Author: annette-owens

How will pregnancy affect your sex life?

Ask your girlfriends who have been pregnant whether they had sex during their pregnancy and you will likely get quite a mix of answers—from “I was constantly horny and felt like having sex every single day,” to “No way, I felt nauseous the first few months and then like an elephant in my last trimester—I NEVER felt like it and it was driving my husband crazy.”

There is no way to predict how you will feel and react, and it can even vary from pregnancy to pregnancy. So just go with the flow, following these general guidelines:

Do listen to your obstetrician or midwife about whether your particular pregnancy calls for any restrictions. If they do not bring up this topic, ask them directly. Sometimes, conditions change throughout the pregnancy and it may turn out that your placenta is located too close to your cervical opening, instead of deep inside the uterus; your health provider may worry that sexual activity might trigger preterm labor; the fluid that surrounds the baby (amniotic fluid) may be leaking; or you may experience unexplained vaginal bleeding. These are all circumstances where it is not O.K. to have intercourse.

But in far more cases, it is perfectly fine and safe to have sexual intercourse throughout the entire pregnancy—that is, if you and your partner feel like it! Some partners worry that having intercourse might hurt you or the baby, and in particular as your belly grows, some men get increasingly hesitant to “put their penis next to the baby’s head,” so to speak. In these cases, be tolerant and try to speak openly about his concerns, and do bring your partner along to some of your regular check ups. It often helps to get reassured by your obstetrician or midwife that having sex during your particular pregnancy is not a problem.

As always, if there is a risk of sexually transmitted infection (STI), be sure to use condoms! In fact, if your partner has a known STI, don’t have sexual intercourse, in order to protect the fetus—and you—from getting infected. Have outercourse instead! There are lots of pleasurable things you can do that don’t involve vaginal penetration.

I have always found this fact a bit exotic, but here is something that would be dangerous to do in any pregnancy: During oral sex, don’t let your partner blow air into your vagina! This could cause air to enter the circulation via the placenta and cause an air embolism (a trapped air bubble in the blood stream), which can actually be fatal to the mother or the fetus.

Your desire for sex may vary from time to time and it is usually related to how you feel, not just physically, but also about yourself. Some women find it much easier to reach orgasm while they are pregnant, something that can be a pleasant surprise to a woman and her partner.

During the later stages of pregnancy, you may need to start using different positions, such as rear vaginal entry (doggie style), or you both lying on your sides. Many couples find that using pillows here and there helps. Just be open minded about trying out different things—there is not one right way to do it.

At the very final stage of pregnancy, when you are at term, having unprotected sex can help start the labor process. Sperm contains prostaglandins, which help soften up the cervix. So having intercourse at this time can be a great way to prepare for labor! On top of that, having an orgasm as well as nipple stimulation causes release of oxytocin from your brain—the same substance (pitocin) that doctors use to start labor. And who wouldn’t trade getting an I.V. at the hospital for having sex at home?

Charlottesville’s Annette Owens, MD, Ph.D., is certified by the American Association of Sexuality Educators, Counselors, and Therapists. She has co-edited the four-volume book, Sexual Health (Praeger).

More than half of all Americans will get a sexually transmitted infection (STI) at some point in their lifetime. If you’re one of them, how will your sex life be affected, during and after treatment? First, let’s take a quick look at some general facts.

The majority of STIs are asymptomatic, which means that there are no signs of an infection and the person may not know that he or she has an STI. So unbeknownst to them, they may pass the infection on to others during sex, unless they use safer sex methods such as condoms and dental dams. Only if that person chooses to get a routine STI check-up will they be diagnosed correctly and can get treated. That is why it is a really good idea for sexually active individuals to check their STI status either at their health provider’s office or at the health department (972-6217)—especially if they have had multiple partners.

Got a new partner? Make sure to talk about each other’s sexual histories and STI status. Of course, this can be an awkward subject to address, but would you buy a new house without having it inspected first, or at least knowing where the leaks are?

Prevention obviously is the key, but what do you do when the bug has already struck? Well, it depends on what type of bug it is, since they all require different treatment strategies. There are basically two types of infections. There are bacterial infections such as Chlamydia, Trichomoniasis (“Trich”), Gonorrhea, and Syphilis, and then there are virus infections such as Herpes Simplex Virus (HSV), Human Papilloma Virus (HPV) and Chronic Hepatitis C. And with over 50,000 new cases estimated in the U.S. each year, HIV is a big concern as well.

