Category: Sexual Health

CONDOMS 101

As a clinician in private practice, I work hard to keep abreast of current research in sexuality. The following post, which I am reprinting in its entirety, came to me through one of my professional list servs and was penned by Massachusetts sex therapist Joseph Winn . I found it readable, clear, and current.

This post provides some basic information about condoms, the types of materials other than latex that are currently available, a brief outline of condom and lubricant compatibility  as well as recent developments and types of barrier methods currently in development. Please feel free to pass this material along to those who may benefit from this information or use this data as a refresher!

Before reading, check out this basic “how to put on a condom” video!

There are five types of condom currently available on the market; 1) lamb skin, 2) latex, 3) polyurethane and 4) polyisoprene, or nitrile, and 5) The Reality Condom or “female condom”, and The VA w.o.w. Feminine Condom.

Lambskin condoms are made from sheep intestine, particularly the cecum. Lambskin condoms are great at preventing pregnancy and they conduct body quite well during sexual activity. Lambskin condoms are compatible with water, oil and silicone based lubricants. Lambskin condoms are also biodegradable which makes them eco-friendly! However, lambskin condoms contain pores that, while small enough to prevent the passage of sperm, are large enough to allow viruses such as HIV and Herpes to pass through the condom barrier and should not be not be used as a form of HIV and STI prevention. It’s important to note that LifeStyles Condoms markets a product called Skyn condoms. These condoms are not lambskin–they are a polyisoprene product–and CANNOT be used with oil-based lubricants.

Latex condoms are the most widely available type of condom on the market today. In terms of manufacturing latex condoms are made from the sap of a rubber tree. Latex condoms if stored and used properly and consistently are safe, strong and cheap, serving as a reliable form of birth control and risk reduction against HIV and most STIs. Latex condoms can be used with water-based lubricants. The only silicone lubricant currently approved for use with latex condoms is ID Millenium.

Oil based lubricants will destroy latex condoms and substantially increase the risk of exposure to unwanted pregnancy, HIV and STIs. As latex condoms are organic they have the undesired result of triggering allergic reactions in some people. These allergic reactions can range from minor localized inflammation and irritation of vaginal and anal tissue to full blown anaphylaxis.

Polyurethane condoms are a good alternative for people with latex allergies. Polyurethane condoms also have the added benefit of being compatible with water, oil and silicone based lubricants. While polyurethane condoms are effective in preventing unwanted pregnancies and remain a good risk reduction strategy for HIV and STI prevention, they have been shown to lose their shape and elasticity during intense sexual activity and have an increased likelihood of breaking during sex. However, if used properly and one is willing to moderate the intensity of their sexual activity, polyurethane condoms provide a good alternative to latex.

Polyisoprene, also known as nitrile, is a synthetic rubber product that does not produce or trigger allergen sensitivities commonly associated with latex. These condoms when stored and used as directed are strong, reliable and serve as an excellent method of birth control as well as HIV/STI risk reduction. Polyisoprene condoms can be used with water and silicone based lubricants. Polyisoprene CANNOT and is NOT oil-based lubricant compatible. Oil-based lubricant will destroy polyisoprene increasing the risk of exposure to unwanted pregnancy, HIV and STIs.

The Reality Condom, also referred to as the “female condom” or FC2. The reality condom is designed for internal vaginal use but has also been modified, see video link below, for receptive anal intercourse. The reality condom when correctly stored and consistently used provides an excellent method of contraception as well as good HIV/STI risk reduction. The Reality Condom is constructed of polyisoprene. Polyisoprene CANNOT is NOT oil-based lubricant compatible. Oil-based lubricant will destroy polyisoprene increasing the risk of exposure to unwanted pregnancy, HIV and STIs. The Reality Condom’s outer ring, which helps to keep it anchored outside of the body, provides greater coverage of the labia and anus during sexual activity and, as a result of this increased barrier against skin-to-skin contact, it has been suggested that The Reality Condom may provide increased protection against the transmission of HPV. However, these claims have not been rigorously studied and, as of this writing, remain uncertain.

Female condom for anal use: http://www.youtube.com/watch?v=6L6YXaVmkCA

Female condom for vaginal sex: http://www.youtube.com/watch?v=OOfZ6VfmQ_s

The VA w.o.w. Feminine Condom is a second-generation internal vaginal condom. The VA w.o.w. condom consists of a latex pouch and sponge at the inserted end of the condom. The internal sponge is designed to hold the VA w.o.w condom in place during sexual activity. The internal sponge is NOT a spermicidal sponge. As the VA w.o.w condom is latex; it is NOT oil-based lubricant compatible.

