Sexual Issues

What is Vaginal Rejuvenation and Can it Help my Sexual Issues?

Rhiannon No Comments

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.

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?


  • 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

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: 

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.


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.


Sex and Attachment

Rhiannon No Comments

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.

Secure Attachment

Seeks emotional closeness with others
Able to establish emotional intimacy
Comfortable with mutual dependence
Comfortable being alone
Positive self-image and other image
Warm and open with others
Accepts criticism without significant distress
Strong sense of self
Self-observational skills
Self-reflective skills
Able to trust in relationship
Relationships tend to be stable, lasting
Open with others about feelings
Positive feelings about relationships
Balanced experience of emotions – neither too little nor too much Values attachment

Dismissing Attachment

Avoidance of getting close or being intimate
Discomfort with closeness
Dismissing behaviors
Aloofness and contempt
Mistrust about depending on others
Difficulty getting close
Preference for remaining distant
Fearful of closeness
Unemotional or minimizing emotional expression
Uncomfortable opening up, especially private thoughts
False self
Pulls away if someone gets close
Illusion of self-sufficiency

Anxious-Preoccupied Attachment

Excessive worry about relationships
Worry that one’s partner won’t care as much as s/he does
Obsessive preoccupation and rumination about relationship
Excessive need for approval
Ignoring signs of trouble in the relationship
Fear of scaring people away
Fear of abandonment/rejection/criticism
Resentment when partner spends time away from the relationship
Angry withdrawal
Frustration if partner not available
Feels extremely upset/depressed when receives disapproval
Easily upset, with intensified displays of distress or anger
Fear of being alone
Compulsive caretaking
Submissive, acquiescent, suggestible
Seeks attachment at the expense of autonomy
Work, school, or friends get less attention than relationship partner
Compulsive care-seeking
Partner describes self as ‘smothered’ or ‘suffocated’
Eager to be with partner all the time
Needs excessive reassurance
Clinging, demanding, nagging, sulking
Desire to merge
Attempts to win favor or impress
Forces responses from partner
Self-centeredness, showing off, center of attention.

Disorganized Attachment

Combinations of behaviors from the two insecure types above
Disorganized internal world
Dysregulated psycho-physiological state
Affect dysregulation (too much or too little)
Lapses in self-observation or monitoring
Discontinuous self-states and affect states
Cognitive distortion, confusion, and drive-dominated thinking
Disorganized behavior
Impaired self-agency and goal directed behavior Inhibition of exploration and play
Disorganized attachment behavior
Activation of contradictory attachment strategies Controlling behaviors
Submissive or excessive care-taking behaviors ‘Stable instability’ in relationships
Defensive aggression and helplessness
Inability to elicit desired responses from others

Individual Treatment for Adult Attachment Issues

My clients often ask- how can you help me?  What will treatment look like?  Especially with attachment issues, my clients often feel like there is nothing that can be done to change me and/or my partner.  Using a specified attachment treatment model, there are three components in attachment-based treatment (this might be above a lot of heads, but it gives you an idea that there is actually a method to our madness as therapists):

  1. Creating new positive attachment representations (Internal Working Models- IWMs) with the Ideal Parent Figure (IPF) Protocol
  2. Enhancing metacognitive ability and functioning
  3. Cultivating collaborative skill and behavior
    1. Treatment frame behavior
    2. Nonverbal collaborative behavior
    3. Verbal collaborative behavior

In therapy with me, we will attempt to resolve many of the attachment issues by building a securely attached relationship with the therapist as a spring board to developing healthy attachment with others.  I have the principle that therapist is a good attachment figure that can co-collaborate with the client to create a healthy attachment.  I create the condition for the client to feel safe, to bring to me what you may never have told anyone before, and we want to create that fertile ground for a client to be able to develop health attachments to us as the therapist and beyond.

