On call: Wife’s disinterest in sex

On call

Wife’s disinterest in sex

Q.My wife and I, who both read your column, have
always enjoyed our intimate relations. Since she went through the change last
year, however, she’s lost interest in sex. She’s only 53, and although I’m 8
years older, I’m as amorous as ever. Do you have any suggestions for us?

A.We’re glad to have you both as readers; in many
households, after all, it’s women who watch over men’s health.

Doctors have learned a lot about the male sexual response in the Viagra era,
but there is less information about female sexuality. Menopause signals an
abrupt drop in female hormones such as estrogen and progesterone, but that
shouldn’t affect the female sex drive. In fact, libido depends on
testosterone, the male hormone, in both men and women.
Testosterone levels are very much lower in women than men, but they drop even
lower as menopause approaches, then remain stable during and after menopause as
the adrenal glands continue to produce small amounts of male hormones. Still,
some women are testosterone deficient and might benefit from testosterone
therapy. Unfortunately, however, data are scant, and much more research is
needed to learn if testosterone is safe and effective — and if it is, which
women should receive it and what dose and preparations are best. At present,
those answers are a long way off; in fact, the same questions about testosterone
replacement remain to be answered for men.

Another area for research is the use of Viagra for women. An early trial
found the drug safe but not beneficial for healthy postmenopausal women. More
research is under way, and other drugs are being developed for sexual
dysfunction in both genders. The FDA has already approved a hand-held
battery-powered clitoral stimulator for women with sexual dysfunction. Your
wife’s problem, though, may be a good deal simpler. Postmenopausal women who do
not take hormone therapy (and with research showing more harm than good, most
should not) develop vaginal dryness, which can make intercourse unpleasant or
even painful. So a simple place to start would be a nonprescription vaginal
lubricant such as Replens. If that doesn’t help, your wife should ask herself if
she might be feeling subtle stress or unhappiness or if she may be reacting to
personal, marital, or family conflicts. Her doctor may be able to help her sort
out possible physiological and psychological issues.

Discuss the problem with your wife frankly, but be patient and supportive,
always looking for mutually satisfactory ways to achieve intimacy and express
love and affection.

How To Spice Up Your Sex Life

Since the dawn of time, people have looked toward elixirs and potions to
improve their sex lives. Why else, after all, would one consume ground tiger
penis, horny goat weed and Spanish Fly?

Perhaps because nearly one in five men in the U.S. suffer from erectile
dysfunction, according to a recent study in the American Journal of
Medicine. Some researchers have estimated that as many as 40% of U.S. women
have low libido or inability to reach orgasm. Most quick fixes simply don't
work, and some, like Spanish Fly, a supposed aphrodisiac derived from beetles
that can cause kidney damage, are harmful.

In Pictures: Thirteen Steps To Better Sex

But modern medicine has found ways--both proven and experimental--to improve
your sex life. One place to start: old-fashioned remedies, which some say work
best. Regular exercise can actually improve erectile function in
most men, says Andrew McCullough, a urologist at New York University Medical
Center--and we're talking jogging, not the acrobatic feats found in the back of
a magazine. Not particularly athletic? Therapists say that paying attention to
your feelings is as important as any pill, nose spray or cream.

"Have a really wonderful role-play with your partner, have a really great
dinner out or watch a romantic movie together," says Robert Dunlap, who has
researched aphrodisiacs at the Institute for Advanced Study of Human Sexuality
in San Francisco. "The greatest aphrodisiac is your mind."

Hope In A Bottle

But that's not stopping the $600
billion global pharmaceutical industry from trying to think up new sex drugs.
Viagra, the little blue pill Pfizer launched a decade ago, brings in $1.7
billion in sales every year. Cialis, the longer-acting imitator made by Eli
Lilly, rakes in another $1 billion, with several hundred million more for
Levitra, from Bayer and Schering-Plough. Other remedies increase blood flow,
like the penis injection Caverject, and bring in $30 million more.

A product that could improve women's sexual function might bring in even more
money, if it were truly effective. So far, though, companies have been
unsuccessful. Viagra failed in tests on women. Procter & Gamble tried to
push a testosterone patch for female sexual dysfunction through the Food and
Drug Administration (FDA) but in 2004 the agency balked, citing a lack of
long-term safety data.

Now the idea of using testosterone as a sex-booster for women is being pushed
by Lincolnshire, Ill.-based BioSante Pharmaceuticals, Inc. Its LibiGel is rubbed
on the upper arm daily, delivering testosterone, which is thought to increase
libido, to the bloodstream over time. The company just began late-stage trials,
and, after discussions with the FDA, will start a big safety trial before
submitting data to regulators in 2009.

Palatin Technologies, of Cranbury, N.J., is trying to get in on the game,
developing a nose spray, called bremelanotide, to treat men and women with
sexual dysfunction. Applied 10 to 15 minutes prior to sex, it travels through
the central nervous system to increase blood flow in the penile or vaginal
tissue. The company hopes to get FDA approval for men in 2009 and women around
2011. "On the female front, we've got a chance to be first to market," says CEO
Carl Spana. "People wonder how many women will come in for treatment, but my gut
tells me they will come in."

What Really Works
Right now, the treatment available for
women with female sexual dysfunction that has been reviewed by the FDA is a
handheld vacuum that can be used with a doctor's prescription to increase blood
flow to the clitoris. Called Eros Therapy, it is made by NuGyn of Minnesota.
Devices such as this go through fewer hurdles than drugs; the Eros device has
been tested in several dozen people, compared with hundreds for a pill such as
Viagra.

Joy Davidson, a Manhattan-based certified sex therapist, worries that all
this technology may cause some people to ignore important cultural factors that
can cause sexual dysfunction. "There are agendas here that are not health-based,
they're profit-based," she says. "If you're not looking at these elements--the
emotional, psychological and cultural--then giving somebody a so-called magic
pill is not going to solve the problem."

Future Fixes
Meanwhile, drug researchers keep coming up
with even more out-there approaches. For instance, a gene therapy, which seeks
to fix erectile function by altering the DNA of cells in the penis, then
injecting them back in to the patient. It should work for six months, according
to inventor Arnold Melman, the researcher at New York's Albert Einstein College
of Medicine. He has co-founded a tiny biotech, Ion Channel Innovations, to
develop the product, which even he doesn't expect to reach the market before
2012. No gene therapy has ever been approved.

"People always say gene therapy doesn't work, but at one point it will," says
Melman. "We think this is the one."

Aphrodisiacs That Really Work

For as long as humans have been having sex, they've been trying to get in the
mood--or get their partners in the mood. And if necessity is the mother of
invention, it's no surprise that humans have developed a wide variety of creative
solutions for the old "I've-got-a-headache" problem.

The most recent solution, of course, is Viagra. But in ancient India, a young
man who proved passionless in the sack might have tried goat testicles boiled in
milk. Oysters are another common turn-on; the Roman satirist Juvenal was the
first to note their seductive qualities. In medieval times, honeyed mead was the
equivalent of Bud Lite for loosening up carousing swains.

Fresh snake blood is still revered as a stimulant in parts of Asia, as are
bat blood, reindeer penises, shark fins and ground rhino horns. And what
sad-sack hasn't at least contemplated Spanish Fly? It's not a fly at all,
actually, but the dried remains of beetles, which irritate the male urogenital
tract, causing a prolonged erection--and potentially causing serious discomfort
and even death, according to the Food and Drug Administration.

In
Pictures: Ten Aphrodisiacs That Work

Beyond their collective exoticism, the only thing the above have in common is
that they don't work. Named for Aphrodite, the Greek goddess of sex and beauty,
an aphrodisiac is just about anything that awakens or increases sexual
desire--be it your own, or the object of your desire's. In reality, however,
most aphrodisiacs are folklore at best and hazardous to your health at worst. As
the Food and Drug Administration has declared: "There is no scientific proof
that any over-the-counter aphrodisiacs work to treat sexual dysfunction."

But there is still some hope for those seeking a libido boost. The herbal
supplement Ginkgo
Biloba is being studied by the Office of Dietary Supplements, a subsidiary
of the National Institute of Health, as a treatment for erectile dysfunction.
The FDA has called animal studies of yohimbine "encouraging." Derived from the
bark of an African tree, yohimbe has been used as a sexual stimulant for
centuries. But the FDA notes that animal studies can't be used to prove
effectiveness in humans.

Even when aphrodisiacs do show promise, they don't always work for everybody.
Sexual desire is rooted in the mind more than the genitals. One person's fantasy
could be another's turn-off. "We're all unique individuals, and we all respond
differently to different things," says Dr. Beverly Whipple, a professor emerita
at Rutgers University and author of, most recently, The Science of Orgasm.

At the root of human sexual desire is the "core erotic personality"--a.k.a.
"sexual template"--which, in a nutshell, is whatever gets you off. "Everyone has
in their mind an image of someone or thing they find sexually desirous,"
explains Dr. William Granzig, dean of clinical sexology at Maimonides University
in North Miami Beach and president of the American Board of Sexology.

That image might be a person of specific age, race or hair color, or it might
be every person. It could be a fondness for a particular style of dress, objects
such as women's shoes or fur-lined handcuffs, or behavior such as cross-dressing
or exhibitionism. Whatever it is in particular, the sexual template is believed
to develop early on during a childhood erotic experience--perhaps as early as
age three or four--and it sticks with you for life.

