wall of the uterus) and possibly endometriosis.  This leads to insulin resistance and a variety of other hormonal conditions, including hormonal mood issues, pain, acne, hair growth, and the list goes on and on. I have found at times I am greatly impacted by the relationship between chronic illness and sex in my life.

Photo by sandiegopersonalinjuryattorney

So, while I don’t really identify myself as such, I suppose I am a person living and dealing with chronic illness.  And I can tell you, from my own personal and professional experience, chronic illness has a GREAT effect on sex, sexuality, and our own sexual self-image.

But it isn’t entirely hopeless- you can do things to ameliorate the effects that a chronic illness has on your sexual self love, identity, and behavior.  And that is where I come in: as an AASECT Certified Sex Therapist with specialized training in dealing with chronic illness and sex AND someone who knows it first hand, I can help you and your partner(s) cope and thrive sexually despite and in spite of a chronic illness or illnesses.  Understanding and awareness is the first step for change- I can help you understand your chronic illness and how it affects your sexual self-identity, sexual arousal, sexual desire, libido, and sexual expression.

While we don’t really have the time and space to deal with the full complexities of chronic illness and sex in a blog, there are a few things that I want to point out that can help you get started on the path to sexual health and wellness around chronic illness and sex.  For more in depth information, please use the form below to contact me and set up an appointment.

The Diagnosis Itself

There are chronic illnesses and injuries out there that have a direct impact on sexual functioning- meaning, one of the direct effects of the diagnosis of a chronic illness is on your sexuality, sexual identity, and sexual arousal and desire.  For example, hormonal issues or prostate cancer can directly affect your sexual system, as well as chronic urinary tract infections or a heart condition where you have to keep your heart rate down and since sexual arousal leads to increased heart rate, this would have a direct impact on your sexual life.

Other chronic illnesses, like fibromyalgia or chronic pain, may have more of an indirect or systemic impact on our sexual systems- meaning while these issues don’t directly affect our sexual health systems physiologically, the diagnosis of the illness itself might greatly impact us sexually through our other systems, such as psychologically, emotionally, mentally, or in other ways, like increased fatigue due to pain leads to less energy for sexual experiences which leads to less desire.  Or having to miss work because of chronic illness, leads to lower self-esteem because one can’t work, which leads to less desire because in general the person is feeling bad about themselves.

It’s important to do your research about how your specific chronic illness affects sex and sexuality.  And while the internet is a wealth of information, what we read on WebMD and other medical based sites don’t often give you the complete picture.  My suggestion is to talk to your health care team- and if you don’t trust them, get a new team or bring on more members of the team.  Take a look at what various Facebook groups, Reddit forums, and other bloggers and folks on the internet are saying.   Read articles and watch youtube.com videos about what people are saying.  Don’t form your opinion from just one source, form your opinion from a multitude of sources and second and third opinions.  And remember, no one knows your health better than you do.  And this includes your sexual health.

Medical and Health Trauma

One of the biggest factors in dealing with the relationship between chronic illness and sex is medical and health trauma, both for the person with the chronic illness and the partner(s) and family members.  Medical and health issues- their diagnosis, treatment, and if no treatment available or accessible, their acceptance, can be riddled with traumatic experiences.  Our culture idolizes western medicine to a point where we often put our blind trust into our health care system to care for us.  But for many of us with chronic illnesses, we have time and time again been let down by “modern” and “western” medicine, or even individual practitioners, clinics and doctors to a point where trauma is often a main area that needs to be treated and can be a huge contributing factor to chronic illness and sex.

Trauma, in and of itself, often regardless of where it came from, can greatly impact our sexual systems.  And it is a curious phenomena in our culture, where often times we look to doctors for solutions to our health problems, including what we perceive as sexual health problems, when they don’t have a lot of answers, training, or understanding of sex and chronic medical conditions.  So that in and of itself can be traumatic- going to the well and there is no water!