Relationship Treatment for Attachment

I see a lot of couples that have mismatched attachment systems.  It’s estimated that approximately 50% of the population has secure attachment, approximately 25% each have anxious/preoccupied and dismissive/avoidant respectively, and somewhere in that approximation, 3% have the disorganized style.  Where I see this the most challenging in couples and relationships is when one person(s) has an “insecure” type (anxious/preoccupied, dismissive/avoidant, and disorganized) and one person(s) is secure.  More challenging and with more inflammation within the relationship is the anxious/preoccupied is paired up with a dismissive/avoidant.  These relationships tend to feel super stuck and completely unresolvable, but they are improvable as we work towards moving both partners towards a more secure relationship attachment style through some individual and relationship work mentioned above.   The first step is awareness of your own attachment insecurities and style and then of your partners, recognizing that it isn’t your partner intentionally doing things that stress or activate your attachment systems, but rather them acting within their own attachment style based on their development of attachment long before you ever came into the picture.

Sex and Attachment

How do our attachment styles, challenges and strengths, affect us sexually.  This is an interesting question, and to answer it, I’m going to reference a 2013 study on “The Associations Among Adult Attachment, Relationship Functioning, and Sexual Functioning”“The Associations Among Adult Attachment, Relationship Functioning, and Sexual Functioning”, a blog entitled “Personality in the Bedroom” by Susan Krauss Whitbourne and a 2002  study on adult attachment and sexual behavior.

I’m also going to share some personal experiences with 10+ years in practice as a licensed marriage and family therapist and AASECT certified sex therapist.  Since this issue is one of the most common issues I confront in my practice, I see a lot of individuals and relationships where their attachment styles negatively and positively impact the sexual part of their relationship.

Anxious/Preoccupied: Sex and Attachment

Based on the research and my own findings, I find that people with anxious/preoccupied attachment styles often value sex more as a barometer of how their relationship is going and how valued they are in a relationship.  And if sex isn’t happening, it can highly activate an anxious/preoccupied attachment disturbances because they don’t feel loved, secure, or valued without that measure of their “okay”-ness.  Anxious/preoccupied seek out sex to connect with their partner, and depending on the reaction of the partner, this can often work in the exact opposite way the anxious/preoccupied wants: it actually pushes the avoidant/dismissive partner away.

Avoidant/Dismissive: Sex and Attachment

People with an avoidant attachment style tend to avoid intimacy, be emotionally withdrawn, and try to be more self-reliant, including in sexual matters.  They report lower sexual satisfaction and often move away from sex more, especially if it doesn’t go exactly as planned.  If sex and their sexual value is tied to their self worth, avoidants will often feel very strongly when sex doesn’t go the way it “has in the past” or the way they expect it to go.  This can lead to avoidance of sex and intimacy, or blaming of their partner.  Here are some more “Sexual Symptoms of Avoidant Attachment“.

If you want to read more about attachment style and how it relates to sexual satisfaction, Psychology Today published an article entitled “How Attachment Style Affects Sexual Desire and Satisfaction“.

While there is a lot more to say about sex and attachment, these are just a few of my thoughts, much better explained in   I’d highly recommend this book Attached by Amir Levine and Rachel Heller.

And if you are struggling with sex and attachment issues and are looking for a therapist to help you, feel free to contact me using the form below:


Consensual Non-Monogamy: A Relationship and Sexual Orientation

Rhiannon No Comments

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?

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 photoSwinging– 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.

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, Sex, and Esther Perel

Rhiannon No Comments

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.



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.


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. 

mother photoIt’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.

Chronic Illness and Sex

Rhiannon No Comments

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.

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.

blood pressure photo

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 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!well water photo

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.

pills photo

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

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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 ( 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.

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

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:

Physiological Effects of Anxiety Physiological Effects of Sexual Arousal
Increased heart rate and cardiac output Increased heart rate and cardiac output
Increased muscle tension  Increased muscle tension
pupil dilation  pupil dilation
increased respiration  increased respiration

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.


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

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.



Breath and Good Sex

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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:


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 and the episodes dedicated to Good Sex at (

breath photo

Breaking Up is Hard to Do

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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)


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.