The difficulty of maintaining sexual desire over the long term, of course, is
that if your partner falls outside of your sexual template--or you fall outside
theirs--sooner or later one of you could lose interest. "Many people whose
template is not, say, age-specific, can have great sex throughout their lives,"
notes Granzig. "But if you're only attracted to 20-year-olds, once your partner
hits 30, your desire will decrease. Unless, of course, you can figure out some
ways to spice things up."

Spicing things up is where sex gets complicated, because men and women
sometimes have wildly divergent desires. For men, a sexy photo is often enough to get blood flowing in the right direction. For
women, pornography can be a major turn-off. Orgasms are also less central to
women, who sometimes need full body stimulation, not to mention mental
seduction, in order to achieve climax. "There are just so many variables that go
beyond the physical in sex for women," says Dr. Janice Epp, a clinical
sexologist at the Institute for Advanced Study of Human Sexuality in San
Francisco.

There are also a host of external nuisances that weigh heavily upon sexual
desire--and that may dampen the mood. Studies routinely rank American culture as
one of the most sexually repressed in the world thanks to its forbidding
Judeo-Christian origins, high incidence of sexual problems and dysfunction, and
a lingering Puritan discomfort with the very topic of sex.

And while Europeans take mandatory month-long vacations, Americans routinely
work 60-hour weeks, and stretch their ten vacation days over the entire year.
With the demands of our modern day technological society, it's little wonder the
search for aphrodisiacs continues. "I see a lot of highly evolved, highly
skilled people who are losing desire because they have such an overriding focus
on their profession," says Epp, who works in Silicon Valley. "For them, the
temptation to believe that there's a magic pill that will make them desirous of
sex again is very strong."

Inspired by the phenomenal success of Viagra, which rang up over $1.6 billion
in sales for Pfizer in 2005, it's perhaps not surprising that there has been a
recent push to find more pharmaceutical remedies for flagging sexual desire.
It's a focus that throws many in the sex field into apoplexy. "The idea that you
can just give someone a pill, and they'll be interested in sex is like putting a
band-aid on a tumor," says Epp.

In the end, the only truly effective aphrodisiac seems to be that's been
working for humans all along. "Your biggest sex organ is the one between your
ears," says Dr. Granzig. "What is desire, after all, other than the hope that
you can fulfill your sexual fantasies? And that's all in your mind."

Sex and Your Psyche

You know the cliche: a woman is so uninterested in sex that she makes a
shopping list while making love. Jennifer and Laura Berman see such women all
the time, and it's frustration—not boredom—that brings them to the Bermans' new
clinic at UCLA.

"I was talking to a woman earlier today about her low libido, which was a
result of the fact that she can't reach orgasm," says psychologist Laura Berman,
Ph.D., who with her sister, urologist Jennifer Berman, M.D., is a founder and
codirector of the Center for Women's Urology and Sexual Medicine clinic.
"Because she can't reach orgasm, sex is frustrating. She feels a hopeless,
fatalistic complacency about her sex life. When she's having sex, her partner
picks up on that and feels rejected and angry, or notices she's withdrawing.
Then intimacy starts to break down. Her partner feels less intimate because
there's less sex, and she feels less sexual because there's less intimacy. The
whole thing starts to break down."

Acknowledgement of sexual dysfunction in America is booming. But with all the
attention on Viagra and prostate problems in men, most people would probably
never guess that more women than men suffer from sexual dysfunction. According
to an article in the Journal of the American Medical
Association, as many as 43 percent of women have some form of difficulty in
their sexual function, as opposed to 31 percent of men.

And yet female sexuality has taken a back seat to the penis. Before Viagra,
medicine was doing everything from penile injections to wire and balloon
implants to raise flagging erections, while female sexual dysfunction was almost
exclusively treated as a mental problem. "Women were often told it was all in
their head, and they just needed to relax," says Laura.

The Bermans want to change that. They are at the forefront of forging a
mind-body perspective of female sexuality. The Bermans want the medical
community and the public to recognize that female sexual dysfunction (FSD) is a
problem that may have physical as well as emotional components. To spread their
message, they have appeared twice on Oprah,
have made numerous appearances on Good Morning
America and have written a book, For Women
Only.

"Female sexual dysfunction is a problem that can affect your sense of
well-being," explains Jennifer. "And for years people have been working in a
vacuum in the sex and psychotherapy realms and the medical community. Now we are
putting it all together."

No single problem makes up female sexual dysfunction. A recent article in the
Journal of Urology defined FSD as including
such varied troubles as a lack of sexual desire so great that it causes personal
distress, an inability of the genitals to become adequately lubricated,
difficulty in reaching orgasm even after sufficient stimulation and a persistent
genital pain associated with intercourse. "We see women ranging from their early
twenties to their mid-seventies with all types of problems," Laura says, "most
of which have both medical and emotional bases to them." The physical causes of
FSD can range from having too little testosterone or estrogen in the blood to
severed nerves as a result of pelvic surgery to taking such medications as
antihistamines or serotonin reuptake inhibitors, such as Prozac and Zoloft. The
psychological factors, Laura says, can include sexual history issues,
relationship problems and depression.

The Bermans codirected the Women's Sexual Health Clinic at Boston University
Medical Center for three years before starting the UCLA clinic this year. At
present, they can see only eight patients a day, but each one receives a full
consultation the first day. Laura gives an extensive evaluation to assess the
psychological component of each woman's sexuality.

"Basically, it's a sex history," Laura says. "We talk about the presenting
problem, its history, what she's done to address it in her relationship, how
she's coped with it, how it has impacted the way she feels about herself. We
also address earlier sexual development, unresolved sexual abuse or trauma,
values around sexuality, body image, self-stimulation, whether the problem is
situational or across the board, whether it's lifelong or acquired." After the
evaluation, Laura recommends possible solutions. "There is some psycho-education
in there, where I'll work with her around vibrators or videos or things to try,
and talk about addressing sex therapy."

Afterward, the patient is given a physiological evaluation. Different probes
are used to determine vaginal pH balance, the degree of clitoral and labial
sensation and the amount of vaginal elasticity. "Then we give the patient a pair
of 3-D goggles with surround sound and a vibrator and ask them to watch an
erotic video and stimulate themselves to measure lubrication and pelvic blood
flow," Jennifer says.

The identification of FSD has been called everything from the final frontier
of the women's movement to an attempt by the patriarchy to shackle women's
sexuality. But given the success that drugs such as Viagra have had in reversing
male sexual dysfunction, the Bermans found an unexpected amount of criticism
from their peers. "The resistance we got from the rest of the medical community
early on was surprising to us," Laura says, explaining that the urological field
in particular has been dominated by men.

Clearly, the Bermans will need hard data to win over their critics. Their
UCLA facility is enabling the Bermans to conduct some of the first systematic
psychological and physiological research on the factors that inhibit female
sexual function. One of their first studies suggests that the pharmaco-sexual
revolution that helped some men overcome their sexual dysfunction may prove less
effective for women. Their initial study of the effects of Viagra on women found
that Viagra did increase blood flow to genitalia and thereby facilitate sex, but
women who took the drug said it provided little in the way of arousal. In short,
subjects' bodies might have been ready, but their minds were not.

"Viagra worked half as often in the women with an unresolved sexual abuse
history as in those without it," Laura says. "So it's just not going to work
alone. Women experience sexuality in a context, and no amount of medication is
going to mask psychologically rooted, or emotionally or relationally rooted
sexual problems." Laura believes the results of the Viagra study counter those
who contend that FSD is simply a tool of pharmaceutical companies to
"medicalize" female sexuality.

"I'm less concerned about it, because I'm aware that it won't work," she
says. "And in some respects, pharmaceutical companies are closing the divide
between the mind and body camps of FSD. Clinical trials of new drugs for FSD are
requiring psychologists to screen participants, and that is an acknowledgement
that an accurate assessment of a drug's efficacy requires a consideration of the
test subjects' feelings about sex. So these physicians who may not be motivated
to bring on a sex therapist are now motivated to participate in a clinical
trial, and then that model becomes the norm."

Currently, the sisters are working on MRI studies of the brain's response to
sexual arousal, the place where mind and body meet. And although there is a lot
more research to be done on FSD, identifying it as a problem has already made a
significant impact on how women perceive their sexuality. "Women now feel more
comfortable going to their doctors, and they're not taking no for an answer, not
being told to just go home and have a glass of wine," explains Laura. "They feel
more entitled to their sexual function."

His & Hers: How To Have Them

Hers: a female orgasm can be frustratingly evasive. While about 85 to 90
percent of women are capable of having an orgasm, according to Beverly Whipple,
Ph.D., vice president of the World Association for Sexology, only about
one-third have had one during intercourse. That said, it's important to remember
that orgasm should never be the goal.

"In goal-oriented sexual interactions, each step leads to the top step, or
the big "O"—orgasm," says Whipple. "Goal-oriented people who don't reach the top
step don't feel very good about the process that has occurred. Whereas for
people who are pleasure oriented, any activity can be an end in itself; it
doesn't have to lead to something else. Sometimes, we're very satisfied holding
hands or cuddling. There would be a lot more pleasure in this world if people
would just focus on the process."

