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Discernment Counseling and Sex Therapy

Rhiannon No Comments

An area of interest of mine that I’d like to write a little about is a model of couples work called discernment counseling.  Discernment counseling is a short term counseling model that aims to help couples who might be on the brink of ending their relationship gain clarity and confidence about the decisions they make in regards to the future of their relationship.  Discernment counseling was based on a model of counseling initially introduced by Betty Carter at a conference in the 1980’s and then revamped and revived by Bill Doherty (2017) after working with a family law judge who was noticing that many couples were in the process of divorcing that seemed ambivalent or unsure that divorce was the right choice for them.  It seemed like some couples get on the divorce train and don’t feel like they can get off it once the train starts moving.

divorce photoDiscernment counseling aims to help couples on the brink of ending their relationship gain clarity and confidence in the next steps of their relationship.  I first became interested in helping couples make decisions about their relationships when I obtained an Advanced Certificate in Divorce Mediation from Hofstra University in 2007.  While we weren’t trained specifically in discernment counseling (it wasn’t really a “thing” back then), we were trained in the therapists role in a divorce mediation process.  Essentially, as a Licensed Marriage and Family Therapist on a divorce mediation team, my role would be to assist the couples in making the best decisions for their relationship, children, family, etc. as they moved through the divorce process.  While the attorneys on the team advocated for the law and in the best interest of the client(s), my presence would lend the attention to the relational factors that needed to be considered in order for the clients to feel empowered in their divorce process and in order for the clients to make the decisions they needed to make that were in the best interest of their families.

I often find couples proceed with divorce because “that’s what you do” when something goes wrong in the relationship (betrayal, cheating, domestic violence, sex addiction, etc.) and aren’t really aware or encouraged to look at all the options that might be out there for them: couples therapy, discernment therapy, planned separation, and/or just taking some time, taking a deep breath, and putting decision making on hold until everyone is in a better place.

Discernment Counseling and Sex Therapy

You might be wondering how a SEX THERAPIST gets involved with helping couples decide what the appropriate path is for their relationship when facing discernment concerns.  Well, often times, my clients come see me for sex therapy but the situation has gotten so dire, usually around sex AND other issues, that there is a leaning out partner (someone who is thinking they might not want the relationship/marriage any more).  While I begin most couple and relationship work with the intention of working on the couple/relationship, some times for a variety of circumstances, the relationship moves into a place where couples therapy doesn’t have a chance of being successful unless the mixed agenda couple (one partner leaning in/one partner leaning out) has a clear path to work on their relationship.  Sometimes a sexual issue is enough to push a couple into a place of discernment- “do I stay or do I go?”.  Often times it is a sexual issue that got the couple into the room, but other issues that contribute to the overall general concerns, are in need of a discernment process.

Do any of these situations sound like you or your situation?

  • If we don’t fix our sex life, I don’t think I can go on in this relationship/marriage.
  • I don’t want to get divorced or break up but I’m getting to a point in our relationship that I think that is what has to be done in order for me to have a sexually satisfying relationship.
  • My partner has said that divorce is inevitable if we don’t get more on the same page sexually.
  • My partner had an affair and is thinking about divorce.  I want to work on the marriage, my partner doesn’t think it can be saved.  I’d do anything to save this marriage.
  • We’ve both been sexually unhappy for a while.  We’ve tried different things swinging, non-monogamy, etc. but I just want to be sexually satisfied in my primary relationship.  I’m thinking about ending things so I can start over with someone else.
  • Our sex life has never been okay and I think that divorce is the only answer for me getting a happy sex life.

Provided there is a leaning in (read more for definitions) partner in each of these scenarios, discernment counseling could be a good option for couples in this situation.


Discernment is a valuable process for many couples and relationships, because working with a relationship where one partner is leaning out and one partner is leaning in a couples therapy doesn’t always prove to be successful. Unless we have a commitment to work on the marriage and work in therapy, results from couples therapy aren’t often successful.

phone call photoHere I’ll go over the basics of discernment counseling.  I often go over these points in the first phone call to each partner(s) in efforts to orient each partner to what it is that we are going to be doing in the discernment process.