Some of the treatments, or lack of treatments, can also be super traumatic.  Some of our interventions are very invasive and can cause fear, anxiety, panic, and just in general a lot of trauma.  Our body is sacred and needs to be protected and when we submit it to painful and scary and anxiety producing diagnostic testing, surgeries, injections, infusions, etc. it can damage our relationship with our body, which can damage our relationship with our sexual sense of self too.

Medical and health-related trauma is real, and can greatly affect our sexual systems.  It’s important that you support yourself throughout your diagnosis and treatment of a chronic illness- therapy can help and it is better to proactively address this through therapy than reactively once symptoms start creeping in.  Remember- our sexual system is an excellent gauge of what is going on in our lives- listen to it.  It might not be the problem, but rather a symptom of a problem.

Medications and Treatment

The first thing you want to understand is how the treatment for your chronic illness affects you.  I don’t know how many times that clients will come to me with long-standing sexual concerns and a lot of times it can be boiled down to the medications, and not the illnesses themselves, that have be a large contributor to sexual issues.  And I also can’t tell you how many times doctors have either omitted talking to their clients about the side effects of medications or assured their clients there are no sexual side effects, when there actually were.  Another factor too- even though the research is important around medications, often times I don’t think pharmaceutical research accurately represents how our sexual excitation and inhibition systems are affected by medications.  And I have also found that sexual concerns are put at a lower priority than the health issue itself- kind of a “deal with it” or “tough luck” attitude.

And when it comes to treatment for chronic illnesses affecting our sex drive and sex life, I’m not just talking about medication, it can sometimes be treatment or absence of medication that impacts it.  For example, a painful injection treatment can greatly affect our sexual systems or in my experience, removing hormonal birth control or other medications can create hormonal imbalances and irregular bleeding which can affect how I feel about myself sexually and has affected desire or arousal.  Or sometimes, there is a high level of desire, but due to treatment or medication or advice of your doctor, you aren’t able to have sex.  Medication and treatments can greatly affect your sexual identity, sexual self esteem, the way you feel about yourself sexually, and your sexual desire, arousal, and ability to orgasm.  If you aren’t sure about how your medication and treatments are affecting your sexual systems, ask your health care provider team and if you want to dive deeper or aren’t sure about what to do to minimize the effects of your medication, treatment, and healthcare issue on your sexual system, feel free to reach out and set up an appointment.

Sex and anxiety are often tied closely together with clients seeking out sex therapy presenting also with anxiety issues.  Anxiety is often the most commonly found emotion tied into sex and sexual dysfunction, and it is important that we address anxiety issues just as much as we address sex issues as issues with sex and anxiety are so closely linked.

Recently, Melissa Hargrave, LPC-S, L-MFT (2018) presented on “The Intersection of Sex & Anxiety: Your Roadmap to Getting Smart About Sex Related Anxiety” at the American Association for Sex Educators, Counselors, and Therapists (AASECT) Meet & Greet held in Austin, TX on February 9, 2018.

Additionally, I’ve had the pleasure to work with Dr. Michael Telch, of the University of Texas Laboratory for the Study of Anxiety Disorders (utanxiety.com) and have added some of his ideas and research in this blog as well.

Here are some thoughts about sex and anxiety and how they interact so closely and can be a major factor that contributes to sexual dysfunction.  First, we will start with a working definition of what is anxiety.

Photo by Scratchdaddy

What is Anxiety? 
Anxiety is the response to a perceived threat and subsequent false alarm.  Basically, when we perceive a threat, our bodies natural inclination is to respond with anxiety or panic (anxiety is a perceived threat in the near or distant future, panic is a perceived threat that is imminent or immediate).  But if the threat is exaggerated, not real, or bogus, that results in a false alarm.

Anxiety is anticipation of future threat, with apprehension and fear, as characterized by symptoms in our body, our thoughts, and behaviors.  Our bodies fear response is a learned response, and can trigger anxiety.