Whipple also points out that the psychological ramifications of dissatisfying
sexual interactions are not often suffered alone; they can cause distress in
both partners. "If one person in a relationship is goal-oriented and the other
is pleasure-oriented, and neither is aware of their own orientation, they don't
communicate that with their partner," she explains. "A lot of relationship
problems can develop. In my workshops with couples, I help them be aware of how
they view sexual interactions and then communicate this with their partner."

Types of Orgasm

Clitoral Orgasm

The most common, they result from directly stimulating the clitoris and
surrounding tissue. What many people don't realize is that the majority of the
clitoris is actually hidden inside the woman's body. Recently, Australian
urologist Helen O'Connell, M.M.E.D., studied cadavers and 3-D photography and
found that the clitoris is attached to an inner mound of erectile tissue the
size of your first thumb joint. That tissue has two legs or crura that extend
another 11 centimeters. In addition, two clitoral bulbs—also composed of
erectile tissue—run down the area just outside the vagina.

O'Connell's findings, published in the Journal of
Urology, show that this erectile tissue, plus the surrounding muscle
tissue, all contribute to orgasmic muscle spasms. With so much tissue involved
in a clitoral orgasm, it's no wonder they're the easiest to have.

Pelvic Floor or Vaginal Orgasms

These occur through stimulating the G-spot, or putting pressure on the cervix
(the opening into the uterus) and/or the anterior vaginal wall. Located halfway
between the pubic bone and the cervix, the sensitive G-spot—named after its
discoverer, German physician Ernest Grafenberg—is a mass of spongy tissue that
swells when stimulated. Because it's difficult to locate, experts have developed
a few guiding techniques:

1. Lying on her back, the woman tilts her pelvis upward so that
   her vulva presses flat against her partner's pelvic bone. According to the
   Bermans, this allows the penis to make contact with the G-spot, simultaneously
   stimulating the clitoris. Putting pillows beneath her buttocks makes angling her
   pelvis easier.
   
2. Whipple suggests placing two fingers inside the vagina and
   moving them in a beckoning motion. The fingertips should stroke the frontal
   vaginal wall, just where the G-spot is located.

The Blended Orgasm

This can be attained through a combination of the first two.

Her Benefits

1. Pain relief: Orgasms help alleviate menstrual cramps. In
   addition, studies have shown that a woman's pain threshold increases
   substantially during orgasm.
   
2. Enhanced mood: According to University of Virginia
   researchers, orgasms boost levels of the female sex hormone estrogen, which in
   turn betters your mood and helps ease premenstrual symptoms. They also release
   endorphins, the body's natural painkillers and depression fighters.
   
3. Increased intimacy: Oxytocin, a hormone that promotes
   feelings of intimacy, jumps to five times its normal level during climax.
   
4. Easier rest: Oxytocin also induces drowsiness. For women,
   sleepiness comes about 20 to 30 minutes after orgasm. Men, on the other hand,
   usually drift off after only two to five minutes.
   
5. Less stress: Stress in women is highly correlated with
   arousal difficulties, lack of libido and anorgasmia, the inability to reach
   orgasm, according to one 1999 study in the Journal of the American Medical
   Association. Just 20 minutes of intercourse, however, releases the
   lust-enhancing hormone dopamine, triggering a relaxation response that lasts up
   to two hours.

Physiologically speaking, male and female orgasms are surprisingly similar.
The related problems men and women experience, however, are distinctly
different.

"There are men who can't orgasm, but I think it's less than I percent of
men," says Jed Kaminetsky, M.D., a professor of urology at New York University
and director of the school's male sexual dysfunction clinic. "That's a much less
common problem than premature ejaculation."

A study published in the Journal of the American
Medical Association found that premature ejaculation is even more common
than erectile dysfunction, especially among younger men. As with most
sex-related problems, it affects both partners—some studies suggest that nearly
30 percent of couples report premature ejaculation as the most prevalent sexual
problem in their relationship. One major obstacle to treating it is simply
defining the problem to begin with.

"It depends on the relationship," Kaminetsky explains. "If a woman takes an
hour to orgasm and the man can last 40 minutes, that's premature ejaculation for
that couple." At the other extreme, one minute is too short an amount of time
for most couples. "Not too many women are going to climax within a minute."

Kaminetsky also sees truth in Whipple's assessment of goal-oriented versus
pleasure-oriented interactions. "Men are very goal oriented; they see a task and
they want to successfully perform that task," he says. "Often that task is to
make their partner have an orgasm. If the woman knows that, she feels like a
laboratory animal—it's not a very sexy thing. That's why women fake orgasms,
which is a sign of lack of communication in a relationship."

Premature Ejaculation

Rarely a physiological problem, premature ejaculation can result from
over-excitement, positioning or rate of intercourse. "The roots of it go back to
the way men learn to orgasm, which is typically through masturbation," suggests
Kaminetsky. "A lot of young boys masturbate quickly, because they don't want
their mom to walk in on them. It becomes a trained behavior." To treat premature
ejaculation, experts suggest changing positions, breathing deeply, thinking
about something other than sex or simply stopping for a moment. Here, Kaminetsky
offers two additional techniques for delaying orgasm:

1. Practice this before reaching "ejaculatory inevitability,"
   the point when ejaculation cannot be stopped; most men recognize it as a
   sensation of deep warmth or pleasure: Squeeze the head of the penis for about
   four seconds or until the sensation subsides, then resume.
   
2. During intercourse, the man should press his pelvic bone
   against the woman's and rock rather than thrust his body. "It won't be as
   stimulating for him so he'll last longer, and it may be more stimulating for the
   woman."

His Benefits

1. Long life: Men who have two or more orgasms a week tend to
   live significantly longer than do those who have only one or none, according to
   research at Cardiff University in Wales.
   
2. Less cancer: Breast cancer is rare in men, but once
   developed, the mortality rate is high. Fortunately, a study published in the
   British Journal of Cancer found that men who have more than six orgasms a month
   are significantly less likely to develop breast cancer than are those who have
   less frequent sex.
   
3. Healthy hearts: A study of 2,500 men at the University of
   Bristol and Queens University of Belfast found that men who have at least three
   or more orgasms a week are 50 percent less likely to die from heart failure or
   coronary heart disease.
   
4. Good health: Having sex once or twice a week also fights off
   the flu and other viruses by strengthening the immune system, psychologists at
   the University of Pennsylvania recently found.
   
5. Youthful looks: A study of 3,500 aging people at the Royal
   Edinburgh Hospital in Scotland found that those who looked the youngest also had
   the most vigorous sex life. The effects were even greater if the subjects were
   emotionally satisfied as well.

Getting Close And Personal

Bee, 25, Copywriter

Masturbating is the easiest way for women to learn how to have an orgasm.
Women who masturbate will be a lot more likely to have an orgasm during sex. I
think it helps you learn the actual mechanics of what turns you on, where things
need to happen.

Because the guy isn't going to know that; there's no reason he would. Every
woman is different. Also, the bonding that goes on during sex seems most extreme
with an orgasm. It's kind of like one or both people have gone completely over
the edge; they're suspended in the other person's grasp, and they're completely
surrendered to it. That intensifies any connection.

Gabriel, 25, Musician

There are guys who don't get a rise out of giving a woman an orgasm and would
just prefer not to have someone else there. I've even heard some guys say they
have better orgasms during masturbation than sex. The mere thought of it
astounds me, but it makes sense if a guy has a fear of intimacy or, even more, a
fear of performing. It probably takes away from his own orgasm if he's overly
concerned with his sexual performance or whether or not she's having one. It's
ironic, because an orgasm during sex is enhanced when it's with someone you
truly care about.

Getting Close and Personal

Kamara, 27, Musician

I'm amazed when I talk to anyone who claims to have never had an orgasm,
probably because I just can't imagine not having them or not being able to have
them. At the same time, it doesn't surprise me: I was raised in a very
conservative religious atmosphere that actually called masturbation "self
abuse," and all sexuality—not to mention orgasms—was beautiful and good only if
it happened in a marriage bed. It takes awhile to expel the load of guilt that
piles up around your sexuality if you're raised in that kind of culture, and I'm
sure some people never do. But there was no way I wasn't going to aim for the
prize once I knew what it felt like. Maybe it depends on your sexual drive—for
me the drive was strong enough that I could never feel guilty about an orgasm
for long.

Steven, 28, Veterinarian

Some guys think sex has to include an orgasm. Orgasms are great, but there's
so much more to sex. An orgasm is more of a physical experience; I guess there
is an emotional aspect, but it's over in a second. I think anybody can give you
an orgasm, but it's the person there after the orgasm that matters. But I think
I'm the exception.

Does Orgasm Equal Sex?

Our ever-changing definition of sex may hinge more on the climax than on the
act itself; Psychologist L.M. Bogart, Ph.D., gave Kent State students a list of
scenarios in which "Jim" and "Susie" engaged in vaginal, anal or oral
intercourse and either did or did not achieve orgasm. Vaginal intercourse was
considered sex 97 percent of the time, followed by anal intercourse (93 percent)
and oral sex (44 percent). Researchers were surprised to find that orgasm
occurrence dictated whether or not the activity was considered sex. Although the
woman was more likely to label vaginal intercourse sex if neither partner
climaxed, when it came to oral sex, the recipient was more likely to consider it
sex than the partner performing the act, especially if the recipient achieved
orgasm—because the stimulator was unlikely to achieve orgasm. For anal sex, it
was more likely to be called sex if Jim had the orgasm, but it was sex to Susie
regardless of whether she achieved orgasm. In general, the lack of orgasm for
women was less likely to affect her labeling the act sex. Although most sex
therapists argue against using orgasm as an end-all definition of sex, Bogart's
study indicates that orgasm is still an important gauge by which we measure
sexual activity.