Here’s the good news: bacterial infections can be easily treated with antibiotics. The bad news: There are no medicines to cure viral infections. Visible genital warts (HPV) can be removed, but not all HPV infections are visible. Usually your body fights HPV on its own and your immune system eventually clears the virus.

However, there are no firm rules as to when this typically happens, and it’s best to have a frank discussion with your health provider about your specific situation and what types of precautions you need to take with your sexual partner. Obviously, you need to avoid unprotected sexual contact while you have visible genital warts—it’s the best way to prevent passing on the virus to a partner. Once again, there is no substitute to prevention and I highly recommend the new vaccination against HPV with Gardasil (see page 19 for more on this vaccine).

If you or your partner has Herpes (HSV), you should avoid sexual contact during outbreaks, but that’s not all there is to it. You also need to be concerned about asymptomatic viral shedding, which is potential spreading of the virus even when there is no active outbreak. Avoid skin contact with areas where the herpes outbreak usually occurs. Barrier methods such as condoms and dental dams can prevent transmission of the virus. And they can help prevent transmission of HIV by blocking an exchange of body fluids that may contain the virus.

If you have one of the treatable bacterial infections, all sexual partners should be checked and (if infected) treated, and you need to hold off on sexual contact until the end of the treatment, to avoid re-infection. Be sure to get clear guidelines from your health provider about when you can resume having sex after treatment.

After serving the Charlottesville community for almost 10 years, I will be closing my office later this fall. It’s been an exciting decade, culminating for me with last year’s publication of the four-volume book, Sexual Health, which I co-edited. Now is a good time for me to shift into lower gears and reflect on the changes in the sexuality field I have witnessed over time.

Viagra became available in 1998 and almost overnight, the taboo of talking about sexual problems such as erectile difficulties was lifted. Especially when former senator Bob Dole took the stage to encourage other men to speak to their doctors about erectile dysfunction (ED), it became O.K. to acknowledge that you had sex—and that in that department things were not always going your way.

Since then, many people have become more comfortable with discussing their sexual challenges, and to seek professional help. And many health professionals such as doctors, physician assistants, nurses, nurse practitioners, and certified midwives have educated themselves to better address the variety of problems that many of their patients face in the bedroom.

It’s not only physical challenges such as ED and pain during sex that are being better addressed today than just a few years back, but also challenges that have psychological roots, and quite a few mental health professionals are seeking training in sex therapy. Nevertheless, the subject of sex can be hard to bring up. 

Here’s a typical scenario: the client or patient waits for the professional to ask him about his sex life, while the professional waits for a green light from the client or patient to talk about this intimate part of his existence. So quite frequently, the topic ends up never being discussed. If you have a question about your sex life, you should break the ice by asking your health provider about it.

Sex and sexuality are integral parts of most people’s lives. The World Health Organization defines sexual health this way: “Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.” I wholeheartedly embrace this broad view and I will continue to consult, lecture, research, and write about sexual health in the years to come.

I look forward to keep contributing to the Sex Files column—just not as frequently as over the past year. Instead of appearing every two weeks in C-VILLE, The Sex Files will continue to be a periodic part of the C-VILLE supplement SUGAR. So stay tuned. And I always welcome feedback and suggestions from you about what to write about next.

Since the spring of 2007, in this column I have covered a wide range of topics, from A (anal sex) to Z (zoology questions such as how mammalians being “in heat” compare to humans being horny). All these articles are available in the C-VILLE Weekly archive online, as well as on my website annetteowens.com, where I will continue to provide current information about sexuality and sexual health.

If you are looking for more information about sexuality, I can recommend these organizations and Web links:

The American Association of Sexuality Educators, Counselors, and Therapists (AASECT, aasect.org) where you can locate certified professionals in your area and where training opportunities are offered.

For sexuality related articles, Q&As, tips, and educational videos, go to loveandhealth.info or sexualhealth.com. Both websites have content that is written by qualified sexuality professionals, something that is not always a given when you are surfing the Web for information about sex.

Wouldn’t it be nice if there were a magic pill that could help boost sexual desire for those who struggle with its ebb and flow? I have written before about how never (or rarely) being in the mood for sex is one of the most common sexual problems that women of all ages can face at any point in their lives. Well, this may be hard to swallow, but there is no quick fix available for waning libido, even though pharmaceutical companies are hoping to eventually uncover a potential gold mine. Scientists all over the world are trying to discover that magic pill, so far without much success.