For a comparison of effectiveness of female condoms see this link: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(13)70054-8/abstract

In development:

Origami condoms. Origami condoms are currently in development and are in the process of being tested by The United States Food and Drug Administration. The Origami condom company is developing a variety of condoms designed for both internal and external use, including specific products for insertion into the vagina and anus! Check out the video links below for more information!”

Male condoms: http://www.youtube.com/watch?v=yPLwLVGCSXA

Female condom: http://www.youtube.com/watch?v=u0VW6AMEXnw

Anal Condom: http://www.origamicondoms.com/#!analcondom/cow7

Please note:

Some late-breaking edits:

Polyisoprene is not the same as nitrile:

Polyisoprene is a natural rubber derivative, not to be used with oil.  Nitrile is a synthetic latex product (but without the latex proteins that cause allergic reactions), and are the same thing medical gloves are made of, and is resistant to oils, water and silicone.

The FC2 female condom is made of nitrile, not polyisoprene, so can be used with oil,water or silicone lubricants.

Another helpful website to consult is : Condomology, http://www.factsaboutcondoms.com/ , prepared by the  American Sexual Health Association.

 

Considering Propecia? Bald May Be Beautiful!

 

Dear Dr Ren,

My boyfriend and I were both getting a bit thin on top and got prescriptions from our doctors for Propecia. Great results, except that where my boyfriend noticed no side effects, I lost pretty much all sexual interest and now have trouble getting an erection. I’ve halved the dosage, but the effects continue. If I discontinue to drug altogether, will I lose the hair I’ve regrown? How long will it take before my libido, and my erections, return?

Hairy but not Horny

bald man re propecia column

Dear Hairy but not Horny,

Here in Canada, where our health care system has generally been pro-patient and benevolent, we tend to trust that our doctors know enough about medications to keep us from harm. Sadly, Big Pharma has become so sophisticated and greedy that its information delivery systems often use very small type in the warnings that negatively affect us.

Doctors are inundated with propaganda and biased reporting, much as the public is. Just as we are bombarded by movie stars hawking the newest and slickest of panaceas, physicians are blanketed with promotional materials and samples by eager and well-paid drug reps. Pressed to care for too many patients each day, doctors simply cannot find time to read peer-reviewed reports of every drug for each ailment they treat. Big Pharma wagers millions of dollars that this is true.

The ‘vanity drugs’ squeak under the radar because we do not consider them life-threatening nor life-saving. Propecia grows hair. How dangerous could it be?

You are learning the answer to that question.

Propecia (Finasteride) converts testosterone into dihydrotestosterone. A complex cascade of effects from this conversion includes a decrease in the production of semen, shrinking of the size of the penis and the prostate, an increase in fibrosis of the penis and possible prostatic nerve damage. Not enough bad news? It also encourages an increase in estrogen production which can lead to gynocomastia, or man boobs. Even a short time on this drug can cause such psychological problems as anxiety, confusion, depression, and sleep disturbances. This whole package is called the “Post-Finasteride Syndrome.”

If you thought this news was bad enough, you are mistaken. The kicker is that in a small proportion of men, these effects are persistent. That means that even if you discontinue the drug, the symptoms continue unabated, sometimes permanently. Yes, permanently.

Surely, you protest, the drug manufacturer, Merck, would be required to publish warnings about such side effects. Their package insert states that “Only a small number of men will experience decreased libido and/or difficulty in achieving an erection. An even smaller number may have problems with ejaculation, including a decrease in the amount of semen ejaculated during sex (although this effect does not seem to interfere with normal sexual functioning). Clinical studies have shown that these adverse reactions will disappear in men who stop treatment with PROPECIA and in many who continue treatment.”(Italics mine)

We do not know how to screen for those who will fall victim to permanent sexual and emotional debilitation from finasteride. We don’t know how to over-ride or treat those who develop the syndrome. The drug companies, denying the problem, are not underwriting research!

In January of this year, Canada launched a class action law suit against Merck. As well, a Dr Michael Irwig is offering support to men like you who have experienced negative side effects of this powerful drug.