Lust For The Long Haul

When my husband and I started dating, we quickly became one of those
obnoxious couples who couldn't keep their hands off each other. We kissed every
time we stopped at a crosswalk -- in New York, that's a lot. At Starbucks we
were so grotesque -- staring into each other's eyes, stroking each other's arms
-- that when the branch removed its tables and converted to carryout, we
wondered if we were the reason. Once, during a protracted public goodbye, a
group of teenagers actually screeched at us to get a room.

We did more than that. We got married. Like most couples in the throes of
passion, we were smug, convinced that all the cliches about things slowing down
described partners who weren't meant to be together in the first place. But
slowly, things did cool off. We still loved one another, still held hands. But
the crosswalk kissing and the subway platform clinches faded away. Instead of
long weekend mornings in bed, we started getting up early and going to the
gym.

I couldn't help (a) noticing, and (b) torturing myself about what it meant.
You'd have to be hiding under a rock for the last decade not to know that half
of all marriages now end in divorce, and that sexual difficulties are one of the
leading complaints of unhappy couples. Was this how it begins?

It's some consolation that many other Americans face the same question. In
the benchmark survey of desire, roughly one-third of all adults reported having
some kind of sexual problem during the previous year. Some pundits blame gender
politics, job stress and cultural changes. Others, more cynical, point to the
monotony of marriage. But these plausible (and socially acceptable) explanations
obscure a more disquieting truth. Sex, and more importantly, intimacy, are
grown-up skills, and most of us, metaphorically speaking, are still in junior
high. We're still clinging to the idea of romance, when real intimacy requires
something a lot more difficult: pushing past your own limits to become a more
fully developed human being.

Conventional wisdom holds that an intimate couple thinks pretty much the same
way about most things. You connect seamlessly -- especially in bed. But
according to the radical ideas of the marital and sex therapist David Schnarch,
we've got it all backward. "Sex is inherently based on intimacy. The problem is
that most people have a very misguided idea of what intimacy means," he says.
"There's this idea that your partner is going to make you feel good and validate
you." It's our cultural template for "true" love. Think Tom Cruise in Jerry
McGuire declaring his love for Renee Zellweger: "You complete me," he says,
with trembling lip.

Except that no one has a marriage like that. What's more, says Schnarch, no
one should. Sure, the you-complete-me stuff works fine in the beginning. It's
even fun. Like two people cinched together for a three-legged race, there is
satisfaction in getting the groove of operating side-by-side with perfect
fluidity. But when you try to keep those tethers on indefinitely, reality
intrudes. Two people aren't going to agree on every move. And they'll get tired
of always accommodating the other -- by keeping quiet, by moving the same way,
by propping the other one up.

Sooner or later, a lot of these three-legged marriages wind up in gridlock:
Each partner is increasingly frustrated by the other's apparent unwillingness to
get on the same page -- and each becomes increasingly annoyed and worried about
it. It's in this juncture, where the conflict between real intimacy and wishful
thinking rears its head, that many of us notice the sex ain't what it used to
be. But while we fear that this is the beginning of the end, Schnarch says it's
often when things finally start to go right. It means marriage is beginning the
relentless process of doing what it's supposed to do, nudging us away from the
Renee-Tom model of partnership and forcing us to figure out who we are as
individuals.

Real intimacy is frightening. It requires a kind of openness, honesty and
self-respect that most of us aren't used to. But Schnarch's 30 years of
counseling couples has convinced him that it's worth it. A truly intimate
connection between adults is less volatile, because couples aren't ticked off
about what their partner is or isn't doing to prop them up. It's more solid,
because it's based on reality. "Ultimately, you get through gridlock and get to
a place of more honest self-disclosure, where the focus is on being known,
rather than being validated," he says. Best of all, the sex often becomes more
relaxed, creative and connected. Literally and figuratively, no one's hiding in
the dark anymore.

Learning the Language of Sex

When couples do try to address their sexual problems, they often focus on
mechanics: Viagra, lingerie, trying out new positions. But sex -- even terrible
sex -- isn't engineering, says Schnarch. It's a language, and its content is
everything else happening in the marriage. The woman who doesn't say a word but
barely opens her knees for her husband is actually speaking volumes. Ditto the
man who is so intent upon pleasing his unpleasable wife that he frequently loses
his erection. "Even the way couples avoid having sex is a window into who they
are together," he says.

Often, sexual disconnect has a similar refrain: I can't show you who I really
am. People's mistaken ideas about intimacy have made them overly reliant on a
partner for their own sense of self. You demand that your partner approve of
you, and you begin to count on him or her to reassure you that you're normal and
that your feelings are valid. This makes it difficult to be completely open or
honest with each other anymore. One or both of you begins to feel suffocated,
and the intense vulnerability of sexual passion that was so easy in the early
days becomes impossible.

Tammy, 36, and her husband, Jack, 34, struggled for years with mismatched
sexual desire. Jack wanted to have sex all the time. Tammy avoided it. "I pretty
much didn't care if I never had sex again," she says now. For her marriage's
sake, she'd tried supplements and testosterone cream to increase her desire.
They hadn't worked. Nor had a therapist who'd advised Tammy to try a little
novelty -- like running a hairbrush all over her husband's body. "I already
didn't want to have sex," says Tammy, still irritated, "and I definitely didn't
want to do that." By the time they wound up at Schnarch's office, they were
inches away from divorce.

Through three intensive days in therapy, it became obvious that Tammy's
problem wasn't biological. Jack was needy, emotionally, and looked to Tammy to
make him feel better, in and out of bed. Tammy, like many women, played the
caregiver role to the hilt. She was a teacher, she had two small children, and
she was even contemplating a new career as a nurse.

They began to realize, with Schnarch's guidance, that although they felt
estranged from each other, they were in fact completely interdependent. Jack
didn't know how to soothe himself when he was feeling anxious. He looked to
Tammy, and to sex, for that. For her part, Tammy had no idea how to take care of
her own feelings, or even what they were. Nor did she have the energy, because
so much went to propping up Jack. In some unconscious way, by avoiding sex with
him, she was saying no more.

For their relationship to survive, each needed to take a step back and change
how they individually dealt with their own emotions, rather than leaning on --
and resenting -- the other. Jack had to learn to deal with his neediness on his
own, and recognize that he couldn't expect his wife to do it for him. Tammy had
to figure out who she was and what she wanted, or live her life without really
ever knowing herself -- much less getting to be known by anyone else. And she
had to speak up when she disagreed, rather than keep quiet in order to not rock
the boat.

A year later, Tammy and Jack are utterly honest with each other. No hiding.
"Before we would just not talk about any of our problems because we didn't want
to get each other upset," Tammy says. Now, she says, they always say what they
are thinking or feeling, regardless of the reaction they anticipate. "It can be
very uncomfortable," she admits. "And I'm still working on tact." But in their
case, she says, it changed everything. Over the course of several months spent
learning to be themselves together, Tammy's sex drive returned. They're happier
than they've ever been, she says: "We just renewed our vows in Vegas."

How Sex Makes Grown-Ups

Schnarch's way of thinking about the interdependence of sex and intimacy is a
big shift from the traditional focus on anxiety as a primary cause of sexual
difficulty. Problems in the bedroom are too often seen as distinct from the
emotional struggles of marriage and partnership. But Schnarch -- and a few other
therapists -- have developed an alternative view, one that puts partnership at
the heart of sexuality and puts both sexuality and intimacy at the center of
human development. Sexual difficulties are a kind of emotional Rorschach test
that offers a glimpse into not just the dynamics of the relationship, but the
continuing agenda of growing into a fully autonomous human being.

Schnarch says that what happens with many troubled couples is analogous to
what happens in children as they mature emotionally. A key developmental task of
adolescence is to form separate and unique identities from our parents. (That's
what the dismissive remarks and the skin piercings are all about.) We assume
that by the time we're married, we're past all that. Not true, says Schnarch.
We've merely switched our focus from our parents to our spouses. Temporarily,
some of us adopt joined-at-the-hip intimacy as an archetype of marriage. But the
rebelliousness, the need to separate ourselves, kicks in again. You know it,
Schnarch says, when you begin to find yourself more at odds with your partner
and less sexually attracted to each other than you used to be.

Or you know it when you engage in something he calls arguing about reality.
That is, you both experience an event -- a movie, or a remembered moment from
your past together. But you see it in entirely different ways, and you can't
stop arguing until one of you caves in. Schnarch describes one couple's memories
of the birth of their first child. The wife thought it was the closest moment
they'd ever shared -- but her husband remembered being nauseated by the blood.
Their contradictory views of this event became part of a bitter argument that
surfaced again and again. Because neither of them would accept the other's point
of view, they felt that they were drifting apart. In Schnarch's view, this
difference of opinion was normal, not an indication that their relationship was
falling apart. They are, after all, two different people.