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,, 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.

PCOS and Sex

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PCOS and Sex: Considering Sexuality and Sexual Functioning With a Diagnosis of Polycystic Ovary Syndrome

One of the MOST common endocrine and hormonal issues facing women of reproductive age (it is estimated to affect 4-12% of women) is polycystic ovary syndrome (PCOS).  PCOS is a challenging, symptom-based diagnosis that can greatly impact a woman’s sexuality and sexual functioning.  PCOS is also the most common cause of infertility in the United States.  What we don’t often talk about after a diagnosis of PCOS is how it affects a woman and their partner’s sexuality and sexual functioning.  This blog will go over a brief review of PCOS and how it affects the sexual aspects of a woman and their partner.


women photo

Prevalence and Symptoms

Despite how prevalent the disorder is (1 in 10 women) many women suffer in silence on how PCOS affects them and how it affects the way they feel about themselves sexually and how it can affect their partner sexually.

I have been living with PCOS for approximately 5 years now, but in retrospect perhaps have had some of the symptoms long before my diagnosis.  PCOS is generally a symptoms-based diagnosis, meaning I was diagnosed based on several symptoms I was exhibiting as well as some imbalances in blood and hormonal levels.

The most common symptoms in women with PCOS include:

  • Irregular menstruation: few or no periods, intermittent bleeding, heavy periods, etc.
  • Hair loss from scalp or hair growth (hirsutism) on the face, chest, back, stomach, thumbs or toes
  • Acne and oily skin
  • Fertility Issues
  • Insulin resistance and too much insulin, causing upper body obesity and skin tags.
  • Depression and mood swings
  • Breathing problems while sleeping (linked to obesity and insulin resistance)

The general reason behind PCOS has to do with the body producing more androgens, causing a hormonal imbalance, and the body has trouble using insulin, called “insulin resistance”.  Overall, the cause of PCOS is not readily understood.

You can watch more about my journey with PCOS and why I decided to freeze my eggs last year as well as my experience as a sex therapist diagnosed with Polycystic Ovary Syndrome below.


PCOS and Sex

Not only is PCOS not well known as a major issue for women of reproductive age and the #1 cause of infertility, even more closeted is how PCOS affects sex and sexuality of the woman and their partner(s).  PCOS can have tremendous affects on a woman and their partner and this blog aims at creating more awareness about how PCOS affects the sexuality and sexual functioning of all people involved.

Body Image

The biggest effect I see in clients (and in myself) living with PCOS is how the symptoms of PCOS can change how we feel about our bodies.  Not only did I gain weight mostly in my breasts, abdomen, and upper arms the more the PCOS progressed, but I also grew a white, fine hair on my face that became more and more embarrassing the longer into the diagnosis I went.  No matter what I did, I still gained weight and the hair still grew.  I have always had issues with acne since adolescence, and I noticed that I was getting increasingly more cystic acne on my cheeks, chin, and even my neck.  Painful red bumps on my neck which had never happened before.  There is nothing less sexy than feeling like I don’t even know what my body is doing and feeling super self-conscious on how it looks due to weight gain, hair, and acne.

Body image can greatly affect all aspects of sex and sexuality.  If you don’t feel good about yourself in your own body, why would you want to share it with anyone else?  Having a negative body image about ones body can also really inhibit desire- the better you feel in your own skin, the more desire you’ll have to be intimate and sexual with yourself and partners.

Partners don’t often understand this and I have seen that a partner sometimes doesn’t like the body that their partner has developed because of PCOS.  Self-acceptance is the first to place to start, and then communicating with your partner WHY you might be having these feelings about your body.  Partners often misinterpret a lack of desire for sex or inhibited arousal as something wrong with THEM.  It’s important to talk to your partner(s) about PCOS and how it affects you and to ask for your partner to work to help you and them accept your body for what it IS, not what it isn’t.