Still, I’m afraid you drew the short straw and your boyfriend didn’t. Regardless, discontinuation of the drug would seem prudent for both of you. If you are really worried about hair loss, you can try a product called Rogaine, less potent—and less toxic—than Propecia. Or you could reorder your priorities. After all, it’s just hair, and Bruce Willis long ago made bald sexy!

But what then? You have lost your sexual drive and your erectile capabilities. Get to your prescribing physicians and report your results. They can attempt what is called re-androgenizing therapies, though those have shown little success in these cases.

Then you are faced with the process of grieving your losses, processing your anger and re-ordering your relationship dynamics. Therapy, for you, your boyfriend, and for the two of you as a couple, can help you with these emotions and transitions.

What has happened to you is not fair. You have had to pay an extremely high price for a bit of vanity. This is not unlike the scores of women who succumbed to the promise of greater self confidence by embedding seemingly “harmless” breast implants in their chests, only to find that the contents poisoned them irreparably. Or the conscientious women who, fearing the crippling effects of osteoporosis, began therapy with Merck’s Fosamax (alendronate), later to learn that the bone tissue they grew had the consistency of spider webs and they were now precluded from dental procedures, so flimsy were their jaws.

We do the best we can with what we know. When we learn more, we do better. Share this knowledge with everyone you know, so that no one else suffers needlessly. Since Big Pharma does not, we must protect our own interests.

Traumatic Masturbatory Syndrome

In his ground-breaking research in the fifties, Kinsey found the most common answer to the question, “How do you masturbate?” was “The usual way.” It still holds true today. Though we each develop individual styles of packing our suitcases or organizing our closets, we assume that everyone masturbates just like we do. Not so.

Generally it doesn’t make much difference how we pleasure ourselves so long as we enjoy ourselves and get the job done. However, for a surprising number of males, there is a style that becomes problematic. It bears the unwieldy title of traumatic masturbatory syndrome.

When men engage in TMS, they lie on their stomachs, often with a pillow under their hips, and tighten their thigh and buttocks muscles rhythmically until they ejaculate. They may or may not rock their hips. They do not touch their genitals with their hands, which are often held tightly at their sides or pulled up against their chests.

TMS
TMS position

You may wonder why your position during masturbation would have any effect on you at all, and you’d be correct in asking. Ordinarily it doesn’t. If you lie on your side, or on your back, or even sit while jerking off, your face and body are exposed to your surroundings. Your hands are likely encircling your penis and stroking your thighs, chest and testicles.

In TMS, none of this is true. Boys who learn this masturbatory technique tend to become isolated with their fantasies during arousal and ejaculation. They close their eyes and go inside–these are not porn watchers. Since they are not touching themselves, they do not learn to associate touch with the pleasure of sex. Also, their rigid body form certainly does not mimic the fluid lovemaking they will be enjoying in later years.

It is the transference of erotic patterning from solo to partnered sex that prompted sexologists to dub this “traumatic” masturbatory syndrome, for these fellows experience great difficulty relating erotically to another person. Everything about partnered sex feels wrong to them. The touch of another’s skin, so much a turn-on for a man who has learned to associate stroking with pleasure, is a distraction and/or an annoyance for one who lies silently, internally focused, clenching and releasing his muscles, hands balled into fists. Eye contact is difficult, as are relaxing and changing positions during lovemaking. Murmuring sweet nothings? Not likely. In fact, sharing the journey from erotic stirrings to orgasm is next to impossible for a man who has learned to masturbate on his stomach without touching his genitals. He becomes sexually crippled in terms of partnered sex.

It requires some intensive therapy to undo the damaging effects of this masturbatory pattern. Not only does the man’s masturbatory behaviour need to change, but also his perspective from inward to outward. If TMS is well-established, many men may find it difficult to relate to sexual partners physically. By the time they come in for treatment, they are often socially withdrawn and sexually anxious.

TMS is far more easily prevented than cured. When speaking to your boys about sexuality, mention that masturbation is self-pleasuring they’ll do on their backs. If you suspect your child is already masturbating, encourage his creative fantasizing by suggesting he get a magazine with pictures that arouse him (he can’t look at pictures with his face buried in a pillow). Your sex positive attitude will also decrease his anxiety about his changing body and his new-found favourite pastime and lead to his leisurely exploration of his sexual arousal pattern. Though this may be tough for you to do, you will be giving him the chance for great sex throughout his lifetime. He and his lovers will thank you (perhaps tacitly) for it, I assure you.