Schnarch's treatment usually involves intense four-day sessions, and doesn't
lend itself to quick tips. All the same, there are basic behavioral shifts that
he finds can benefit many unhappy couples. They all involve the same process:
Each partner takes responsibility for his or her own emotions and learns to
tolerate the idea that his or her partner is not a spiritual twin. That means no
longer expecting a partner to validate you -- so that he or she can admit that
sometimes your ideas are half-baked, rather than always reassuring you that
you're right. You examine your own behavior and see what you expect others to do
for you that you could be doing on your own -- for example, learning to feel
good about yourself without requiring someone else's praise and compliments.

But don't expect your partner to applaud when you tell the truth about
yourself. Learn to lick your own wounds -- it's not your partner's job to soothe
you, it's yours. Try to tell the truth for the right reason. Being honest
doesn't mean being vindictive. "The idea is that you are telling each other the
truth, even when it is difficult, out of caring and commitment, not because
you're pissed off and want to carve each other up," he says. The irony, says
Schnarch, is that rather than increasing conflict between couples -- as you
would think might happen -- emotional honesty has the opposite effect. The issue
is no longer about what your partner does or doesn't do: You can accept that
they, like all people, have their own limitations and failings. Instead, the
focus shifts to you, and whether you're being a grown-up -- or not.

The Joys of Adulthood

Schnarch is still something of a maverick in the field of sex therapy. Talk
to 10 sex therapists (I did), and you'll get 10 strong opinions. Some think he's
done the sex and marital therapy version of cracking the code of DNA. Others
find his ideas interesting, but don't believe that they apply to all couples.
Many say they incorporate a little of what he preaches into their practice --
like a spice in a tomato sauce." The Atlanta-based marital therapist Frank
Pittman, author of a self-help book called Grow Up: How Taking Responsibility
Can Make You a Happy Adult, is one whose approach resembles Schnarch's.
"What he's doing is teaching people the joys of adulthood," he says, "of the
wonderful things that can happen in a relationship when you take responsibility
for yourself, whether you've got your pants on at the moment or not."

The reward for all of this hard work, say Schnarch, Pittman and others, is a
kind of intimacy that helps you be more of the person you want to be and
supports an intense lifelong bond. In return you are seen, known and understood
-- truly -- for who you are. And loved and desired, to boot. It's a rare thing,
perhaps the most powerful connection we can hope for.

With this outing of yourself, so to speak, goes a greater freedom in bed.
You're no longer pretending. Schnarch considers the ability, for example, to
look into your partner's eyes while engaged in a sexual act or in the midst of
orgasm to be the height of intimacy. It's an act of mutual self-revelation that
cannot be matched almost anywhere else in life. "Once people try it, they
totally get what real intimacy is about," he says.

Eye-to-eye sex is not for the faint of heart. Even Schnarch's wife,
psychologist Ruth Morehouse, who now works with him as a marital and sex
therapist and uses his techniques, confesses to having had her doubts. At the
time that her husband was developing his ideas in the 1980s, she says, she
wasn't crazy about them. She describes herself at that time as fairly reliant on
others to give her great feedback about herself, personally and professionally.
She wasn't too keen to grow up, in the way her husband advocated. And the
eyes-open thing, well. "At first, I was mad at him for even suggesting that this
is something that people were supposed to do," says Morehouse. "It was a stretch
for me. At first, I literally couldn't keep my eyes open. After a couple of
times, I was able to do it, and it made sex more emotional and meaningful. It's
now a routine part of my sex life."

Does this mean that all sexual issues can be solved this way? Probably not.
Growing up won't do a lot for a faulty blood vessel that's contributing to an
erection problem. Or for the couple who are genuinely exhausted from chasing
small children around all day. But it maps out some promising new territory,
where personal growth and existential concerns become as much a part of sexual
therapy as do anxiety and pathology. Schnarch is creating a new way of thinking
built on growth and possibilities. Making relationships, and sex, better. How
could anyone not be fascinated by the potential?

As for me, I suspect I still have a lot of growing up to do. (Arguing about
reality? Guilty.) And I haven't dared bring up the idea of eyes-open sex with my
husband yet, for fear he'll take me up on it. I have a feeling I'd have to keep
my eyes open with pliers. But I am intrigued. And now, as I stand on subway
platforms or street corners, watching couples who really ought to get a room
groping one another without shame, I don't feel as if I've been banished to the
land of slippers and ratty bathrobes. Because according to Schnarch's model, in
which sex only gets better as you get older and wiser, I'm ahead of the game. Or
at least those couples. And that makes me feel smug all over again.

Senior dating: Resuming sexual activity later in life

Q:

I am a 76-year-old female. I've
not been sexually active in many years. But I'm in a relationship now and wonder
if I will be able to resume sexual activity again at this late time?

A:

You will be happy to learn that you can resume sexual activity — as
long as you're willing to invest a little time and patience.

As women age, they experience several changes in their vaginal area. The
vagina and vaginal opening often become smaller, especially when estrogen levels
are low. As a result, it often takes longer for the vagina to swell and
lubricate when you're sexually aroused. Together these changes can make
intercourse painful.

The good news is that there are steps you can take to make sexual intercourse
more comfortable, including:

• Longer foreplay. Foreplay helps stimulate natural
  lubrication.
  
• Over-the-counter lubricants. Products such as K-Y
  Lubricating Jelly and Glide are available for this purpose.
  
• Topical estrogen treatment. For some women, treatment with
  vaginal estrogen creams is the best way to increase natural lubrication.
  

If a woman hasn't had intercourse for a while, it will take time to stretch
out the vagina so that it can accommodate a penis. Talk to your partner about
what works best. You may want to try different sexual positions or different
times of day.

You should also keep in mind that sex is more than intercourse. Touching and
cuddling are an important part of sexual activity. Communicating with your
partner is the best way to achieve sexual satisfaction.

Like a Sex Machine

At last, women may have their answer to Viagra. The EROS Clitoral Therapy
Device (EROS-CTD) is the first product developed to treat female sexual arousal
disorder (FSAD). Characterized by diminished sexual sensation, FSAD affects
approximately 43% of American women. It results from inadequate blood flow to
the clitoris and can cause a host of other difficulties, including lack of
desire and difficulty achieving orgasm.

Enter EROS, a clitoral suction device that draws blood to the clitoris to
trigger sexual arousal and enhance orgasms. In a study presented recently at an
American Urological Association conference, 80% of FSAD sufferers reported
improved sexual satisfaction after using EROS before intercourse. But EROS is no
mere sex toy, says Kevin Billups, Ph.D., an urologist and one of the study's
researchers. "People say, 'Oh, this is just a fancy vibrator'--but it isn't," he
explains. "It's a physiological device."

Because FSAD can also hurt relationships by causing lowered self-esteem,
depression and poor body image, "women suffering with sexual dysfunction may
have a relationship in crisis," says Laura Berman, Ph.D., a female sexual
dysfunction expert. She suggests these women consider using EROS in conjunction
with professional counseling. And the best news may be yet to come: Women who
used EROS regularly reported enhanced sexual satisfaction even after they
stopped using it.

Sex and Your Psyche

You know the cliche: a woman is so uninterested in sex that she makes a
shopping list while making love. Jennifer and Laura Berman see such women all
the time, and it's frustration--not boredom--that brings them to the Bermans'
new clinic at UCLA.

"I was talking to a woman earlier today about her low libido, which was a
result of the fact that she can't reach orgasm," says psychologist Laura Berman,
Ph.D., who with her sister, urologist Jennifer Berman, M.D., is a founder and
codirector of the Center for Women's Urology and Sexual Medicine clinic.
"Because she can't reach orgasm, sex is frustrating. She feels a hopeless,
fatalistic complacency about her sex life. When she's having sex, her partner
picks up on that and feels rejected and angry, or notices she's withdrawing.
Then intimacy starts to break down. Her partner feels less intimate because
there's less sex, and she feels less sexual because there's less intimacy. The
whole thing starts to break down."

Acknowledgement of sexual dysfunction in America is booming. But with all the
attention on Viagra and prostate problems in men, most people would probably
never guess that more women than men suffer from sexual dysfunction. According
to an article in the Journal of the American Medical Association, as many as 43
percent of women have some form of difficulty in their sexual function, as
opposed to 31 percent of men.

And yet female sexuality has taken a back seat to the penis. Before Viagra,
medicine was doing everything from penile injections to wire and balloon
implants to raise flagging erections, while female sexual dysfunction was almost
exclusively treated as a mental problem. "Women were often told it was all in
their head, and they just needed to relax," says Laura.

The Bermans want to change that. They are at the forefront of forging a
mind-body perspective of female sexuality. The Bermans want the medical
community and the public to recognize that female sexual dysfunction (FSD) is a
problem that may have physical as well as emotional components. To spread their
message, they have appeared twice on Oprah, have made numerous appearances on
Good Morning America and have written a book, For Women Only.

"Female sexual dysfunction is a problem that can affect your sense of
well-being," explains Jennifer. "And for years people have been working in a
vacuum in the sex and psychotherapy realms and the medical community. Now we are
putting it all together."

No single problem makes up female sexual dysfunction. A recent article in the
Journal of Urology defined FSD as including such varied troubles as a lack of
sexual desire so great that it causes personal distress, an inability of the
genitals to become adequately lubricated, difficulty in reaching orgasm even
after sufficient stimulation and a persistent genital pain associated with
intercourse. "We see women ranging from their early twenties to their
mid-seventies with all types of problems," Laura says, "most of which have both
medical and emotional bases to them." The physical causes of FSD can range from
having too little testosterone or estrogen in the blood to severed nerves as a
result of pelvic surgery to taking such medications as antihistamines or
serotonin reuptake inhibitors, such as Prozac and Zoloft. The psychological
factors, Laura says, can include sexual history issues, relationship problems
and depression.