In my last column, I praised a new book, The Porn Trap, by Wendy and Larry Maltz, that can help some people get excessive porn use under control. This time, I will cover an equally valuable new book, The Return of Desire: A Guide to Reclaiming Your Sexual Passion, by Gina Ogden, Ph.D., whose previous books are The Heart and Soul of Sex and Women Who Love Sex.

Ogden writes: “…instead of viewing desire as a commodity, something that we’re in danger of losing or missing out on, I’d like us to agree up front that sexual desire is energy—a sustainable resource that’s available to all of us if we want it, even those of us who may not have it right now. Not just to lead us into steamier encounters, but to reconnect us with ourselves and our partners, and to discover new sources of pleasure and joy.”

The reader is encouraged to examine her own sexual responses from a broad perspective, one that includes not only physical aspects (such as how much she lubricates, whether she can reach orgasm, or enjoys genital touching and intercourse); but emotional (e.g. feeling passion, compassion, love, caring, empathy, safety, power, pleasure, intimacy, etc.); mental (e.g. decision making, memories, messages from childhood such as “Good girls don’t”); and spiritual ones as well.

You may wonder what spirituality has to do with sex. In the late 1990s, nearly 4,000 women ages 18 to 86 answered Ogden’s survey titled “Integrating Sexuality and Spirituality” (ISIS). Based on this survey, Ogden discovered that for many women (and men as well) sex sometimes includes a spiritual component that leads to sexual experiences that “radiate far beyond the bedroom to energize their whole lives.”

Don’t get me wrong. The book is in no way religious, and as far as Ogden is concerned, you are free to believe in any God (including the God of orgasms, I suppose), or none at all. She simply points out that sexual desire is complex, and that once a woman who struggles with low libido acknowledges the various aspects of it, she will be able to tap into a much larger part of herself when trying to rediscover her lost sexual passion than if she only focused on her physical responses.

Each person is different, of course. Ogden has the reader explore her own path to sexual desire, depending on what her life- and relationship-circumstances are. Each of us has the potential to gain clearer insight and greater understanding in what factors affect the libido. And sorry, there is just no quick fix for that. It takes time and effort to uncover. This book is a good resource to help you do just that.

Ogden also covers life events such as the time after giving birth, having your relationship threatened by an affair, wondering about your sexual orientation, and the after-effects of sexual abuse and trauma. All those events can cause people to lose their desire for sex, and mentally dealing with them is necessary in order to rediscover passion.

Helpful resources including Internet websites, books, and organizations are listed at the end of the book. To find out more about it, go to ginaogden.com.

Sometimes, couples want to introduce new elements into their sex lives, such as using toys or role-playing, but they may be worried about feeling too self-conscious. I was asked the other day, how can you overcome the giggle factor with each other? Here’s what I tell people:

The more you giggle the better! It’s the best way to loosen up. Somehow, for many people, sex ends up being very serious and their entire focus becomes on achieving better erections, reaching superior orgasms, and performing at their best in front of their partner. Relax, people! It’s not the Olympics.

Why not replace one P-word, “Performance” with another one, “Pleasure?” Have fun, relax with each other, and by all means, giggle as much as you like. An ironic side effect is that by doing just that, you often end up having more enjoyable orgasms without having to worry about them. (Same with his erections.)

Start your quest for a more relaxed approach to sex by making a trip to Spencer Gifts at the Fashion Square Mall—together. You may start giggling right there, searching the aisles for fun and harmless sex games that might appeal to you. If you prefer the Downtown Mall for shopping, go to Cha Cha’s and pick up a set of Sex Flash Cards or a booklet of Sex Coupons.

Or if that’s not enough, go to Barnes & Nobles’ stuffed sex book aisle. Don’t worry about being seen searching those topics in public. It’s as O.K. as being in the cookbook section, probably even better. All you are doing is planning to introduce a little spice into your sex life.

And if you don’t have any sex toys already and you don’t want to go online to get them, you should check out Ultimate Bliss just off Rte. 29N, or the back room of Videos Etc. on Fontaine Ave. You need to be 18 or older to do so.

Another way of getting your hands on sex toys in a discreet, yet relaxed and educational way is to let Rain Krause or Tess Sprouse throw you a Passion Party right in your own house. This way, your girlfriends can benefit as well. Call Rain at 249-4296 or Tess at (540) 308-0589.