Regardless of your masturbatory style, try doing it new ways occasionally. It will keep you ever ready to try new and different sexual positions and experiences, knowing that your body can respond to varied stimulations. You’ll be glad you did.

New Birth Control Methods

I want to dedicate this month’s column to the abundance of new and improved contraceptive choices now available to women. Such was not always the case. Reliable contraception (the Pill) did not arrive until 1960. Before then, women relied on nothing more than bulky and fragile condoms, the unreliable rhythm method, and good luck to avoid unwanted pregnancies. Hasty and unhappy marriages resulted when those methods failed and many young women’s dreams of education and career terminated because their pregnancies could not—Roe v Wade did not grant women sovereignty over their bodies until 1973!

How different is our personal landscape today. The new millennium rang in scientifically sound methods of birth control our mothers could not even imagine. We have pharmaceutical choices as well as barrier methods, and better understanding of our bodies’ subtleties resulted in even more reliable natural methods of conception control. Though this column outlines the newest and brightest stars on the pharmaceutical scene, I encourage you to explore all your options and make your decision in concert with your partner(s) and your health care provider(s).

So what’s new? There’s a lot of buzz about the new low-dose pill named Seasonale that allows us freedom not only from worry about unintended pregnancy but also from more than four periods a year. Another option is Lybrel, a low-dose estrogen and progesterone pill taken every single day, eliminating periods altogether and therefore the attendant fluctuations of our hormonal cycles, a boon to those who suffer PMS, migraines, acne, etc. It will be available to us here in Canada next year.

Don’t want to bother with taking pills at all? Or worried that you may forget to take them every single day? A smoker over thirty-five? Not to fret. Perhaps you’d be interested in trying the NuvaRing , a slim, flexible circle you insert into your vagina once a month. It releases a low dose hormone that mimics the effect of the oral contraceptive. What could be easier?

Actually, I have an answer to that. If you have already given birth to a child, you may want to consider an IUD. I can hear you now, complaining of the cramping and the long bloody periods. But, wait. IUDs aren’t what they used to be. The Mirena is an easy-to-insert model that releases just enough progesterone to keep you from becoming pregnant while keeping your periods cramp-free and light in volume. Gone are the days of the Dalkon Shield, recalled like a bad Buick. Women now have real choices about how to regulate their fertility and their menstrual cycles, and they can do so with a high degree of confidence about their physical safety. Hallelujah!

But, you say, you’re not in a steady relationship and you require birth control protection only irregularly? Yes, we have answers for you, too. You might want to investigate the spermicidal sponge. Wasn’t that around years ago, you ask? Yes, it was. Seems water at the plant that manufactured the Today Sponge was contaminated and, rather than invest in the necessary cleanup, the company closed the plant. Consumer demand being what it is, the competition began marketing their own brands and now even the original Today brand sponges are available, but only in Canada. Note well: the effectiveness of the sponge is severely compromised in the presence of yeast-fighting medications, and it works far better in women who have not borne a child.

Add to these recent additions the pharmaceutical storeroom of condoms, diaphragms, cervical caps, contraceptive jellies and foams, natural family planning methods, ‘traditional’ birth control pills (makes me smile), IUDs, and sterilization methods for men and women (some reversible), and we can appreciate how vast are our options for choosing conception. If given proper information, each of us can be responsible for our body and treat parenting as the privilege it should be. Could it be that those who carried placards in the ‘60s bearing the Utopian ideal “Every child a wanted child” might see their dream realized? Science and education could make it so.*

*Below you will find an email communication from Dr Linda Hendrixson (Assistant Professor, Health Education Department, East Stroudsburg University) regarding statistics on the efficacy of various birth control techniques. It’s fairly dry reading, but offers current and accurate data that can help us determine our best choices.

~

I have the 17th edition of Contraceptive Technology-1998. It lists the failure rate for typical use of “periodic abstinence” (just avoiding intercourse during ovulation) as 25% (% of women experiencing unintended pregnancies in the first year of use). So, typically, it’s 75% effective, so to speak.

CT lists the failure rate for perfect use of “periodic abstinence” as between 1% and 9% (91%-99% effective) depending on which fertility awareness-based method is used:
Calendar method: Typical use=13% failure rate. Perfect use=9% failure rate.