The Bermans codirected the Women's Sexual Health Clinic at Boston University
Medical Center for three years before starting the UCLA clinic this year. At
present, they can see only eight patients a day, but each one receives a full
consultation the first day. Laura gives an extensive evaluation to assess the
psychological component of each woman's sexuality.

"Basically, it's a sex history," Laura says. "We talk about the presenting
problem, its history, what she's done to address it in her relationship, how
she's coped with it, how it has impacted the way she feels about herself. We
also address earlier sexual development, unresolved sexual abuse or trauma,
values around sexuality, body image, self-stimulation, whether the problem is
situational or across the board, whether it's lifelong or acquired." After the
evaluation, Laura recommends possible solutions. "There is some psycho-education
in there, where I'll work with her around vibrators or videos or things to try,
and talk about addressing sex therapy."

Afterward, the patient is given a physiological evaluation. Different probes
are used to determine vaginal pH balance, the degree of clitoral and labial
sensation and the amount of vaginal elasticity. "Then we give the patient a pair
of 3-D goggles with surround sound and a vibrator and ask them to watch an
erotic video and stimulate themselves to measure lubrication and pelvic blood
flow," Jennifer says.

The identification of FSD has been called everything from the final frontier
of the women's movement to an attempt by the patriarchy to shackle women's
sexuality. But given the success that drugs such as Viagra have had in reversing
male sexual dysfunction, the Bermans found an unexpected amount of criticism
from their peers. "The resistance we got from the rest of the medical community
early on was surprising to us," Laura says, explaining that the urological field
in particular has been dominated by men.

Clearly, the Bermans will need hard data to win over their critics. Their
UCLA facility is enabling the Bermans to conduct some of the first systematic
psychological and physiological research on the factors that inhibit female
sexual function. One of their first studies suggests that the pharmaco-sexual
revolution that helped some men overcome their sexual dysfunction may prove less
effective for women. Their initial study of the effects of Viagra on women found
that Viagra did increase blood flow to genitalia and thereby facilitate sex, but
women who took the drug said it provided little in the way of arousal. In short,
subjects' bodies might have been ready, but their minds were not.

"Viagra worked half as often in the women with an unresolved sexual abuse
history as in those without it," Laura says. "So it's just not going to work
alone. Women experience sexuality in a context, and no amount of medication is
going to mask psychologically rooted, or emotionally or relationally rooted
sexual problems." Laura believes the results of the Viagra study counter those
who contend that FSD is simply a tool of pharmaceutical companies to
"medicalize" female sexuality.

"I'm less concerned about it, because I'm aware that it won't work," she
says. "And in some respects, pharmaceutical companies are closing the divide
between the mind and body camps of FSD. Clinical trials of new drugs for FSD are
requiring psychologists to screen participants, and that is an acknowledgement
that an accurate assessment of a drug's efficacy requires a consideration of the
test subjects' feelings about sex. So these physicians who may not be motivated
to bring on a sex therapist are now motivated to participate in a clinical
trial, and then that model becomes the norm."

Currently, the sisters are working on MRI studies of the brain's response to
sexual arousal, the place where mind and body meet. And although there is a lot
more research to be done on FSD, identifying it as a problem has already made a
significant impact on how women perceive their sexuality. "Women now feel more
comfortable going to their doctors, and they're not taking no for an answer, not
being told to just go home and have a glass of wine," explains Laura. "They feel
more entitled to their sexual function."

READ MORE ABOUT IT: For Women Only: A Revolutionary Guide to Overcoming
Sexual Dysfunction and Reclaiming Your Sex Life Jennifer Berman, M.D., and Laura
Berman, Ph.D. (Henry Holt & Co., 2001)

HIS & HERS... and how to have them

Hers: a female orgasm can be frustratingly evasive. While about 85 to 90
percent of women are capable of having an orgasm, according to Beverly Whipple,
Ph.D., vice president of the World Association for Sexology, only about
one-third have had one during intercourse. That said, it's important to remember
that orgasm should never be the goal.

"In goal-oriented sexual interactions, each step leads to the top step, or
the big "O"--orgasm," says Whipple. "Goal-oriented people who don't reach the
top step don't feel very good about the process that has occurred. Whereas for
people who are pleasure oriented, any activity can be an end in itself; it
doesn't have to lead to something else. Sometimes, we're very satisfied holding
hands or cuddling. There would be a lot more pleasure in this world if people
would just focus on the process."

Whipple also points out that the psychological ramifications of dissatisfying
sexual interactions are not often suffered alone; they can cause distress in
both partners. "If one person in a relationship is goal-oriented and the other
is pleasure-oriented, and neither is aware of their own orientation, they don't
communicate that with their partner," she explains. "A lot of relationship
problems can develop. In my workshops with couples, I help them be aware of how
they view sexual interactions and then communicate this with their partner."

TYPES OF ORGASM

Clitoral Orgasm

The most common, they result from directly stimulating the clitoris and
surrounding tissue. What many people don't realize is that the majority of the
clitoris is actually hidden inside the woman's body. Recently, Australian
urologist Helen O'Connell, M.M.E.D., studied cadavers and 3-D photography and
found that the clitoris is attached to an inner mound of erectile tissue the
size of your first thumb joint. That tissue has two legs or crura that extend
another 11 centimeters. In addition, two clitoral bulbs--also composed of
erectile tissue--run down the area just outside the vagina.

O'Connell's findings, published in the Journal of Urology, show that this
erectile tissue, plus the surrounding muscle tissue, all contribute to orgasmic
muscle spasms. With so much tissue involved in a clitoral orgasm, it's no wonder
they're the easiest to have.

Pelvic Floor or Vaginal Orgasms

These occur through stimulating the G-spot, or putting pressure on the cervix
(the opening into the uterus) and/or the anterior vaginal wall. Located halfway
between the pubic bone and the cervix, the sensitive G-spot--named after its
discoverer, German physician Ernest Grafenberg--is a mass of spongy tissue that
swells when stimulated. Because it's difficult to locate, experts have developed
a few guiding techniques:

o Lying on her back, the woman tilts her pelvis upward so that her vulva
presses flat against her partner's pelvic bone. According to the Bermans, this
allows the penis to make contact with the G-spot, simultaneously stimulating the
clitoris. Putting pillows beneath her buttocks makes angling her pelvis easier.

o Whipple suggests placing two fingers inside the vagina and moving them in a
beckoning motion. The fingertips should stroke the frontal vaginal wall, just
where the G-spot is located.

The Blended Orgasm

This can be attained through a combination of the first two.

HER BENEFITS

o Pain relief: Orgasms help alleviate menstrual cramps. In addition, studies
have shown that a woman's pain threshold increases substantially during orgasm.

o Enhanced mood: According to University of Virginia researchers, orgasms
boost levels of the female sex hormone estrogen, which in turn betters your mood
and helps ease premenstrual symptoms. They also release endorphins, the body's
natural painkillers and depression fighters.

o Increased intimacy: Oxytocin, a hormone that promotes feelings of intimacy,
jumps to five times its normal level during climax.

o Easier rest: Oxytocin also induces drowsiness. For women, sleepiness comes
about 20 to 30 minutes after orgasm. Men, on the other hand, usually drift off
after only two to five minutes.

o Less stress: Stress in women is highly correlated with arousal
difficulties, lack of libido and anorgasmia, the inability to reach orgasm,
according to one 1999 study in the Journal of the American Medical Association.
Just 20 minutes of intercourse, however, releases the lust-enhancing hormone
dopamine, triggering a relaxation response that lasts up to two hours.

His Physiologically speaking, male and female orgasms are surprisingly
similar. The related problems men and women experience, however, are distinctly
different.

"There are men who can't orgasm, but I think it's less than I percent of
men," says Jed Kaminetsky, M.D., a professor of urology at New York University
and director of the school's male sexual dysfunction clinic. "That's a much less
common problem than premature ejaculation."

A study published in the Journal of the American Medical Association found
that premature ejaculation is even more common than erectile dysfunction,
especially among younger men. As with most sex-related problems, it affects both
partners--some studies suggest that nearly 30 percent of couples report
premature ejaculation as the most prevalent sexual problem in their
relationship. One major obstacle to treating it is simply defining the problem
to begin with.

"It depends on the relationship," Kaminetsky explains. "If a woman takes an
hour to orgasm and the man can last 40 minutes, that's premature ejaculation for
that couple." At the other extreme, one minute is too short an amount of time
for most couples. "Not too many women are going to climax within a minute."

Kaminetsky also sees truth in Whipple's assessment of goal-oriented versus
pleasure-oriented interactions. "Men are very goal oriented; they see a task and
they want to successfully perform that task," he says. "Often that task is to
make their partner have an orgasm. If the woman knows that, she feels like a
laboratory animal--it's not a very sexy thing. That's why women fake orgasms,
which is a sign of lack of communication in a relationship."