The trick about minimizing self-consciousness when you start introducing sex toys is to take baby steps at first. Don’t start with a triple treat vibrator with numerous arms that can be hard to figure out where to place, but choose a simple toy that appeals to both of you. You can always advance to more sophisticated toys as you get used to using them. And you may want to try the toy out on your own first.

As far as role-playing is concerned, you should talk to your partner about it first. What would you both like to do, and more important, what would you not like? Getting on the same page about this beforehand is crucial in order to avoid awkward moments. And it also requires that you feel very comfortable with your partner.

I can recommend the book Love Skills by sex therapist Linda De Villers. She takes you through different stages, step by step. De Villers first teaches you vertical Love Talk (when you are standing up, as for example in the kitchen or while walking together), followed by horizontal Love Talk in the bedroom.

Following is a section about Body Love, starting with learning to love your own body, and then your partner’s. After that the book advances you to learning different Love Touches and finally, for those who are inclined, there is a great section on Love Play (including creative, oral, and daring love play). In case you need it, there is a chapter on “Love Skills Tips for Anxious Moments” at the end.

Annette Owens, MD, Ph.D., is certified by the American Association of Sexuality Educators, Counselors, and Therapists. She has co-edited the four-volume book, Sexual Health (Praeger).

I try to keep up with new sexuality books as much as I can—sometimes not for professional reasons, but for my own entertainment, such as Bonk: The Curious Coupling of Science and Sex, in which hilarious science writer Mary Roach turns her curiosity toward today’s sex research. Two other books I have read over the summer are The Porn Trap, by Wendy and Larry Maltz, which I’ll talk about here, and The Return of Desire by Gina Ogden, about reigniting sexual desire and passion, which I’ll cover in my next column.

Not surprisingly, these book titles earned me quite a few scrutinizing stares from fellow travelers at airport departure gates during my most recent travels. Over my years as a sexologist, I have often noticed that the person in the airplane seat next to me takes their eyes off their Harry Potter book and discretely glances at my sexuality-related reading material, be it The Science of Orgasm, She Comes First, or The Alchemy of Love and Lust. I have finally learned not to get involved in any conversation, unless I want to spend my entire trip listening to people’s sexual problems.

I’m a strong believer in the power of bibliotherapy, so I often recommend self-help books for my clients to read. The Porn Trap is one book I will now be definitely “prescribing.”

There is no doubt that many men and women enjoy watching pornographic material (e.g. porn magazines, adult websites, XXX-rated films and videos) and that it can be used in a healthy way to spice up a sexual relationship, especially when viewed together and when both individuals enjoy watching it. But there also is no doubt that some men and women fall into what Maltz and Maltz call “The Porn Trap.” Here’s how these authors frame their approach:

“We chose the name ‘The Porn Trap’ because it communicates the danger that pornography use can hold. It also describes how many people feel when they realize pornography is causing them serious problems, but don’t want to or can’t give it up. What’s more, the analogy helps us to organize the stories, research, exercises, and tips into a structure that mirrors the healing journey many people go through—from the first time they see and experiment with porn, to sinking deeper into the trap, to feeling desperate, and eventually discovering how to free themselves.”

I have covered ways to combat porn addiction before in this column, but here we finally have a book that I believe will prove a great resource for individuals struggling with excessive use of pornography. The different case stories (such as Victor, who after dealing with his personal problems for five years, stepped out into the public to give inspirational presentations to groups of men in recovery, and Mary, an isolated widow and single mother who craved masturbating to porn for seven years like a drug, before her child’s youth pastor came across her Internet history of XXX-rated websites when fixing her computer) illustrate how a wide range of men and women can get trapped. But more important, Maltz and Maltz manage to give a wealth of advice along with concrete suggestions for steps to take to overcome the vicious cycle. What makes the book so valuable is the fact that so many tips and pieces of advice are combined in one handy resource.

The book also will be helpful for sexual partners in dealing with the incredible pain they often experience when they discover that their “trusted” partner has been addicted to porn. Knowing that other couples suffer from similar problems helps, but having an actual road map in your hands to help you navigate out of the situation is priceless.