When we learn a fear response to something in sex (because of a traumatic event or other issue) or if our body responds with false alarms to perceived but bogus threats (my marriage will be over if I don’t have sex), we often develop a strong relationship between sex and anxiety.

According to Telch (2018), the following are common features for all anxiety problems: subjective anxiety (dread, apprehension, fear); physiological activation (physical symptom gets activated); pathological worry; avoidance and other safety behaviors; and faulty threat perception.

These above stated processes can greatly affect our sexual lives, sexual self-identity, and sexual sense of self.  Anxiety is a disorder of the future, what will happen in the FUTURE, and any time our minds are focused on the future, we are not focused on the present, removing us from our partner and our sexual experience.

“All anxiety is a distraction from sexual success” – Laurel Steinberg, PhD

Common Symptoms of Anxiety

Photo by mugwumpian

Some common symptoms of anxiety include

• Excessive worry
• Muscular tension
• Digestive problems
• Avoidant behavior
• Hyper arousal (sleep, irritable, anger, restless, hyper vigilant)
• Panic (racing heart, sweating, trembling, short breath, nausea, derealization)
• Compulsivity
• Self doubt, Self consciousness
• Flashbacks
• perfectionism
• fatigue
• trouble concentrating

Anxiety symptoms are persistent, pervasive, and often excessive.  Sometimes these symptoms can often mask sexual dysfunction or create sexual dysfunction, and a causal relationship isn’t always necessary as they can be somewhat unrelated.  But I have often found that there is such a close relationship between sex and anxiety sometimes it isn’t clear which is the cause and which is the symptom, but the fact of that matter is anxiety and sex don’t gel well together.

How Does Anxiety Impact Sex & Intimacy?

Here are some common sexual issues that are impacted by anxiety:

• arousal/desire- hyper or hypo
• orgasms, erections
• vaginal lubrication, clitoral tumescence
• dyspareunia
• chronic pelvic pain
• trauma- disassociation, startle, touch, body memories
• avoidance of intimacy
• body positivity challenged
• sexual aversion- panic, phobia, SAD
• interpersonal and sexual relationship challenges
• psychosomatic- headaches, weight, nausea

Sexual responses of arousal can mirror bodily response of fear and anxiety and anxiety creates a challenge to be vulnerable or “to let go”.   For example, below is a table showing the similar/same physical effects of sexual arousal vs. the physical effects of anxiety:

Anxiety and sexual arousal can often feel like the same process with some people.

Anxiety can cause sexual problems and sexual problems can cause anxiety.  Sexual dysfunction and anxiety may not be causally related.  Anxiety symptoms may be different expressions of the same process- part of sex therapy is to figure out which is which.

False Safety Behaviors
False safety behaviors maintain, retain, and refuel our behaviors.  False safety behaviors (Telch, 2017) are unnecessary actions taken to prevent, escape from, or reduce the severity of a perceived threat.  The important point here is that they are unnecessary and the threat s not real but rather a false alarm.  Safety behaviors fall into five categories: 1) avoidance; 2) checking; 3) mental maneuvers; 4) Use of safety aids; and 5) Reassurance Seeking from Others.  Safety behaviors are designed to keep us safe, but actually wind up leaving us more stuck in the anxiety of perceived threat/false alarm.

Treatment

In treatment for anxiety that affects sexuality, we want to replace our responses and retrain the brain.  We want to move toward relaxation, instead of resisting anxiety.  We need to move from “protect and defend” or “avoid and escape” to step forward and risk.  Our COURAGE is incompatible to our FEAR.

Melissa Hargrave (2018) suggests the following Five Step Model around treating sex and anxiety:

Treatment 5-Step Outline

1. Assess
2. Self-Monitor
3. Psychoeducation
4. Relaxation Training & Mindfulness
5. Cognitive Restructuring

I will explain each of these steps below in the treatment plan.  If you are coming to session for issues with sex and anxiety, this is often how a course of treatment would look like.

