Troubleshooting Orgasm Problems (Part Two)

Recently, I wrote about troubleshooting orgasm problems, and described one strategy for improving orgasmic response by increasing arousal. Today, I’m describing another strategy, which you can use in combination with the increasing arousal: improving the ability to sustain arousal.

Orgasm is a reflex response to a sustained high level of arousal. “Sustained” is the key word here. Anxiety kills arousal; you can’t reach orgasm if your process of building arousal is being constantly deflated by worries like “do I look bad?”, “are the kids about to bust into this room?”, “am I turning my partner off?”, “did I remember to turn off the stove?”,  “do I have enough money in my bank account to pay the rent tomorrow?”, and so on. 

That’s not to say that people who are experiencing stressful things can’t ever have satisfying sex. They can and do, all the time. In fact, sex can be a lovely stress-reducer for some! What I’m getting at is that being able to experience arousal, and sustain that experience for long enough to reach orgasm, takes some anxiety-management chops. 

So, when you’re working with a client who is not reaching orgasm when they would like to, along with considering what kinds of stimulation work for them and how to increase arousal, consider what might be disrupting the sustaining of that arousal. 

If one of the things disrupting arousal and interrupting pleasure is intrusive thoughts, which it often is, you can help your client build the skills to handle that. As a therapist, this is probably squarely within your wheelhouse: they can develop the ability to let emotions come and go, stay in the moment and in their body, and choose connection with their partner over a negative thought-feeling spiral. Developing these skills will help them with every aspect of their relationship, not just sex. 

Another thing to assess any time you’re working with sex issues in the therapy room is sex pain. Pain, like anxiety, can kill arousal in a snap–and more than that, it can be immensely damaging to bodies, minds, and relationships, if left untreated. Sex pain can be caused by all kinds of things, from vaginal atrophy to endiometriosis to undiagnosed STIs to sex positions that just happen to bump the cervix and many other things. The best thing to do if your client reports sex pain is to get them a medical evaluation ASAP so that a team of health care providers can start sorting out exactly what’s causing the problem. Meanwhile, you can help with the relational dynamics and personal thoughts/feelings/meanings that tend to surround the experience of painful sex. 

A combination of those two strategies–helping your client increase pleasure, and thereby arousal, by increasing sensory input and experience; and helping them effectively managing anxiety and other thought/emotion spirals that may disrupt arousal–is a wonderful two-pronged approach to tackling the vast majority of orgasm issues.

How Sex Changes in Midlife

I’m continuing to answer questions sent in by my readers. This week, I’m tackling one that comes up quite a lot: Why does sex change so much for women in midlife, and what can they do about it? First off, it’s worth acknowledging that everyone, regardless of gender, moves through different life stages that affect sexual function, connection, and desire in all kinds of ways, including in midlife. Some of the most powerful shifts involve hormone changes, and midlife is a time when hormones typically change a lot. To keep it simple(ish!) I’ll narrow my answer to the hormone changes experienced by cisgender women.

Estrogen drops substantially in midlife, and that drop has a wide range of effects on the body. Here’s a rundown of the most common effects:

  • Vaginal dryness
  • Lower sexual desire
  • Weaker orgasms
  • Decreased muscle tone and flexibility including in the pelvic floor muscles

If you want to learn more about how midlife affects sexuality, the Femani Wellness website is an excellent resource; you can start here.

It’s definitely possible to mitigate some of these shifts with lifestyle choices and specific interventions:

  • If your orgasms are weaker than they were before, it may be the result of changes in your pelvic floor muscles. Just like any other muscle, you can strengthen your pelvic floor with exercises. You might consider contacting a pelvic floor physical therapist to start; your primary care MD can give you a referral, or you can contact a PT directly.
  • If you’re not experiencing as much desire for sex, many people find that exercise helps; it increases free testosterone in the body, which often boosts desire.
  • A mindfulness practice, with a focus on perceiving and experiencing subtle physical sensations, can help a LOT with both desire and the experience of orgasm.
  • One possible effect of lower estrogen levels is vaginal atrophy, in which the skin of the vaginal walls becomes less padded and thinner, leading to pain with penetration. Thankfully, there’s an awesome treatment for that: the Vaginal Renewal Program, a non-pharmacological program that works through a combination of moisturizing, vibration, and massage. It can make a huge difference for people experiencing vaginal atrophy. Refer to the FeMani Wellness website for more information.
  • My #1 recommendation for sexual health, improved sexual function, as well as overall health, is reducing inflammation in the body. Eating an anti-inflammatory diet, doing strength training, and ensuring that you’re sweating through 30 minutes of cardio every day can make a huge difference. You could end up feeling better than ever before, and enjoying sex more too.
  • Use it or lose it. The more sexual pleasure you enjoy, the more you will have the physiological structures and neural connections to enjoy sexual pleasure. Have some orgasms, alone or with a partner. Enjoy genital massage with or without orgasm. Get the blood flowing, and learn to enter a pleasure-focused state of relaxation.