There are no more excuses not to step up HIV prevention efforts, especially in the black and gay male population, after a new study has found that the incidence of new HIV cases in the U.S. may be much higher than previously thought. The study was conducted by the Centers For Disease Control and Prevention (CDC) and published in the August 6 issue of the Journal of the American Medical Association (JAMA).

“Incidence” is a measure of the risk of developing a certain condition within a specific time frame. In contrast, the term “prevalence” means the total number of cases of the disease in a population. In other words, while incidence measures the risk of getting a disease, prevalence measures how widespread it is.

The problem about incidence numbers is that they cannot be measured directly, but have to be estimated. So we never know whether an incidence rate is really true or way off.

Why then does it matter so much? Well, the success or failure of preventative measures are related to how much funding they get, and those numbers in return typically depend on what the incidence rates are. If a disease is estimated to have a low risk in a population, it’s not worth spending a lot of money to prevent it. On the other hand, if the risk is high, it will make sense to channel more money into preventative efforts, because in the end that process would save the country more money—and in the case of HIV prevention, ultimately more lives.

Earlier this month, a cover article in The New York Times reported that the U.S. for years had significantly underreported the incidence of new HIV infections occurring nationally each year. This article announced the new CDC study a few days before it was released in JAMA.

The study, based on an improved technique to diagnose HIV infection and estimate incidence rates, found that 56,300 people became newly infected with HIV in 2006, compared with the 40,000 figure the agency has cited as the recent annual incidence of the disease. Forty-five percent of infections were among black individuals and 53 percent among men who have sex with men. Why did it take the CDC so long to announce the new incidence rate for HIV, which is actually 40 percent higher than previously thought?

Frankly, the study had been anticipated for months, and the CDC had come under fire for not releasing the new data in a timely manner. Already back in June, an editorial in the British journal The Lancet had concluded: ”Either way, the figure shows that U.S. efforts to prevent HIV have failed dismally. The CDC must not fail U.S. citizens further by delaying the release of the data behind this fact.”

According to The New York Times article, the CDC has known of the new figures since last October, when the authors completed a manuscript and sent it to the first of three journals. But the agency refused to release the findings until they were published in a peer-reviewed medical journal. It can take quite a while for a scientific paper to pass through a journal’s review process, and apparently in this case a lot of complicated statistics were involved.

So now that the news is finally out, what should the core of prevention efforts be? It’s the same old story: Condoms, as the JAMA article notes, are highly effective in preventing the sexual transmission of HIV infection, but frequently are not used. We simply need to find better ways to reach out to the population at risk—especially blacks and gay males—with condom education and distribution.

Imagine my surprise during my first Danish triathlon when, emerging from the ice-cold water, I passed naked butt after naked butt lined up in the transition area where you get ready for the bike part of the race. Unlike American triathletes who tend to keep their clothes on during the race, many Danes simply drop their suits after the swim to change into dry biking shorts, without bothering to cover up. Why waste crucial transition time by fooling around with a towel?

Let me add that despite this public display of athletic nudity, spectators do not have much to stare at. Unless there is the rare heat wave, the old Danish saying holds true: “He went into the water as a king, and he emerged from it as a queen.” Cold water does indeed send any penis into hiding.

Here’s another thing: When nature calls during the race, it’s perfectly acceptable for men and women to discretely use a tree instead of a Porta-John. It’s not that Danes are exhibitionists. It’s simply not a big deal to show a little (or a lot) of flesh in public.

Obviously, whether public nudity is acceptable varies widely from culture to culture, and even within one country there can be great differences between regions. I don’t know of any other places in the U.S. than South Beach, Miami, where you can get away with taking off your bikini top on a public beach without a trip to the police department.

Most European countries have a very relaxed attitude towards nudity. Having lived in the U.S. for well over a decade now, I notice this every time I visit my old home country, Denmark. Spotting the first nudist on the beach each summer has become a tradition, but after that, ubiquitous naturalists hardly get anyone’s attention. And often, it’s not that pretty a sight. Beer bellies are far more frequent than well-toned abs, and the topless “Greetings from Denmark” post card beauties are often few and far between.

Freikörperkultur (FKK, meaning Free Body Culture) was a movement that started in Germany in the late 1800s and gained popularity in the 1960s and ’70s. The naked body was no longer viewed as shameful, and the joy of being nude was considered unrelated to sexuality. Anyone who has ever skinny-dipped in a lake or an ocean will understand that it has little to do with sex, but rather is a sublime all-body sensation, just as a professional massage can feel great without being sexual.