Goal of Discernment Counseling:

The goal of discernment is to help couples arrive at greater clarity and confidence in their decision making about the future of their marriage based on a deeper understanding of the problems in the marriage and each person’s contribution to them.

  • Greater clarity and confidence in their decision making about divorcing.
  • Better equipped to understand their prospects for reconciliation.

Discernment Counseling focuses on getting the clients solidly on one of three paths:

Path 1: Status Quo Path- Marriage goes on as it is.

Path 2: Separation or Divorce Path- Proceed with Separation/Divorce

Path 3: Possible Reconciliation Path- Both partners agree to a 6-month all-out effort to make the marriage healthy without divorce on the table, to see if they can get the relationship to commit.   A PROVISIONAL commitment.

Discernment Counseling

  • Is not therapy, we don’t problem solve but if problems come up, we can note them as problems that need to be addressed if Path 3 (Intensive Therapy) is chosen.
  • The goal is to help you decided whether to try to solve your problems or choose a different path.
  • No change should be expected in the relationship during the discernment process as this isn’t therapy.
  • We are going to ASSESS the situation, not TREAT the situation. You won’t get assignments as couples, but may get separate assignments based on where you stand.
  • The point of discernment counseling is to prevent half-hearted couples therapy attempts and failures in couples work.

Who is Discernment Counseling Good For:

When one is leaning in, and one is leaning out (mixed agenda couples)

Leaning In Partner- partner who is leaning towards maintaining the relationship and reconciliation and are motivated to fix the relationship

Leaning Out Partner– partner who is leaning towards ending the relationship or wants out, but has not made any final decision

Mixed Agenda Couple– when one partner is leaning out and the other leaning in

When is Discernment Counseling Not Recommended:

  • When both partners are leaning out.
  • When divorce is 100% inevitable and everyone is out the door.
  • When you just want a safe place to announce to your partner that you want a divorce
  • When someone(s) not sure if I want to stay in this marriage, but they are SURE they want to work on it and give it a try and they aren’t a mixed agenda couple. They want to roll up their sleeves and try couples therapy.

What it looks like:

Length of treatment: 1-5 sessions, no need to commit to all sessions, we will only commit to one session at at time

Session Time: Generally each session is 100 minutes, with one-to-one conversations, and conjoined conversations

 

Does this sound like something that would be helpful to you or your clients?  If so, please feel free to reach out using the form below!

 

 

 

Furries, Therians, Pets and Pups

Rhiannon No Comments

#Furries #Therians #Pets and #Pups

My #FetishFriday segments touch upon furries and pony play but I wanted to dive a little deeper into the topic of furries, therians, pets, and pups as well as pony play in order to reach out to a large group of folks that might be seeking out sex therapy services but don’t know where to find an affirming and furry-friendy and pet-aware therapist.

For those of you who don’t know what all this means, that’s okay!  I ask that you read this blog with an open mind AND to be open to perhaps one of these topics is exactly what you might be missing in your own sex and fantasy life (and that many of these personas/identities have little to nothing to do with sex).

For those of you who DO know what this all means, I am hoping by writing this blog, you’ll have more hope on finding an affirming and knowledgeable therapist who won’t pathologize or judge your play/identity.  If you are located in the states of Maine, Massachusetts, New Hampshire, New York, or Texas, I can work with you online or in person in Austin, TX.  If you live beyond those states, I would recommend checking out www.aasect.org to help you find an affirming therapist to work with- after all, furries have therapy needs too right?

A lot of the information I am presenting in this blog come from my own clinical experience and training as well as drawn from the presentation “Furries and Pets and Therians, Oh my! Exploring Humanimal Intersubjectivities” presented by Carly Goodkin at the 2018 AASECT Conference.