Ovulation method-assessing cervical mucus: Typical use=20% failure rate. Perfect use=3% failure rate.

Sympto-thermal (measuring basal (resting) body temperature + assessing cervical mucus): Typical use=20% failure rate. Perfect use=3% failure rate.

Post-Ovulation ( I presume this means restricting intercourse only to the days after ovulation has occurred): Typical use=no failure rate noted. Perfect use=1% failure rate.
It must be noted, however, that CT takes its typical use failure rates from national surveys done in 1976, 1982, and 1988. Perfect use failure rates are the best “guesstimates” of the authors. Obviously, more up-to-date data are needed for typical use failure rates for this and other methods discussed in CT. Perhaps the 18th edition, recently published, sheds more light on the subject.

Regarding continuous abstinence, the goal of abstinence-only programs: Advocates for Youth carries a report dated 9/27/2004 called “Five Years of Abstinence-Only-Until Marriage Education: Assessing the Impact,” which is a good analysis of short-term and long-term effects of a number of these programs in thirteen states. From the conclusion of the study: “. . .none of these programs demonstrates evidence of long-term success in delaying sexual initiation among youth exposed to the programs or any evidence of success in reducing other sexual risk-taking behaviors among participants.” It is a worthwhile report to read.

So far, then, continuous abstinence, at least among youth in many abstinence-only education programs around the country, is showing a high typical use failure rate.

Premature Ejaculation (PE) for Women

Some time ago a client came to me for treatment of premature ejaculation. Like most men, he had suffered with this condition his whole life. Married many years, he reported with great sadness that his sexual difficulties had so eroded his relationship that his marriage was on the brink of collapse. His wife had given him a final ultimatum: get fixed or get out.

I explained the course of treatment and we began. All went well until it was time for his wife to join us. Despite his initial success and my encouragement, she steadfastly refused to attend sessions. She would not even speak with me on the phone. Since this was not her problem, she would not be involved in its resolution. She simply wanted him “fixed.”

Months passed. My client called again, reporting some progress. His wife had agreed to read literature about PE aimed specifically at wives. What did I have? I went to the Internet. Nothing. I appealed to a sexologists’ list serve. They suggested couple’s therapy. Hmm.

Therefore, I designed this month’s Hot Topic for the wives of men who suffer with timing their ejaculation. My hope is that when you finish reading this, you will be inclined to join your mate in counselling, for they need you there with them. In the meantime, I hope this column will address your needs.

Many of you have lived for years hoping that perhaps this time sex will be fulfilling, that he will last long enough for both of you to enjoy the connection and intimacy that intercourse can bring. Then he comes fast again. He mumbles he is sorry. You look away, tell him it’s all right, and soothe him. You both turn away from each other, silent and disappointed.

Eventually you avoid his touch. You do not let yourself give in to the expectation of arousal and release. What’s the point? You accommodate his advances so you don’t have to have a discussion or, worse yet, a scene. You feel like a receptacle. You resent him. This is not what you signed on for. Why doesn’t he do something to fix this!? God knows, you’ve been patient, forgiving and loving. Inside you start turning to ice.

As time progresses, your frustration leaks into other areas of your relationship. You no longer view him as someone you can count on. The respect and admiration that once made you breathless is long gone. He becomes just another child to be tended. You can’t even rage at him about this given men’s fragile egos. You consider an affair but reject the idea, for you know the only way you can maintain your family and your sanity is to deny your body any touch. The first whisper of sensual pleasure and you know your defenses would collapse. You are a prisoner in your frozen world. You hate him for this. You cannot punish him enough!

Now he goes to therapy and says he is better. On the few occasions you submit to intercourse he is just as nervous and incompetent as ever. He tells you his therapist says it will be that way until you come in for treatment, too. No way are you falling for that! You have been hurt enough. Why should you risk any more?

I have an answer for you.

You should risk now because your mate and his therapist are telling you the truth. He has gone as far as he can on his own. He has done weeks’ worth of masturbatory exercises (and in some cases taken pharmaceuticals) to learn a new sexual response language to replace the one that did not work.

When he comes to you, the sexual scene is the same. He needs this, too, to be different, and he cannot do this alone. As a team, he and I want to teach you his new language so that you two can speak it together – cautiously and haltingly at first – until slowly and lovingly you become fluent lovers once again. Joyous, relaxed lovemaking awaits you.