I want to emphasize one point: It is 100% possible to have awesome sex, no matter what age you are or what bodily shifts you are experiencing. The strategies I’ve mentioned above can be a huge help, but the truth is, there’s only one indispensable skill you need in order to have an awesome sexual connection over the course of a lifespan: flexibility.

By flexibility, I mean the ability to roll with the punches, respond to what’s happening in the moment, and not get dragged down by negative assumptions or meaning-making when things don’t go as planned. It’s totally fine if you’re not there yet; flexibility is something you can cultivate, and the best time to start is now!

The changes many cisgender women experience in midlife can disrupt their settled patterns of sexual connection. That can be quite distressing and scary, particularly if you haven’t yet had a lot of practice cultivating flexibility in your sexual interactions. But if you can get past that distress, and embrace flexibility, it’s also a fantastic opportunity to learn a lot more about yourself and about your partner, and possibly discover some new and exciting ways to explore intimacy together. Many people have the best sex of their lives past midlife, for exactly this reason.

Here are a few mindsets you might choose to experiment with,, which are designed to help you
cultivate flexibility:

  • It’s completely normal and expectable for things not to go as planned when you’re having sex. It doesn’t mean that there’s anything wrong with you or with your partner.
  • There are infinite ways to connect intimately, from self-pleasuring together, to sharing fantasies, to pleasuring one another with toys. If one particular activity isn’t pleasurable or possible today, this is your chance to explore some others!
  • You and your partner are teammates; your goal is to create as much pleasure and connection as you can together. Keep your eye on that goal, and let go of any sense you “should” engage in any specific activity.

What Everyone Needs to Know About Painful Sex

Sex shouldn’t hurt. Too many people believe that having some pain with vaginal penetration is normal and to be expected. That’s simply not true. NO ONE should be having painful sex–unless it’s the kind of pain that is desired and negotiated in advance. Pain with sex is not something you just have to put up with. And, almost always, it can be resolved with a little help.

If you ignore sex pain and keep engaging in the painful action, it will almost certainly lead to worse issues down the road. And besides the physical damage, nothing will tank your libido like engaging in sex with unwanted pain. Every time you grit your teeth and keep doing the thing that hurts, you’re forging a link in your brain between that activity and pain. Over time, as sex and pain become more closely linked in your mind, your desire for sex will wane.

This is important to recognize, as one big reason that people continue to engage in painful sex is to avoid hurting their partner’s feelings or because they feel obligated to provide sex as part of their relationship. Even if simply grinning and bearing it will keep your partner from feeling rejected or uncomfortable in this moment, continuing to engage in painful sex will do your sex life more harm than good in the long term. And I suspect your partner would actually want to know. Hopefully, they want to do whatever is needed to help you have enjoyable sex.

The first step is to have that awkward conversation now. Let your partner know what you are experiencing, and that you’d like to see what can be done to help improve your experience of sex by decreasing pain. Be sure to let your partner know this is almost always something that can be resolved.

The second step is to stop participating in the activity that hurts. This is a temporary measure to make sure your body’s natural protective response doesn’t make the issue worse.

The next step is unravelling what’s going on with your body, with the help of a medical practitioner, a sex therapist, or both. There are countless potential causes for sex pain. You can start by using a high quality lubricant, and also consulting with your primary care physician. But be aware (your doctor may not be!) that resolving many issues requires the help of specialized professionals, like a pelvic floor physical therapist or a vulvar pain specialist. If your doctor doesn’t suggest one of these specialists, and your sex pain doesn’t resolve, ask your doctor for a referral to a pelvic floor PT and let them advise you on how to proceed.

If you are feeling frustrated and things aren’t improving, consider consulting with a sex therapist, who can help sort out the issues and refer you to the right resources. With the help of skilled professionals and a little bit of patience, regardless of whether painful sex is new for you or something you’ve been living with for a long time, you are very likely to uncover the cause, resolve it, and start having pain-free, enjoyable sex.

It is also important to recognize that while you are working to resolve painful sex,  your sex life doesn’t need to grind to a halt. You can’t engage in the activity that produces pain–but there are plenty of other ways for you and your partner to create pleasure and experience closeness, which is (at least as I see it) what sex is really about. There is no reason your relationship has to suffer just because one activity isn’t possible for the moment. Situations like this one are the reason I often say that flexibility is the key to a happy, healthy sex life. This is an opportunity to work on that flexibility, and perhaps even discover new ways of connecting intimately that can become favorite additions to your sexual repertoire.