PREMATURE EJACULATION

Rarely a physiological problem, premature ejaculation can result from
over-excitement, positioning or rate of intercourse. "The roots of it go back to
the way men learn to orgasm, which is typically through masturbation," suggests
Kaminetsky. "A lot of young boys masturbate quickly, because they don't want
their mom to walk in on them. It becomes a trained behavior." To treat premature
ejaculation, experts suggest changing positions, breathing deeply, thinking
about something other than sex or simply stopping for a moment. Here, Kaminetsky
offers two additional techniques for delaying orgasm:

o Practice this before reaching "ejaculatory inevitability," the point when
ejaculation cannot be stopped; most men recognize it as a sensation of deep
warmth or pleasure: Squeeze the head of the penis for about four seconds or
until the sensation subsides, then resume.

o During intercourse, the man should press his pelvic bone against the
woman's and rock rather than thrust his body. "It won't be as stimulating for
him so he'll last longer, and it may be more stimulating for the woman."

HIS BENEFITS

o Long life: Men who have two or more orgasms a week tend to live
significantly longer than do those who have only one or none, according to
research at Cardiff University in Wales.

o Less cancer: Breast cancer is rare in men, but once developed, the
mortality rate is high. Fortunately, a study published in the British Journal of
Cancer found that men who have more than six orgasms a month are significantly
less likely to develop breast cancer than are those who have less frequent sex.

o Healthy hearts: A study of 2,500 men at the University of Bristol and
Queens University of Belfast found that men who have at least three or more
orgasms a week are 50 percent less likely to die from heart failure or coronary
heart disease.

o Good health: Having sex once or twice a week also fights off the flu and
other viruses by strengthening the immune system, psychologists at the
University of Pennsylvania recently found.

o Youthful looks: A study of 3,500 aging people at the Royal Edinburgh
Hospital in Scotland found that those who looked the youngest also had the most
vigorous sex life. The effects were even greater if the subjects were
emotionally satisfied as well.

READ MORE ABOUT IT: The Good Girl's Guide to Bad Girl Sex Barbara Keesling,
Ph.D. (M. Evan and Co., 2001)

Sexual Fitness: 7 Essential Elements of Optimizing Your Sensuality,
Satisfaction and Well-Being Hank C.K. Wuh, M.D. (G.P. Putnam's Sons, 2001)

GETTING CLOSE AND PERSONAL

Bee, 25, Copywriter

Masturbating is the easiest way for women to learn how to have an orgasm.
Women who masturbate will be a lot more likely to have an orgasm during sex. I
think it helps you learn the actual mechanics of what turns you on, where things
need to happen.

Because the guy isn't going to know that; there's no reason he would. Every
woman is different. Also, the bonding that goes on during sex seems most extreme
with an orgasm. It's kind of like one or both people have gone completely over
the edge; they're suspended in the other person's grasp, and they're completely
surrendered to it. That intensifies any connection.

Gabriel, 25, Musician

There are guys who don't get a rise out of giving a woman an orgasm and would
just prefer not to have someone else there. I've even heard some guys say they
have better orgasms during masturbation than sex. The mere thought of it
astounds me, but it makes sense if a guy has a fear of intimacy or, even more, a
fear of performing. It probably takes away from his own orgasm if he's overly
concerned with his sexual performance or whether or not she's having one. It's
ironic, because an orgasm during sex is enhanced when it's with someone you
truly care about.

GETTING CLOSE AND PERSONAL

Kamara, 27, Musician

I'm amazed when I talk to anyone who claims to have never had an orgasm,
probably because I just can't imagine not having them or not being able to have
them. At the same time, it doesn't surprise me: I was raised in a very
conservative religious atmosphere that actually called masturbation "self
abuse," and all sexuality--not to mention orgasms--was beautiful and good only
if it happened in a marriage bed. It takes awhile to expel the load of guilt
that piles up around your sexuality if you're raised in that kind of culture,
and I'm sure some people never do. But there was no way I wasn't going to aim
for the prize once I knew what it felt like. Maybe it depends on your sexual
drive--for me the drive was strong enough that I could never feel guilty about
an orgasm for long.

Steven, 28, Veterinarian

Some guys think sex has to include an orgasm. Orgasms are great, but there's
so much more to sex. An orgasm is more of a physical experience; I guess there
is an emotional aspect, but it's over in a second. I think anybody can give you
an orgasm, but it's the person there after the orgasm that matters. But I think
I'm the exception.

DOES ORGASM EQUAL SEX?

Our ever-changing definition of sex may hinge more on the climax than on the
act itself; Psychologist L.M. Bogart, Ph.D., gave Kent State students a list of
scenarios in which "Jim" and "Susie" engaged in vaginal, anal or oral
intercourse and either did or did not achieve orgasm. Vaginal intercourse was
considered sex 97 percent of the time, followed by anal intercourse (93 percent)
and oral sex (44 percent). Researchers were surprised to find that orgasm
occurrence dictated whether or not the activity was considered sex. Although the
woman was more likely to label vaginal intercourse sex if neither partner
climaxed, when it came to oral sex, the recipient was more likely to consider it
sex than the partner performing the act, especially if the recipient achieved
orgasm--because the stimulator was unlikely to achieve orgasm. For anal sex, it
was more likely to be called sex if Jim had the orgasm, but it was sex to Susie
regardless of whether she achieved orgasm. In general, the lack of orgasm for
women was less likely to affect her labeling the act sex. Although most sex
therapists argue against using orgasm as an end-all definition of sex, Bogart's
study indicates that orgasm is still an important gauge by which we measure
sexual activity.

Sexual Assault - The Danger of STDs

You'll also be tested for sexually transmitted diseases (STDs), including
gonorrhea, chlamydia, genital herpes, syphilis, and AIDS. If the rapist has an
STD, there's a reasonable chance that he has passed it on to you through his
semen or blood.

It takes 3 to 5 days to get the results back from initial STD testing. You'll
also need follow-up tests 90 days later. Because of the chance that you were
exposed to gonorrhea or chlamydia, the doctor will probably start treatment
without waiting for the test results.

Symptoms of gonorrhea, if left untreated may be very mild, and you might not
even notice them. You may have some abdominal pain, burning during urination,
and a vaginal discharge. It is possible to get a gonorrhea infection in your
mouth or anus, as well as in your vagina.

With chlamydia, you may notice a thin discharge from your vagina, as well as
stomach pain and a burning sensation when you urinate some time after the
exposure.

Trichomoniasis and vaginosis are forms of vaginal inflammation that can be
caused by sexually transmitted organisms. They produce burning and itching
sensations, odor, and a discharge.

In women, STD symptoms are not as noticeable as they are in men, and some
types show no early warning signs at all. You should report anything
unusual?discomfort or discharge, for example?to your doctor.

Syphilis begins with genital sores?which may go unnoticed?and progresses into
flu-like symptoms. This disease is so contagious that it can be passed on just
by kissing, and, if left untreated, it will eventually attack other organs,
causing heart trouble, blindness, and severe mental illness. For more on this
and other STDs, see "Coming to Terms with Sexually Transmitted Disease."

Dos and Don'ts After an Assault DO... Seek medical help as soon as possible Bring a change of clothes to the emergency room Get tested for sexually transmitted disease Inquire about emergency contraception Remember that what you say to medical personnel could be used in court DON'T... Shower... Douche, or... Change clothes until after the exam Hesitate to call the police

AIDS?acquired immune deficiency syndrome?leads to the total destruction of
the immune system, but unless you get tested, you can carry the HIV virus that
causes it for years without knowing it. You may be tested for the virus at the
emergency room. If the results are negative, you'll learn the good news fairly
quickly, sometimes within an hour. Positive results take longer because they
must be confirmed by a second test. Finding out that you have this dreaded
illness could be devastating, but it's still better to know. Doctors do have
drugs that can stave off the disease. For more information, see "The Persistent
Threat of AIDS."

If there is even a remote chance that you have gotten HIV or another STD,
it's best to abstain completely from sex until you're sure you don't have it. If
you do have sex, be sure to use a condom to help avoid the possibility of
passing on HIV or other serious STDs to your partner.

Sexuality after cancer treatment: What women can expect

Sex might be the last thing on your mind as you start thinking about cancer
treatment options and cope with the anxiety that comes with a cancer diagnosis.
But as you start to feel more comfortable with yourself during treatment and
afterward, you'll want to get back to a "normal" life as much as you can. For
many women, this includes resuming sexual intimacy with their partners.

An intimate connection with a partner can make you feel loved and supported
as you go through your cancer treatment. But sexual side effects of cancer
treatment can make resuming sex more difficult. Find out if you're at risk of
sexual side effects after treatment and which treatments can cause these side
effects. Knowing more about your situation can help you feel more in control and
help you find a solution that will work for you.

Who's at risk of sexual side effects?

Women being treated for breast or gynecologic cancers are most likely to
experience side effects that make having sex painful or difficult. But cancers
anywhere in the pelvic region can cause these effects. Pelvic cancers
include:

• Bladder cancer
  
• Cervical cancer
  
• Colon cancer
  
• Ovarian cancer
  
• Rectal cancer
  
• Uterine cancer
  
• Vaginal cancer

Treatment for each of these cancers carries the risk of causing physical
changes to your body. But having cancer also affects your emotions, no matter
what type of cancer you have. These emotions can also impact your attitude
toward sex and intimacy with your partner.

What sexual side effects are most common?