I am not so naïve as to believe this is happening in a relational vacuum. I want to see you alone as well as with your mate. I am well aware of your need to vent and to grieve. I understand that you have sacrificed your own sexual expression and may be hopping mad. I realize that we must repair other areas of your relationship as we mend your sexuality. You have been silent for too long. Now is the time to have your story heard in an environment of safety and solace.

Are you afraid that it is too late for you? Do you think that your sensual, responsive nature is hard and dry now, that it can no longer be awakened? It can.

You are no more frightened than your man was. Your stakes are the same. Your reward for taking this risk is also the same – a chance to reconstitute the promise you two made so long ago, buried under disappointment, good intention, and inadequate communication.

Please consider joining your husband in his treatment for PE. It offers not only a chance to repair your beleaguered sex life but also an opportunity to work on the damage done by the effects of dashed hopes, disappointments, and unresolved anger. So much more is possible. Isn’t the risk worth the chance of renewing your relationship?

First Visit Reactions

A number of clients have shared with me their reactions to their initial sex therapy visit. I thought it might be instructive to those of you considering therapy to hear what they had to say.

A man in his mid fifties told me that the pre-session homework I ask of everyone had been enormously helpful. This involves answering two simple questions: “What are the problems?” and “What would need to happen for you to know the problems have been resolved?” He explained how this exercise had focused him, even before our first meeting, on the precise nature of his troubles and on his goals. He added that the questions reminded him that this appointment was dedicated solely to talking about him, which he had been avoiding for ages. This brought up mixed feelings of trepidation and relief.

Another new client, a woman in her thirties, disillusioned by the disconnection between the myth of happily-ever-after and the reality of maintaining a real-life relationship, shared her relief that she had found a place where she could admit her fears and doubts to someone who would not judge her. Though her friends offered a comfortable place to vent and share good times, they could not give her a neutral and confidential ear. She also appreciated learning accurate information about her body and its sexual functioning.

Then there was the couple who had grown so estranged that visiting me marked their last attempt to save their marriage. I noticed that they did not touch or even make eye contact. They were still emotionally connected and got along well, but it had been a long time since they had experienced any intimacy. I asked them if they would do exercises at home. They admitted they had not like the idea—felt it was juvenile and pointless—but they agreed. Their willingness to risk feeling awkward and vulnerable with each other signalled their willingness to change the character of their relationship.

Sometimes people come in just because they need a safe place to talk about something. It can be difficult to find someone non-judgmental and uninvolved, especially regarding sex. Clients generally tell me they feel a bit anxious when they first arrive, but that it doesn’t last long.

Other times clients need accurate information and want help in determining how that information best applies to their lives. Often that can be sorted out in a session or two. Still, it can feel a bit humbling to admit we don’t know something about sex. We all want to be knowledgeable about something that’s supposed to “come naturally.” I try to make the learning fun and relaxed.

Still other times clients come in who feel quite hopeless about their sexual situation. They arrive bursting with questions and emotions. I can hardly give them information and support fast enough and I watch their anxiety dissolve as the session progresses. Their body language and even their breathing change over the course of the visit. I hear phrases like “I never thought of it that way before” and “I wish I’d come in ages ago.”

Few people have contacted a sex therapist before. I’m used to that. I appreciate the trust put in me as folks stretch their boundaries to learn more about their sexuality and relationships. I hope this peek into what initial sessions can be like helps you to feel more comfortable in approaching the process of sex therapy with anticipation. It can be an exciting adventure. After all, the potential reward is great sex for the rest of your life!

Labioplasty

It seems recently that every radio talk show host calling has the same question. Ditto each magazine reporter. Everyone wants to talk about labioplasty: surgically trimming the labia to look like a porn star’s.

I’ve been around long enough to remember attending women’s health conferences in the early 70s where we considered ourselves brave and liberated for looking at our own cervixes with mirrors and flashlights. I once lay head to head with another woman as a parade of onlookers circled us, each bending to peer into our specula-stretched vaginas. One matron straightened, alarmed, and alerted me, “My dear, you have blood up there!” I responded that I had my period. Her face worked for a moment as she processed this information. Then she smiled. “Oh, yes,” she nodded, “of course that’s where it comes from,” and she moved down the line. We knew so little of ourselves then that we prized each new piece of knowledge and power.