How I Manage It:
It sucks.  And its not fair.  But I tried to focus on my body as something that needed my help and love and support, and not something to loathe and despise.  I tried several different very restrictive diets, only to find that the Ketogenic Diet was the most successful.  I lost a little a weight and felt better about my body, but I also mourned the loss of what my life and my body used to be before PCOS.  I’ll talk more about how Keto has helped other aspects of PCOS later in the blog.

I also started waxing my face, which helped, but since then, I have began laser hair removal monthly for all dark, hairy areas of my body (including a brazilian!) and getting my face dermaplaned ever other month (takes care of the hair and also leaves my skin looking fantastic!)  Even though my hair growth was the white, soft hair  on my face and lasering doesn’t work for that kind of hair, feeling good in my body and managing other unwanted hair helped.  I feel like a hairless sexy vixen, which helped my body image.

Another factor was to embrace my curves.  I try to wear clothing that accentuates my body, and doesn’t make me feel self-conscious.  With a bigger abdomen, certain outfits (shorts for example) just didn’t make me feel good about myself.  But dresses looked bomb!  I really tried to find clothing AND lingerie/undergarmets that made me embrace my Marilyn Monroe figure, something that isn’t easy to do when I have been encouraged (societally) to be as skinny as possible.  I also decided that when I needed to wear a swim suit, I would wear the sexiest one piece I can find.  I’m 34 and it might be time to rock the pinup look instead of the bikini look. The feedback has been incredible!  I have found partners CAN eroticize a more full-figured look.  I look like a W-O-M-A-N, and most of them have found that VERY sexy.  And so I have I- because I mean, if I don’t think I’m sexy, how can anyone else?

I was prescribed Spironolactone to manage the acne and some of the other symptoms.  Spironolactone helped right away clear my skin and clear up the hormonal acne that was increasingly getting more severe on my neck and face.  What it also did, however, is cause me to spot bleed more (my doctors denied that this was a thing, but the nurses did not).  So I made sure I kept the dosage as low as I could, since bleeding was a major issue for me.  Overall my skin looks great.

It took a long time and losing 5 lbs. to fall back in love with my body (I gained about 15 lbs after my diagnosis).  I still feel self-conscious at times but body image is something that most people struggle with indefinitely, regardless of health issues.

Depression and Mood Swings

Depression and mood swings, in and of themselves can greatly impact your sexuality and your desire, arousal, and ability to orgasm and experience sex as well as your relationship with your partner.  The hormonal and insulin related nature of depression and mood swings of PCOS can make for a very unstable emotional climate within oneself and interacting with your world (i.e.: partner).  If someone isn’t stable emotionally, due to the side effects of PCOS, or depressed, their sex life will be impacted, with low libido, low desire, low arousal, and difficulty experiencing pleasure and/or orgasm.

And since a lot of the depression caused by PCOS is treated with psychopharmaceuticals like SSRI’s and antidepressants which are CRAZY notorious for impacting desire and sexual functioning, its like a double whammy.  Ultimately, I tell my clients to weigh the benefits vs. the costs of treating their depression:  If you are depressed or have bad mood swings and those are untreated, you aren’t going to want to have sex or enjoy sex.  If you are on antidepressants or mood stablizers, you could feel a lot better but your desire and ability to be aroused or experience orgasm could be inhibited.  Which is better or worse?  Which offers you the best quality of life?  These are decisions to talk about with your doctor and your therapist.

And it is important to keep your partner(s) in the loop.  It can be really confusing to a partner and can impact them as well if depression and mood swings are a part of your life.  Partners can feel blamed, criticized, defensive, and can subsequently develop their own anxiety and depression over their relationship because things aren’t going well or they perceive they aren’t.  Open and honest communication and psychoeducation about PCOS are really important.  No one wanted this- not you, not your partner, not anyone.  Supporting each other and working together is the main goal of dealing with depression and mood swings, no matter what is the cause.