 

furries photo

So let’s get going!  Let’s start with some definitions so we know what we are talking about here (and if it isn’t clear with what we are talking about, feel free to do some of your own research on what it is that we are talking about!):

Furries: someone with an interest in anthropomorphic animals.

Anthropomorphism: the attribution of human characteristics or behavior to a god, animal, or object.

Fursonas: an avatar or alter ego that someone role-plays or identifies as when interacting with other members of the community of furries, also known as the Furry Fandom

Furries is not zoophilia or beastiality.  The majority of furries do not cite sexual gratification as their main motivator (International Anthropomorphic Research Project, 2016)

Pet Play: form of role-play in which one of the multiple participants adopt the role of domesticated, wild, livestock, or mythical animal.  What one might do as a pet:

  • Eating
  • Resting
  • Training
  • The pet may exhibit traditionally animalistic characteristics, such as extensive non-verbal communication featuring animal noises, biting, and nuzzling
  • Pets may interact with each other at conventions

Often associated with the kink community and power exchange.  There might be packs associated with pets, that might have a hierarchy.  There is a lot of gear and the gear/toys generally fall into two categories (gear that help you channel that animal identity- tails, ears, clothes or gear that you would have to play with a pet- leashes, bowls, pet toys).  Pet play can be a scene pet (playing as a pet only in a scene) or a lifestyle pet (playing as a pet as a greater identity in their own lifestyle- home, public, school, work?).

Human Pets: Some individuals engage in human-pet play, a form of role-play in which an individual is treated as a pet without taking on animal characteristics.            Below is a great online petplay class by a youtuber that will walk you through her experience of petplay and being a human pet.

Therian/Therianthrope: People who believe that they are, in whole or in part, a non-human animal and this is part of their core being spiritually or mentally

There is sometimes an Awakening: realizing and accepting that you are a therian and some therians identify as transpecies and draw parallels with transgender narratives.   There can also be mental and/or physical shifting: perceived changes in one’ mental state or aura from human to animal.

Otherkin: People who identify, in whole, or in part, of something non-human:
– Divine
– Monsterkin
– Aviankin
– Godkin
– Spacekin
– Alienkin
– Angelkin

There is a great YouTube Channel: Therian Nation that can explain these concepts more in detail than I do here.  Here is their intro video:

Working with Furries, Pets, Pups, and Therians in the Therapeutic Context

As an affirming therapist and aware and friendly of the furry, pet, pup, therian and kink communities, I want to make sure that my clients who identify in these populations at the very least feel comfortable with not only sharing with their therapist how they identify/play but also feel comfortable that their therapist will not judge or pathologize them for being a part of these communities.

Many furries report not feeling comfortable either going to therapy or sharing with their therapist they participate in this community because of fear of judgment and lack of understanding and the fear of being stereotyped into a category of people that only participates sexually in this identity.  As mentioned before, most furries do not participate for the main reason of sexual gratification.

Why do People Participate/Identify as these Identities?

So why do people participate in these identities? A lot report that it feels more natural (therians) and that this is a fundamental part of their identity.  Some share that it is a social and emotional outlet for them and that they built a strong community within the communities around participate (furries).  Many enjoy the erotic, imaginative, and playful nature of the play (pups, pets, and ponies).  Almost all report a change in their headspace.

Headspace: a basic mindset permission to go away from executive functioning and going primal.

“Great psychological and emotional release to be able to come home and let loos the restrictions of humanity and what humans are ‘supposed to be like'”.  – Skylerpet

People often report that getting into their character or playing in these scenes allows them to let go of human stressors, expectations, anxieties and just be more primal and basic in their play.

Others report that this is the only time they find that allows them to explore their identity and sense of self.

Identity and self-exploration: People share that taking on animal forms allow them to express or explore an innate part of self, and gives them the opportunity to explore different characteristics culturally associated with animals (pups are playful, foxes are mischievous, mules are stubborn, bunnies are timid).  This augments their inner strengths and allows them to create an identity that is an idealized version of self.