The treatment you receive and your type and stage of cancer will determine
whether you experience any sexual side effects. The most commonly reported side
effects among women include:

• Difficulty reaching climax
  
• Loss of desire for sex
  
• Pain during penetration
  
• Reduced size of the vagina
  
• Vaginal dryness

Not all women will experience these side effects. Your doctor can give you an
idea of whether your specific treatment will cause any of these.

Common sexual side effects of selected cancer treatments

Treatment	Difficulty climaxing	Loss of desire	Painful sex	Reduced vaginal size	Vaginal dryness
Chemotherapy	 	X	X	 	X
Pelvic radiation	 	 	X	X	X
Surgery Radical hysterectomy	 	 	 	X	X
Radical cystectomy	 	 	X	X	X
AP resection	 	 	X	X	X
Vulvectomy	X	 	X	X	 
Hormone therapy Medications	 	X	X	X	X
Oophorectomy	 	 	X	X	X

Adapted from: American Cancer Society, 2005

How does cancer treatment cause sexual side effects?

Cancer treatments that are more likely to cause sexual side effects
include:

Chemotherapy
Many women experience a loss of libido
during and after chemotherapy. Often the side effects of the treatment, such as
nausea, hair loss, and weight loss or gain, can make you feel unattractive. Side
effects usually fade soon after treatment ends. But it may take time to rebuild
your self-confidence to bring back your desire for sex.

Chemotherapy can cause a sudden loss of estrogen production in your ovaries.
This can lead to symptoms of menopause, such as a thinning vagina (vaginal
atrophy) and vaginal dryness, which both can cause pain during penetration. Ask
your doctor about what you can expect from your chemotherapy drugs, as some can
cause permanent ovary damage. Depending on your cancer type, your doctor may
prescribe estrogen replacement therapy — also called hormone therapy
for menopause — to reduce the sexual side effects you experience.
However, women with breast or ovarian cancer should discuss this carefully with
their doctors, as some cancers are hormone sensitive and shouldn't be combined
with hormone replacement therapy.

Radiation therapy
Sexual side effects related to
radiation therapy are most common in women receiving treatment aimed at their
pelvic area. Radiation to the pelvis causes:

• Damage to the ovaries. The amount of
  damage and whether it's permanent depends on the strength of your radiation
  treatments. Damaged ovaries don't produce estrogen. This causes symptoms of
  menopause, such as vaginal dryness. If you've already been through menopause,
  you likely won't experience such symptoms.
  
• Changes in the vaginal lining. Radiation
  therapy can irritate healthy tissue in its path. This can cause the lining of
  your vagina to become inflamed and tender. Penetration during sex may be
  uncomfortable during treatment and for a few weeks afterward. As the lining of
  your vagina heals, it may become thickened and scarred, causing your vagina to
  tighten and resist stretching during penetration. Your doctor might recommend
  using a vaginal dilator to prevent scar tissue from forming after radiation.
  

Talk to your doctor about what you can expect from your specific radiation
treatments. Some side effects may be preventable. For instance, surgery to
relocate your ovaries to another part of your body might spare them from the
damage of radiation and preserve your fertility. Ask your doctor about your
options.

Surgery
Whether surgery affects your ability to have sex
will depend on your type of cancer, where it's located and its size. Surgeries
that are likely to cause sexual side effects include:

• Radical hysterectomy. Women with cervical
  cancer may opt for a radical hysterectomy to remove their uterus and related
  ligaments, as well as their cervix and part of their vagina. A shortened vagina
  usually doesn't change your ability to have sex, though it may take some
  adjustment. Women over 40 may also have their ovaries removed during this
  procedure. If you're premenopausal when your ovaries are removed, you'll
  experience menopause.
  
• Radical cystectomy. In this operation for
  bladder cancer, the surgeon removes your bladder, uterus, ovaries, fallopian
  tubes, cervix, the front wall of your vagina and your urethra. Your surgeon
  reconstructs your vagina, though it may be shorter or narrower than it was
  before surgery. This can make sex painful. If you haven't been through
  menopause, removal of your ovaries will cause early menopause.
  
• Abdominoperineal (AP) resection. AP
  resection is used if you have colon or rectal cancer. Your surgeon removes your
  lower colon and rectum. Without the cushion of the rectum, you might experience
  pain in your vagina during penetration. Some women who have an AP resection also
  have their ovaries removed. If you're premenopausal, this will cause premature
  menopause.
  
• Vulvectomy. You may undergo vulvectomy if
  you have cancer of the vulva. Your surgeon removes the entire vulva, including
  the inner and outer lips, as well as the clitoris. These play a major part in
  sexual arousal in women. Removing the vulva and the clitoris can make the area
  less sensitive and make it harder for you to reach orgasm.

There isn't a clear link between breast cancer surgery and decreased sexual
function. You may be self-conscious of your scars after surgery, which can cause
a loss of libido. However, women who undergo breast-saving surgery, rather than
complete removal of the breast (mastectomy), are more likely to enjoy breast
caressing.

Hormone therapy
If you have a hormone-sensitive cancer,
you might receive hormone therapy through medications, such as tamoxifen, or
through surgery, such as removal of your ovaries (oophorectomy). If your cancer
relies on hormones to fuel its growth, these measures can block or alter its
supply.

Both medications and surgery for hormone therapy cause menopausal signs and
symptoms, including vaginal atrophy and dryness. Removing your ovaries causes
permanent menopause. Side effects of hormone therapy medications usually wear
off after you stop taking them. Keep in mind though, that women taking hormone
therapy for cancer usually take these drugs for five years or more.

The vulva is the outer part of the female genitalia, including the labia and
clitoris.

What can you do to regain your sexual function?

Knowing what sexual side effects to expect before you begin your cancer
treatment can help you be more prepared to deal with them as you go through
treatment. If you experience sexual side effects, find out as much as you can
about what's impeding your sexual function. This will help you feel more in
control of the situation and help guide you to treatment options. You may also
want to:

• Talk with your health care team. You
  might be embarrassed to talk about the sexual side effects you're experiencing,
  but don't be. Though talking about sex can be awkward, you'll never find a
  solution if you don't let someone know what you're experiencing. Write down your
  questions if it makes you feel more comfortable. Also know that your doctor may
  be embarrassed or hesitant to talk about sex. Ask to be referred to a specialist
  or seek support from other members of your health care team, such as nurses and
  counselors.
  
• Talk with your partner. Let your partner
  know what you're experiencing and how he or she can help you cope. For instance,
  you might find that using a lubricant eases your vaginal dryness or changing
  positions helps you avoid genital pain during sex. Together you can think of
  solutions to ease you back into a fulfilling sex life.
  
• Explore other ways of being intimate.
  Intercourse isn't your only option for closeness with your partner. Consider
  spending more time together talking, cuddling or caressing. Connecting in other
  ways might help make you feel more comfortable and less anxious about the sexual
  side effects you're experiencing.
  
• Talk with other cancer survivors. Your
  health care team might be able to steer you to a support group in your town.
  Otherwise, connect with other cancer survivors online. If you're embarrassed
  about discussing sex face-to-face with strangers, the online environment
  provides you anonymity. Start with the American Cancer Society's Cancer
  Survivors Network.

It may simply take time for you to regain your sexual function after cancer
treatment. While that can be frustrating, know that if you had a positive and
satisfying sex life before cancer, you'll likely resume that after your
treatment.

Slow and Steady

You don't have to make the change all at once.

I love it when people wake up one day and say, "That's it. No sugar, pasta,
bread, alcohol. I'm going to work out 18 hours a week, and no more fun." I
wonder if it occurs to them that this approach may be one of the reasons they
don't make it to the second week. Granted, for a small percentage of individuals
out there, this works. However, for the rest of us flesh and blood humans,
change is difficult.

How about we approach the change with a slow and steady strategy?

1. Write down what changes you want to make in your day-to-day
   lifestyle.
   
   
   
2. Make a list of foods that you can't live without and foods that you are
   willing to give up.
   
   
   
3. Figure out what forms of exercise are attractive to you, that you relate to,
   and that you can see yourself participating in on a regular basis.
   
   
   
4. Create some goals.

• lose weight
  
• have more energy
  
• exercise 3-4 times a week
  
• go out and do something fun just for you once a week
  
• read more
  
• laugh with your family
  
• be more spontaneous
  
• take that risk you have been contemplating

OK, you get my point. These are just ideas, but make it your own list.

After you've written all of this information down, start to create your
strategy. If you can't live without pasta, then start slow. Don't go cold turkey
but try to eat it less often. If you eat it three times a week, then make a vow
to only eat it once. You could even begin by "substituting" healthier
alternatives (e.g., rice pasta). If you can't live without five diet sodas a
day, switch to an unsweetened tea and only have one soda a day.

Are you sedentary right now? Well don't start hitting the gym 5 days a week
and kill yourself. Begin with walking and doing little things at home with light
weights, and then start heading to the gym. Start by taking a few classes and
lifting 2 times a week. You don't need to begin by going 2 hours a day -- start
with 30 minutes.

How does that sound? I know you can make the changes. Just have a real plan
to support you while going through the process. I like the idea of keeping a
journal and writing it all down.

If you are up for it, you could even create a calendar to keep track of all
of the changes --what activities you're doing, what foods you are or aren't
eating. This way, the change will not only become obvious in you, but you'll be
able to track how far you've come.