How I Manage It:
diabetes photoSince so much of my mood and emotions were influenced by sugar and my blood sugar and insulin being so imbalanced, when I got the sugar and insulin and glucose reaction under control, this improved a lot, but I’m still prone to some low level depression (its interesting  after I got the diagnosis a lot of things made sense including a long standing low level depression, the acne, and probably irregular periods except I had been on hormonal birth control for so long) I manage it with diet, exercise, nutritional supplements (I work with a naturopath), and a lot of rest.  I can’t overwork like a lot of people without shutting down so self-care is really important.  I’ve also had some success with medicinal foods and supplements such as St. Johns Wort, 5HT-P, SAM-E, and other products, but I don’t advise taking these unless you consult a doctor since they can interact with a variety of other medications (even reducing the efficacy of birth control) so even though you don’t need a prescription for some of them, they should be only taken under the supervision of a medical professional.  If you want to know more about Medicinal Foods, read my blog on Medicinal Foods For Sexual Functioning .

Another thing that a lot of people discuss is Metformin.  I have been prescribed metformin many times but I still resist taking it.  I am not sure why- I think I am stubborn and am trying to manage these things naturally.  But metformin often greatly improves these symptoms for many (as well as various other side effects/symptoms of PCOS).

Sexual Self-Esteem

Body image issues and mood aside, living with PCOS can greatly affect ones sexual self-esteem.  The unpredictability of menstrual cycles and bleeding and fertility issues can cut us at the core of what is often an already fragile sexual self image.  PCOS can make us mistrust our body or feel like we know nothing about it, which can lead to a lack of awareness of ourselves, our sexuality, and what brings us pleasure.  I would not be surprised if a high-level of women living with PCOS also struggle with orgasm and desire issues, as well as other sexual dysfunctions, such as painful sex.  And many of the pharmaceutical treatments for the symptoms of PCOS have the unpleasant side effects of affecting our sexual functioning.

Another factor, PCOS aside, is how high WAS/IS your sexual self esteem?  Sex and the way we feel about ourselves is something we should be exploring indefinitely.  It isn’t a destination, our sexuality and how we feel about ourselves sexually is a JOURNEY.  As a sex therapist, I am constantly learning and growing and reading and journalling and going to conferences about sex.  That is my profession- but what is everyone else doing to feel good about themselves sexually?  To grow sexually?

On my Facebook page, I have tons of links to great books on sex and sexuality.  But two I recommend for all women include Come as You Are (Dr. Emily Nagoski) and a new one Becoming Cliterate (Dr. Laurie Mintz).  But there are so many more.  Our sexuality has been totally neglected for most of us.  Isn’t it time we build our own sexual self-esteem through KNOWLEDGE?

Oh and a brief word about partners- how is their sexual self-esteem?  What are they doing to improve themselves?  Is there stuff rubbing off onto you or vice versa?

How I Manage It:

The biggest factor on this was my irregular periods/bleeding.  There was a time prior to my diagnosis and finding the correct hormonal birth control to be on that I was bleeding every day.  EVERY.SINGLE.DAY.  This really restricted my ability to be sexual with a partner (and since I have been mostly sexually single throughout my journey with PCOS, it made it REALLY hard to be sexual with a new partner).  My sexual self-confidence, even as a sex therapist, plummeted and I felt like I constantly lived in fear of spot bleeding.  It made it really hard to have desire, arousal, and orgasm and made me at times want to avoid sex all together.  I wound up finding a hormonal birth control that helped ease the bleeding and then had to be prescribed a stronger hormonal birth control since I was bleeding through the original after a while.  I also cut back down on the spironolactone and stopped taking a few supplements that I think contributed to the bleeding.  Overall, it took months to figure it out but I’m happy-ish where I am at right now.

As a note- not all birth controls are equal for those of us with PCOS and medications and supplements that we are prescribed MAY VERY WELL have side effects that are distressing as well (like antidepressants on sexual functioning).  Make sure you research yourself what the potential side effects are of a medication and trust your body.  You know yourself better than anyone else.  You can also ask your doctor, but they don’t always have or give you the full information on side effects.  With PCOS, doctors don’t always know a lot about this disorder and they don’t always know all the side effects that will affect us, so make sure you do your homework and be your own advocate.