Gender and Sexual Orientation Exploration: It allows people to the opportunity to play with fantasy around gender and sexual orientation.

Provides expanded social experiences: People cite this as one of the main reasons for playing and exploring these areas.  Playing/being in these spaces allow stronger nonverbal forms of interaction and broadened forms of physical affection.  Movement beyond normative forms of social interaction to experience altered communication and physical contact could be enjoyable for people.  Many are seeking novelty and often participants report having higher levels of skin hunger.  These communities can easily accommodate and welcome those who have language barriers, who might typically struggle with socializing, and who are differently abled physically or mentally.  Where people may have not felt that they belonged in other social experiences, these communities are very inclusive.

Community Inclusivity: These communities have an emphasis on acceptance and inclusivity, including people who are marginalized on basis of gender identity and sexual orientation and disability status.

Escape from Oppressive Structures: These spaces allow participants to escape from oppressive structures and experience a freedom from the ways they SHOULD be.

With a combination of headspace, inclusivity, and expanded ways of interacting can mean an escape from: capitalist/materialistic concerns and oppression, homophobia, transphobia, racism, body shaming, ableism, and other issues of the world… where else can someone get this?

Expanded BDSM Experiences: human-animal intersubjectivity may offer different experiences of subjugation, humiliation, or degradation; dependence or caregiving especially in a pet/owner dynamic.

Sex as a Motivator: For some people sexual gratification is a primary or partial motivator.  This can be through watching content, in-person interactions, and online chatting or roleplaying.  There is a common interest to meet partners who participate and are accepting of the lifestyle.  But as I mentioned several times, most do not participate for sex or sexual interactions as a main, primary motivator.

A subset of furry pornography is called “Yiff” which is defined as furry content porn.

Yiffing: is the act of having sex when you are this furry mindset.  Most people are not having sex in their fur suits: expensive, hard to clean, and really hot.

 More Research on Anthropomorphism

International Anthropomorphic Research Project

Conventions

Anthrocon

FurFest

Furry Fiesta

Hopefully, this piece has helped to explain these often misunderstood but very delightful sexual subcultures.  If you are a furry, therian, pet, pup, pony and any way you are and are looking for a therapist, feel free to reach out at the number or email below.

 

EMDR and Sex Therapy

Rhiannon No Comments

A new technique I am happy to begin to introduce and to integrate into some clients’ sex therapy treatment plan is EMDR (Eye Movement Desensitization and Reprocessing) Therapy.  My landing on EMDR has been a curious one- as a client myself I have had some experience with EMDR, but never with EMDR and sex therapy and I’ve also had many clients have successful experiences with EMDR therapy to work with trauma and intrusive thoughts and memories.

But recently, I had a wonderful opportunity to start my own EMDR Training through the first weekend of EMDR Basic Training on June 29-July 1, 2018 in Austin, TX.  My entire EMDR training will be two, 20-hour training weekends plus 10 additional hours of small group and one-on-one consultation and training sessions for a total of 50-hours of training in the EMDR Basic Training.  My second weekend will be in October, 2018 in Austin, TX so by January, 2019, I will have completed the EMDR Basic Training.  Until then, I will be following the practice guidelines in between training and will only begin integrating some EMDR with clients who I have an established relationship who meet the qualifications to begin the work with me.

My intention is ultimately to integrate EMDR with sex therapy clients and to specifically to start working with victims of sexual assault in Austin, TX.  A unique training and volunteer opportunity presented itself recently that I applied for and out of hundreds of applications, I was one of 57 therapists, social workers, and counselors selected to participate in a program that aims to assist survivors of sexual assault in Austin TX.  Through a partnership with Austin Police Department, Victim Services Division and the Austin/Travis County Sexual Assault Response and Resource Team (SARRT), an innovative program was funded that will provide complete EMDR training to therapists in the private and not-for-profit sectors in Travis County in order to provide free therapy for survivors of sexual assault in the City of Austin and Travis County.