Step 1: Assess Anxiety
Hargrave (2018) suggests to draw up a working model of the client’s unique symptoms by asking about clients worries, getting a history, using clinical judgment and assessment models, identifying the clients goals around sex and anxiety, and making sure the client gets a medical assessment for both sex and anxiety.

Step 2: Self-Monitor Anxiety
Step 2 involves tailoring mindfulness exercises to meet the needs of the clients.  In this self-monitoring phase, clients work on managing triggers, physiological responses, recognizing false safety behaviors, work towards ending negative thoughts, look to reduce intensity, frequency, and variation of the anxiety, and focuses on measuring progress.

A quick thought-stopping exercise Hargrave (2018) suggests can be found below:

Step 3: Psychoeducation
Psychoeducation is an essential part of the treatment of sex and anxiety.  All psychoeducation should be again tailored to the clients needs and aims to help inform insight for better symptom management.  Psychoeducation often includes tracking and monitoring anxiety, readings, and other assignments.  Psychoeducation increases insight, self-confidence, and empowerment, however it needs to be limited and balanced, and matched with appropriate homework for maximum retention.

Step 4: Relaxation Training
Relaxation Training regulates the body’s response of anxiety and daily practice is a must.  We have found that the following helps to work to regulate the body’s response to anxiety: yoga, diaphragmatic breathing, meditation, progressive muscle relaxation, self hypnosis, visualizations, exercise, mindfulness, exposure and response prevention.  I have also found that the practice of tantra and orgasmic meditation can also be specific sexual relaxation training that can help manage sex and anxiety.

Step 5: Cognitive Restructuring
In cognitive restructuring, we aim to do exactly what it sounds like: restructure your faulty cognitions that are contributing to your anxiety.  This includes focusing on the value and emotional meaning of the thoughts as well as content, identifying worries and interpretations – not the event, examining accuracy of thoughts, identifying cognitive distortions (i.e. catastrophizing), identifying cognitive fusion (thinking thoughts are reality), developing coping thoughts, and making a plan.

If you are struggling with anxiety and sexuality and are ready to choose courage over fear, please contact me through the form below or by emailing rhiannon@sextherapy-online.com.

Most of this information was taken from Melissa Hargrave’s (2018), LMFT-S, LPC-S presentation and Dr. Michael Telch’s (2017) work on anxiety.  Please cite accordingly.

There is such a strong connection between breath and good sex.  I’ve written about it before in previous blogs and if you are a client or want to be a client, you’ll know that we work a lot on deep breathing and meditation.

At the 2017 American Association for the Society of Sexuality Educators, Counselors, and Therapists (AASECT) Conference, Charlie Glickman (2017)  presented on somatic work with clients.  He stated the following statement:

“The key to really good sex is not technique: it’s breath movement and sound”.

Anyone who practices yoga or meditation will know about deep, rhythmic breathing.  And breath is a fundamental foundational exercise in the practices of tantra and orgasmic meditation. It’s an easy way to bring mindfulness, awareness, and connection to oneself and a partner.  Here is a GIF demonstrating a basic deep breathing technique.  Try it and follow along:

via GIPHY

I know what you might be thinking?  Good sex is so much more COMPLICATED than the breath- that breath and good sex might be connected but it isn’t that strong of a relationship.  I’ll challenge y0ur thinking on that by offering you a couple exercises to try with your partner next time you express yourself sexually.

 Deep Breathing Exercise (Solo or within a Relationship)

Sit or lay comfortably, either alone prior to a solo sexual session or prior to a partner(s) session.  Do deep, rhythmic breathing, or what this video calls “belly breathing”.  We suggest for 3-5 minutes and if you have a difficult time with it, do a guided breathing exercise (easily found on podcast app or this other video below.