Glucose/Insulin/Pre-Diabetes/Blood Sugar

This definitely has an impact on your sexual functioning and can range to very little impact to the same affects on your sexual functioning that diabetes has.  Diabetes can greatly affect your sexual functioning, including neuropathy, low sexual sensation, desire issues, issues orgasming and a variety of other issues.  I don’t have the space or time to go into the complete complexities of diabetes and sexual functioning, but it’s worth a perusal of what the internet says…

How I Manage It:

I’ve tried very diets and programs to manage this, and the only thing I really have found that helps me has been the Ketogenic Diet.  Sure, keto is challenging sometimes, but overall, I feel great on it, I feel way more in control of my hunger and appetite, I’m not self-medicating with sugar and carbs (which was pretty much what was happening- my blood sugar was so unregulated I was using sugar and carbs to manage mood swings, emotions, and just generally feeling crummy), and I’ve lost a little bit of weight.  I know Keto is the long game for me, and I just take it a week at a time of making good food choices and learning more about the keto diet.

I’m also considering testing my blood sugar (I already test for ketones) but since I have responded so well to the keto diet, I wonder if I can do even better if I test myself regularly for blood sugar fluctuations.  That might be the next chapter in my management of PCOS.


If you are struggling with a diagnosis of PCOS or think you might have PCOS and are looking for help and guidance with dealing with the symptoms of PCOS, please contact me.  I am a PCOS-knowledegable and PCOS-aware therapist who can help you cope with PCOS and live the best life possible!


More Resources on PCOS

PCOS Awareness Symposium 

In person conference held annually to discuss PCOS developments and research.

The PCOS Summit

Online series of interviews with experts in PCOS available for free for two weeks then for a fee afterwards.

PCOS Diet Support

Online support forums and weekly recipes designed to naturally manage symptoms of PCOS.

There are also a TON of Facebook PCOS groups that can be helpful.  Just type PCOS into your search bar on Facebook and let the joining of the groups begin!

Dealing with Jealousy

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Jealousy can be so painful and fiery and dealing with jealousy can be even harder than experiencing it.  And jealousy is SO prevalent.  At the recent 50th Annual 2017 American Association for Sexuality Educators, Counselors, and Therapists (AASECT) in Las Vegas, NV, there was a presentation entitled “Coping with Jealousy: Tools for Individuals and Relationships” presented by Erica Marchand, PhD and it was SO popular it had to be held in the main ballroom and had nearly 500 people attend.  And it was just a break out session!  There seemed to be more people than the keynote and plenary sessions!

Why was this presentation so popular?  Because jealousy is one of the most intense and powerful and common emotions in intimate relationships.  And we’ve all felt it, and we are all afraid of it.

Most of this information was reference from the presentation by Dr. Erica Marchand and is credited to her presentation.

So what is jealousy?

Jealousy is an emotional state aroused by a perceived thereat to a valued relationship or position, involving feelings of hurt, anger, anxiety and/or betrayal, which often motivates behavior aimed at countering the threat. Jealousy is different from envy, where jealousy is a fear of losing what you have, while envy is desiring what someone else has.

Theories of Jealousy
There are a variety of theories psychologically on why jealousy occurs and why it occurs is important because it informs us as clinicians on how to treat it.  In the therapy room at SexTherapy- Online, we approach jealousy from an integrated model of all these perspectives.

From a psychodynamic and attachment perspective, jealousy is caused by painful childhood experiences, such as loss of love, loss of parent, or threat thereof and poor attachment with primary caregivers.

From a systems perspective, jealousy arises from relationship dynamics and serves a purpose in the relationship.

From a cognitive-behavioral perspective, jealousy is a learned response that can be unlearned and people can be retrained.  From a social perspective, jealousy is shaped and defined by culture and social norms.

evolution photoFrom an evolutionary perspective, jealousy functions to guard against losing mate and/or associated resources.