lab photoIf you aren’t from Austin, TX or Texas and/or don’t know what has been happening with rape kits from sexual assault survivors, in the short of it, we had a huge and unacceptable backlog of rape kits that had not been processed, with over 2,200-3,000 kits waiting to be tested dated as far back to the 1990’s just in Austin alone, with nearly 10,000-20,000 kits backlogged in other counties and the state as a whole.  I won’t get into WHY this was happening (it’s complicated and involves a lot of factors, not just negligence and long wait times and lab contracts, but victim cooperation and a variety of other issues), but it is totally unacceptable (you can find out more information online from various news sources about this).  As of April 10, 2018, all kits from Austin’s backlogs are in process or have been sent out, but now what?  It was becoming painfully clear that these survivors needed services as their kits came back and their cases began the long and arduous journey of being considered and processed.  APD Victim Services and SARRT realized that these survivors need services with trained trauma professionals, and got funding to train local professionals to provide evidence-based trauma treatment.  Each trained professional is required to provide at least 50 pro-bono sessions to survivors of sexual assault in the three years after training.  Through this program, over 3,000 pro-bono sessions will be provided to the survivors of sexual assault in the Austin and Travis County area.

I am very proud to be selected for this program, help victims of sexual assault in my community, and to develop my skills to begin integrating EMDR and sex therapy.  Specifically, my goal in helping my clients and survivors of sexual assault is to not only address the trauma but specifically work with sexual functioning concerns and post-assault/trauma sexuality.  Because I am a sex therapist, I am a more specialized therapist than many of the therapists, social workers, and counselors in the training in that my training is sex, sexuality, relationships, and gender specific.  I have a more specified knowledge of treatment of sexual issues related to sexual trauma and assault as well as relational and gender issues.  I am greatly looking forward to not only providing quality sex therapy services to existing clients but also welcome survivors of sexual assault into my practice and integrate EMDR and sex therapy.

So I wanted to take a little time to inform my clients, new and existing, a little bit about what EMDR is, what it treats, why we think it works, and what its about.  This is by no means an extensive explanation, and there is so much research out there on EMDR that you can find a ton of other information about it in books, articles, webinars, etc.

To get started, here is a video from Bessel van der Kolk, a leading theorist, therapist and author of a pivotal work on trauma and the body entitled The Body Keeps the Score: Mind, Brain, and Body in the Transformation of Trauma

 

Here is a popular short video that explains a little bit about what to expect with EMDR and how it is believed to work:

 

What is EMDR?

Eye Movement Desensitization and Reprocessing (EMDR) Therapy is an evidence-based therapy model that has been empirically proven and validated with more research conducted and published on the treatment of trauma than any other therapy model.  This model works and has been PROVEN to work.  That is pretty cool!  EMDR is a distinct, comprehensive treatment approach and includes 8 phases of treatment:

  1.  History Taking and Treatment Planning
  2. Preparation
  3. Assessment (Setting Up Target)
  4. Desensitization (Reprocessing of Memory)
  5. Installation (of Positive Cognition)
  6. Body Scan
  7. Closure
  8. Re-Evaluation

It is important to note that EMDR Therapy has these 8 phases of treatment, most which do not involve any eye movement/reprocessing.  Often times, clients will be eager to get to the eye movement interventions but sometimes Steps 1-3 take quite a bit of time to get to.  It’s important to understand that EMDR is a treatment and therapeutic program, not just a one and done technique.

What does EMDR treat?

  • Post-Traumatic Stress Disorder (PTSD)
  • Complex Post-Traumatic Stress Disorder (C-PTSD)
  • Disorders of Extreme Stress (DESNOS)
  • Depression
  • Dissociative Disorders
  • Phobias
  • Complicated Grief
  • Addictions
  • Anxiety Disorders
  • Performance anxiety or enhancement
  • Treatment of Children
  • Couples Therapy
  • Chronic Illness and Somatic Disorders
  • Eating Disorders

What SEXUAL ISSUES does EMDR help with/treat?