Tantric Breathing: Breathing in Unison

Sit across from your partner comfortably so you can look into your partners eyes, some partners like to sit crossed legged, knee to knee, and some need more support from pillows and chairs.  Be comfortable- you will do this exercise for five minutes so I suggest you setting a timer.  Sit across from your partner and gaze into their eyes.  For five minutes, I want you to match each others breath while gazing into each others eyes.  Generally, one person will need to breath deeper than the others, because our lung capacity is different.  Try to breath deep together, increasing air flow and connectivity.  For more information, see my blog on Tantra Sexuality: Weaving Spirit and Sex

Tantric Breathing: Alternating Breath

Like the exercise above, but alternate breath: when one of you inhales, the other exhales. Do this for five minutes.

If you’d like to learn more about how to have Good Sex, listen to my podcast love.sex.ATX and the episodes dedicated to Good Sex at (love.sex.atx).

Breaking up is hard to do.  There are wrong ways to do it, better ways to do it, but regardless of what goes down, ending a relationship through breaking up, divorce, or other ways is a process and a transition.  No matter what happens, there will be pain.  Here are just some thoughts about how to break up in the best possible way.

Whether going through a break up, divorce, or ending a job or other type of relationship, I always speak of four characteristics that are essential to any of these types of conversations.  Provided a person acts with all four of the following character assets, no matter what the message, it will be less painful and more productive.

Four Horsepeople of the Disclosure
(a play on the Four Horsemen of the Apocalypse from John and Julie Gottman)

Honesty
Kindness
Respect
Integrity

Photo by Damanhur, Federation of Communities

My basic argument is this: no matter what you have to say and who you have to say it to, if you speak your truth with honesty, kindness, respect, and integrity, you did all that you could do to maybe share a painful message in a more productive way.  Telling someone no or no thank you is hard, and likely will be painful for both on some level.  NO ONE LIKES TO BREAK UP.  In fact, so many people don’t like to end a relationship (with a partner, friend, lover, employer) that many would rather stay in the painful relationship than SAY NO or end it.  They choose to suffer over speaking their truth and feeling that pain.  To me, it isn’t worth it.

I believe that if you deliver a message with kindness, honesty, respect, and integrity, you have done all you can do to minimize the hurt caused by a painful message. So just keep repeating these in your head when you have to deliver a tough message:

Am I being kind? (to myself and others)
Am I being honest? (with myself and others)
Am I being respectful? (to myself and others)
Am I acting with integrity?

That last one might not be completely obvious since many people, when asked, don’t know how to define integrity.  What is integrity?  How would you define acting with integrity?

Various definitions exist out there but the one I think I liked the best went something like this: integrity is the concept of CONSISTENCY of actions, values, methods, measures, principles, expectations, and outcomes and the honesty and truthfulness of ones actions.  That word consistency is essential to our next discussion about ending a relationship with a high level of integrity.

Consistency
Somewhere along the way in my career, I read somewhere that the best way to break up with someone is through continuous reinforcement.  What this looks like reminds me of the early behaviorism experiments with the rats and the lever- Skinner Boxes and Operant Conditioning and schedules of reinforcement.  Basically, there was a rat, in a box.  He presses a lever and gets a pellet.  Every time.  So he learns that the lever gives the pellet.  That is continuous (consistent) reinforcement.  Best way to establish/extinguish a behavior- continuous reinforcement (lever-pellet or lever-no pellet).

Without getting all Bill Nye on everyone, the other schedules of reinforcement are more challenging to establish/extinguish.  So how this all applies is that when you break up with someone, and you end it, and continuously reinforce that ending, it is healthier in the end, than intermittently reinforcing through break up sex, living with each other after the break up, gradually moving out of the break up with intermittent reinforcement of the relationship and the break up (we go to this wedding as a couple, even though we are broken up… confusing) etc. etc.  There are a million of examples of people doing confusing things during a break up that winds up prolonging suffering.  Here are some facts via youtube, our generations encyclopedia AND how-to manual.  Not super relevant but it goes more into the theory.