Fast forward three decades. Now periods are optional and the thrill of ownership of our genitals is eclipsed by the anxiety of comparing them to the perfect digitally retouched porno pussy. Sigh.

Labia are like faces. All have the same basic parts yet each is distinct. Labia are filled with sensitive nerve endings that deliver the most exquisite sensations when swollen and treated nicely. Beneath the skin of the labia lie the crura or legs of the clitoris (the hard round button tucked under the clitoral hood is but a fraction of the organ). Since the labia are rarely symmetrical, each responds a bit differently to touch, providing more and varied sensations as we climb towards orgasm. Many women use knowledge of these anatomical differences during masturbation. As we get closer to orgasm, we may pull on that slightly larger left labia to increase traction on the clitoral hood, for instance. The wise lover will pay attention to these details and explore his/her lover’s geography to learn the many available exciting pleasure paths.

Labioplasty has nothing to do with pleasure. Zero, zip, nada, zilch. Trimming your pussy lips to be tiny, tight, and symmetrical is entirely about meeting some theoretical perception of what the ‘perfect’ woman’s labia is ‘supposed’ to look like. This month. Considering we can’t see our own vulva without a mirror and a flashlight, genital plastic surgery certainly isn’t about our own visual satisfaction. Is it solely in response to what we believe are the wishes of our male partners? But if you ask most men to describe the ugliest pussy they ever saw, they’ll quickly respond, “It was beautiful!”

So why are women submitting to this surgery? We’ve already bought that our breasts are too small, our bottoms not appropriately peachy, our thighs too cottage cheesy, and our stomachs too slack. Our icon models are anorexic waifs while our real life population gets fatter and fatter. Perfection seems ever more unattainable.

Each of us owns our own body and has every right to do with it whatever we want. No question. It troubles me greatly, though, that so much emphasis is placed on appearance with barely a reference to function or pleasure.

Before we consider removing the tissues that cause us to call out God’s name, let’s think hard about what we are doing and why. If you feel that your relationship would be improved by having slimmer labia, examine your relationship! Invest in a copy of Joani Blank’s book, Femalia, and celebrate the beauty and diversity of the women’s vulvas photographed in those pages. If you want to change the appearance of your netherlips, get a piercing or shave your pubic hair, but please, think twice before surgically altering your tender bits. Remember: fashion changes, but pleasure is forever.

Testosterone for Women

Testosterone (T) for women is generating a lot of interest recently. As our knowledge of the function of the human body increases, our questions become more sophisticated as well. We know that testosterone drives sexual appetite. That said, if a man desires more sex than his female partner, wouldn’t giving her a dollop of testosterone remedy the situation?

Testosterone can be a magic elixir for women. However, to benefit from the libido-boosting effect of T, women must be deficient, which is rare. Our bodies maintain a small but essential level. Testosterone and its related androgens make estrogen, and we have storage facilities for it throughout our bodies. We produce T in the ovaries and indirectly through the adrenal glands. We even cleverly store it in fat cells, especially after menopause. If we are testosterone-deficient, we may experience lessened sexual desire and responsiveness and loss of energy and wellbeing. In other words, we are not much interested in anything, including sex, but those symptoms can have many causes. It is worth investigating for women who have had their ovaries surgically removed or who experience a precipitous drop in energy and libido that cannot be otherwise explained. Check with your health care professional. For the few women who are deficient, there are tests to determine it, effective treatments to correct the condition, and fun activities to celebrate the ‘cure’. Former sexual appetite is restored, as is energy.

If you find, however, that your lack of sexual interest is not hormonally based, you have a number of other leads to follow. Many women complain that we lack agency over our sex lives. Raised to be receptive to men’s advances, we did not learn initiation skills and therefore forfeit the privilege of asking for sex when we want it. Instead we must use charm and flirtation to manipulate our lover to invite us to make love. The result is that women are always figuratively, if not literally, on the bottom. Eventually this lack of control robs us of our entitlement to our own sexiness. We lose our sense of ownership of our lust and begin to feel like objects rather than subjects. In the angry years of the Feminist revolution we blamed this on men; it has taken a long time to understand our own complicity in this counter-productive dance.