Gender Differences
Men experience more jealousy in response to sexual aspects of infidelity, while women experience more jealousy about emotional aspects of infidelity.  Sometimes this is credited to evolutionary psychological factors, but its a little more complicated than that.  When working with clients, Marchand says that the evolutionary explanation washes over a lot of other relevant information and factors.  Sexual and emotional infidelity are overlapping concepts and research on gender differences and infidelity has not been replicated consistently. Jealousy and infidelity overlap a lot, but in this blog, we are really just talking about jealousy, and not aspects of infidelity.

Jealousy has been been reported at higher levers among people who have experienced infidelity, people who have been unfaithful, and person(s) with less power/status in the relationship.

Same Sex Relationships
lesbian photoIn same sex relationships, Marchand says there is not a lot of research out there but a few items to note: gay men in monogamous relationships experience more jealousy than in non-monogamous relationships and that intimate partner violence in same sex couples is more prevalent if jealousy is present.

Consequences of Jealousy

There are significant outcomes and consequences of jealousy.  In individuals, when one or both partners are jealous, individuals experience lower self-esteem, anxiety, anger, betrayal, and hurt. Attempting to address jealousy often threatens the relationship and the person can be prone to seeking reassurance, provoking conflict, exerting control, and investing more time and energy into the relationship in efforts to increase their value in the relationship.

If that doesn’t sound EXHAUSTING, I don’t know what does!

In relationships, jealousy can often lead to hostile, aggressive or abusive behavior.  Jealousy can also mask as a perception of love, caring, and investment in the relationship (this is the argument that if one didn’t love someone, they wouldn’t be jealous).  When jealousy occurs, the partner’s reassurance as a response to jealousy is associated with greater relationship stability (I don’t see this happening ALL that often, but it does occur!)

So if you are struggling with jealousy, and need help getting out of its clutches, I can help.  Feel free to contact me at the form below or check out the Schedule An Appointment page for more information.

But here are some of the things we would be working on.  If jealousy is bothering you as an individual, we would focus on the following:

  • Accepting /tolerating distress
  • Increase self-esteem and perception of value
  • Increase self-awareness about beliefs and experiences that are contributing to jealousy
  • Increase ability to self-soothe
  • Create response flexibility

I also see couples, poly-relationships, and Non-Monogamous relationships which can particularly prone to jealousy.  If you came to therapy for your relationship(s) and coping with jealousy, we’d be working on:

  • Developing a critical awareness of relationship patterns
  • Changing relationship dynamics
  • Improving and Adjusting Communication
  • Reconciliation and healing

Some questions you can get started with for homework on helping you better understand your jealousy:

For the Individual
How do you respond to jealousy?
What are your feelings, thoughts, beliefs?
What did you learn from past experiences?
– About other people and relationships?
– About acceptable or desirable responses to jealous feelings?
What do you fear losing
What do you gut-level want to do?  What do you frontal lobe level want to do?
How can you treat yourself like a valuable person?
Make a list of qualities that make you valuable.
List five affirmations a day of your value and worth.
Make a list of ways to be kind/nice/awesome to yourself
Imagine if…
What do you need to do to take care of yourself?

For the Relationship
– Create space for talking about jealousy
– Take responsibility for own feelings/validate others feelings
Make an inventory of partners relationship experiences and expectations
List how to build trust/express affection/reassurance
– Things your partner can do or say to reassure you when you feel afraid, anxious, jealous (do it for self and other person)

If there is infidelity, you will want to focus on rebuilding relationship security, ethos, self-esteem
– Create space to talk about emotions related to affair- including jealousy
– Complete above lists
– Set new boundaries/agreements
– Hurt partner rebuilding
– Atone/Atune/Attach

[The majority of this blogs content was taken from “Coping with Jealousy: Tools for Individuals and Relationships” presented by Erica Marchand, PhD at the 50th Annual 2017 AASECT Conference in Las Vegas, NV]

Still need help with dealing with jealousy, give me a call.  You don’ have to suffer alone!