Now I’m not suggesting a complete shut down and shut off of the other person during a break up.  Break ups are really painful and that wouldn’t be treating that other person with kindness, respect, or integrity.  But its important that the break up is continuously reinforced out of kindness, respect, and HONESTY for the both parties that the relationship is over.

Why Dragging it Out is More Damaging and Painful In The Long Term

Often times, break ups get dragged out for a variety of reasons: finances, living situations, mutual friends, life transitions, pets, kids, family and often because there is a sense of ambivalence or confusion about the decision to break up.  I often see what we call “polarized relationships” where one wants out, and the other does not OR couples where it is Too Good to Leave, Too Bad To Stay.

The problem with ambivalent or polarized couples is that change is inevitable but strongly resisted so the suffering just increases, increases, and increases.  The lack of decision only leads to longer damage and often results in a crisis (affair, blow up, accelerated break up) instead of a more kind, respectful, thoughtful break up.

And with ambivalent relationships, when one or more isn’t sure if they want to go or not, it is important that there is the option to COME BACK if both parties choose to.  And by not making decisions often leaves this option NOT an option because so much damage occurs during this period the couple passes the point of no return.  If you want to preserve the relationship, it is better to work with a therapist on a planned or controlled separation (Should I Stay or Should I Go: How Controlled Separation Can Save Your Marriage) or go through a course of discernment counseling (a short-term model of counseling that aims at three paths- status quo, divorce/separation, or a six month commitment to couples therapy).

Not acting and having it blow up could leave more wreckage that might not be able to be salvaged if the two (or more) of you decide to reconcile down the road.  If you aren’t sure, its better to get the help to decide rather than let things stay the same.

Reasons to Break Up
The decision to break up and end a relationship is a deeply personal one and shouldn’t be made lightly.  I reference Dr. Stan Tatkin’s books Wired for Dating and its marriage/relationship counterpart Wired for Love
a lot in my work with relationships.  In Tatkin’s (2016) book Wired for Dating , he discusses 18 questions to consider when deciding if you should say goodbye.  They are posted below:

1. Do you or this partner have one foot in and one foot out of the relationship?
2. Is it hard for you or this partner to feel relaxed and comfortable around each other?
3. Is it hard for you or this partner to feel safe and secure around the other?
4. Has any abuse or violence occurred in this relationship?
5. Do you or this partner resist having sex with the other?
6. Are you or this partner strongly an island or wave? [text will explain this further]
7. Do you find it hard to tell how this partner is feeling?
8. Does this partner show little or no interest in your feelings?
9. Do you or this partner find it hard to calm or soothe the other?
10. Do you or this partner ever let thirds (such as people or tasks) take precedence over the relationship? (Note: This could include cheating or betrayal, but it doesn’t have to get that far.)
11. If you or this partner feels hurt or injury, does the other fail to repair it right away?
12. Have you and this partner tried to talk over your differences, but failed?
13. Do you and this partner fight frequently, nastily, or without resolution? (Note: This question is not whether you fight at all).
14. Have you or this partner already tried on one or more occasions to break up?
15. Do you and this partner keep secrets from each other?
16. Do you have no sense of future with this partner?
17. Did vetting with either your or this partners family and friends yield negative results?
18. Would you say a couple bubble has not even begun to form for you and this partner? (179-180)

In my podcast, love.sex.atx, we recently had an episode that discussed breaking up and moving forward.  We talk a lot about how breaking up is a life transition and a journey, and often times necessary for growth, learning, and development, albeit painful.  Take a listen to episode 1:10 our Season Finale, and where an on-air break up actually occurs!

Going through a break up or thinking about breaking up with your partner?  Reach out to me- I specialize in working with individuals as they decide to stay or go and can offer referrals for the relationship.