All these factors—lower testosterone levels, social and cultural expectations of submissive role posturing, lack of assertiveness skills—keep women from exploring their full sexual potential. Having sex only when he wants it, how he wants it, on his terms eventually erases a woman’s unique contributions. She loses interest because she no longer feels involved. Sex has little to do with her. As surely as these factors affect heterosexual women, they shape the sexual responses of lesbians as well, though the dynamics are a bit different. I will address these in a separate column.

It is by boldly embracing sexuality as our own that we become fully involved in the action, equal partners and peers with our men. This requires us to confront the messages we learned as children about how women—and men—are supposed to behave. We need to question our belief systems and critically analyze our media and everyday speech. We need to have deep conversations with our lovers about the roles of sex and power between us and how we can equalize them. We need to negotiate and renegotiate the rewards and costs of redefining our relationship dance.

The pay-off, of course, is improved sex in a peer relationship with someone you like who respects and honours you. Oh, yeah, and having your mojo running, too.

Premature Ejaculation

A common complaint among heterosexual male clients is their inability to control the timing of their ejaculation. They come too soon. What is too soon? A general perception is that other men last 10-30 minutes. Not so. In his ground-breaking research in the 1950s, Kinsey found that the average time between intromission (when the penis enters the vagina) and ejaculation is two minutes! Most of the time spent in lovemaking is not actual thrusting but in kissing, fondling, caressing and stroking.

In assessing the problem, the number of minutes is less important than the satisfaction of the people involved. If ejaculation occurs sooner than the lovers wish and this causes distress in the sexual relationship, then the ejaculation can be regarded as ‘premature’.

PE is learned early, when adolescent boys hurry through masturbation to avoid getting caught. They focus little emphasis on pleasure; efficiency is the goal. When they begin dating, furtive gropings in inappropriate venues rarely allow boys to luxuriate in the enjoyment of arousal. Ejaculation is often hurried of necessity. When these boys become men and form stable couples, the premature ejaculation sometimes fades as the couple develops a loving sexual rhythm. Those men who more easily learn to control their ejaculatory timing are those who appreciate sensuality and luxuriate in foreplay. They tend to form relationships with women who do not focus on penetrative aspects of sex but rather delight in the overall playfulness of sex. Their relationships are more often egalitarian than those designed along gender role guidelines. Even in stable marriages, however, periods of stress may aggravate PE. When we feel pressured, we often revert to old patterns.

Though a rapid ejaculation pattern generally begins in adolescence, it sometimes occurs later in life in response to a withering relationship or a high stress life change. It can be triggered by the nervousness and excitement of a new sexual experience (partner or situation). Performance anxiety does little to promote relaxation and pleasure, key ingredients for good control. Sometimes after the jitters settle down the problem resolves, but for those men who suffer chronic PE treatment is imperative.

For those men who do not learn ejaculatory control in early relationships, PE can be a difficult behaviour pattern to break, and not all relationships create an environment that promote change. Some components that breed sexual dysfunction are: sexually demanding partners, unrealistic expectations, disparate desires, partners who also have a sexual dysfunction, and an excessive desire to please. A partner’s derogatory remarks uttered in frustration develop a cycle of failure and anxiety. Poor communication and trust underscore these problems.

PE challenges a man’s sexual self esteem and sense of self control. He feels like a bad lover, for in fact he often fails to please his partner. Shamed into silence, he eventually stops discussing other aspects of lovemaking as well. The bedroom is no longer an exciting place to be.

Addressing PE can lead to a new openness about sex that enriches more than ejaculatory control. When trying to deny pleasure to delay coming doesn’t work–and anyone who experiences PE knows that fact—it is time to consider a treatment program. The good news is that a professionally monitored program offers an 85-95% lifelong success rate, and the key to its success is in learning to embrace pleasure. It’s true that it requires commitment and patience, much like learning a new language. The reward is many long years of terrific sex, unmarked by the frustration and humiliation of unintended ejaculation.

Perhaps acknowledging the problem and that you can’t fix it yourself is the toughest hurdle to overcome. No doubt calling a perfect stranger and asking for help with such a personal issue is difficult as well. But with each step in the treatment, your self confidence swells and your ability to control your ejaculation increases. The big bonus is that you begin to experience real pleasure with arousal and sex becomes a glorious expression of joy.

If premature ejaculation is dogging you, consider confronting it. With our modern treatment programs, you can enjoy years of the magnificent sex you deserve!

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