  • PTSD and C-PTSD from sexual trauma/abuse/assault
  • Depression and anxiety
  • Sexual anxiety
  • Dissociation during sex
  • Fear of Sex
  • Aversion to sex, sexual aversion
  • Grief and loss related to and unrelated to but affecting sexual functioning
  • Sexual addiction, sexual compulsivity, problematic sexual behavior
  • Sexual performance anxiety
  • Couples and relationship sexual therapy
  • Chronic sexual pain and chronic sexual illness
  • Chronic illness that has sexual effects
  • Somatic processing issues around sexual functioning
  • And many others!

How does EMDR work?

This question can be answered in many different ways, from simple answers to complex answers.  Here is a sample explanation of EMDR that might give you some insight to how it works:

“Often when something traumatic happens, it seems to get locked in the nervous system with the original picture, sounds, thoughts, feelings, and so on.  Since the experience is locked there, it continues to be triggered whenever a reminder comes up.  It can the basis for a lot of discomfort and sometimes a lot of negative emotions, such as fear and helplessness that we can’t seem to control.  These are really the emotions connected with the old experience that are being triggered.  The eye movements we use in EMDR seem to unlock the nervous system and allow your brain to process the experience.  That may be what is happening in REM, or dream, sleep: The eye movements may be involved in processing the unconscious material.  The important thing to remember is that it is your own brain that will be the healing and that you are the one in control”

– Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures.  New York: The Guilford Press. pg. 123-124.

That may seem like a vague answer, but there are a lot of theories on how and why EMDR works and I don’t want to spend a ton of time explaining why (if you want to know, I suggest doing a little more research) but it gives you an idea of a few of the theories on WHY and HOW EMDR works.

So what is EMDR all about?

EMDR Therapy is a treatment program and therapeutic model that aims to help you change your relationship, neurologically, emotionally, cognitively, and physiologically with memories, trauma, disturbing cognitions, or disturbing emotions.  In using EMDR and sex therapy, I hope to use it as a therapy in and of itself with my clients, existing and new, as well as an adjunct model with clients that may have other complicated therapeutic needs but a component of the work would be appropriately addressed by EMDR.  Like I mentioned above, many clients believe that we will get right into eye movements if we are doing EMDR, but in fact, EMDR is a treatment protocol that is a lot more than just eye movements and takes time and multiple sessions to assess, prepare, and conduct.

What EMDR can do though, is incredible- it can unlock and allow you to reprocess cognitions, emotions, and sensations that you may have previously felt that there was nothing you can do about.  Trauma is everywhere, but you don’t have to suffer or struggle with trauma- you can heal and reprocess your experience of trauma.

“The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern.” – Elisabeth Kubler-Ross

If you aren’t located in Austin, TX and want to find an EMDR professional, the EMDR International Association (EMDRIA) is a great place to start:  FIND AN EMDR THERAPIST


If you are in a dangerous situation or need help now: please call 911.

You can also call the National Sexual Assault Telephone Hotline: 1-800.656.HOPE (4673)

You can also call the Austin, TX Crisis Helpline: 512-472-HELP(4357)

If you are in Austin, TX (and beyond) and have been a survivor of sexual assault or trauma, here are some resources for you.

Austin, TX Victim Services Resources

The SAFE Alliance

If you are interested in FREE therapy in Austin, TX and are a survivor of sexual assault, the following organizations offer free therapy to survivors of sexual assault:

YWCA Greater Austin

SAFE Place Counseling 

  • SAFE Place offers a mens survivor support group as well as individual and relationship counseling.

If you are interested in working with me, please fill out this form below and I’ll contact you within 24-48 hours to see I can be most helpful!

 

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?

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

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.

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.

 

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-esteem
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
Ambivalence
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
Jealousy
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.

 

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. 

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 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!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

Rhiannon No Comments

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.

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.

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.

 

 

Breath and Good Sex

Rhiannon No Comments

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).

breath photo