I clearly remember the first German FKK nudists in the mid-’70s, causing us teens to chuckle. Until then nudity had been restricted to only selected beach areas. But it didn’t take long until beachgoers felt free to do whatever they liked—keep their bathing suits on, take their tops off, or expose their entire bodies to the sun and waves. This trend slowly spread throughout most of Europe, and today topless sunbathing is commonplace even in Catholic countries such as Italy, Portugal and Spain.

All in all, there is a much more relaxed, natural attitude to nudity in many European countries compared to here. Nudity is not viewed as an overt expression of sexuality, but rather as what it is, a display of the simple suit you were born in.

My previous column focused on the most common sexual problem for women: low libido. Now I will address the most frequent male concern: rapid or premature ejaculation (PE). About 30 percent of men climax earlier than they want. For some it only happens once in a while or only with a certain partner; for others it occurs every time they have sex. Usually, the more anxious men get about the problem, the less control they have, creating a self-perpetuating cycle. The good news, however, is that it is often possible to make a clean break and start anew.
 
Until recently, PE was diagnosed when a man could last no longer than two minutes. This arbitrary definition did not work very well, and now he is said to have PE if he ejaculates or comes earlier than he intends to, no matter how long he lasts.

Coming early is not always an issue in a relationship. In fact, some men have told me that they have always been quick to ejaculate, and it was never a big deal with a past partner, but that with their current partner, the problem can’t be ignored.
 

Each case is different and I spend a lot of time asking questions, not because I am nosy, but because I need the information to give specific feedback and advice.

When did the PE start happening? Does it also happen during masturbation? Is it only a problem with a certain partner or with all sexual partners? Can he obtain another erection and last longer the second time? Does he have any specific thoughts before it happens? What does he think about when it happens?

When I get to the latter two questions, a lot of guys say that they think about baseball scores to distract themselves in order to last longer. This is actually the completely wrong thing to do. Instead of trying to distract themselves, they need to start focusing on their sensations and learn to monitor their arousal and how close they get to ejaculating. Easier said than done, maybe. It’s a skill that’s usually not acquired overnight, but one that’s indeed possible to learn.

There are different techniques to treat PE. The one I prefer is called the “Start–stop technique.” It’s a masturbation exercise where a man learns to monitor his sexual arousal more closely. He starts masturbating but stops stimulating himself when he has reached a point near ejaculation. Once he has “cooled down” sufficiently, he starts masturbating again, then stops again, and so on. Let me emphasize that sex therapists and sexuality counselors only talk to clients about assignments, which they then practice at home. There never is any nudity or touching in the sessions—that would go against our ethical guidelines and professional boundaries.

I often start with a reading assignment. Bernie Zilbergeld’s book The New Male Sexuality is a great resource. His first chapter, “The making of anxious performers” goes right to the heart of the problem. And the second chapter, “It’s two feet long, hard as steel, and will knock your socks off: The fantasy model of sex,” takes it a step further, explaining why so many men have unrealistic expectations about their sexual performance. Zilbergeld devotes an entire chapter on developing ejaculatory control.

Another good book, by Helen Singer Kaplan, called PE: How To Overcome Premature Ejaculation, is unfortunately no longer in print, and is difficult to find. But Michael Metz and Barry McCarthy’s Coping With Premataure Ejaculation, which I recommend, is readily available.

I always invite the female (or male) partner to join our sessions. Even though it may seem as if the problem is his, it obviously affects both of them and it takes understanding from both partners to address it. The partner can take a real active role in some of the assignments I give them. And most importantly, the more relaxed and reassuring she is about the PE, the better. The less he stresses about it, the easier it will be to let him develop confidence and eventually better control his ejaculation.

Luckily, a lot of people are satisfied with their sex life and don’t need professional counseling. But what about the unhappy ones? What are the most common complaints women and men have when it comes to sex? The top issue for women is low libido, and for men it’s premature ejaculation. The second topic I will cover in my next column.

By the way, some men also complain about decreased sexual desire–or their sexual partners complain to them about it. Usually the couple tells me that “everything else in their relationship works well, but this problem is overshadowing everything, causing friction and sometimes fights.” In many cases, sex happens less and less frequently. Sometimes the low-libido partner will initiate sex out of guilt after a long period of time has passed since the couple last had sex. The other partner, tired of being rejected time after time, often has given up initiating sex at this point, or will only do so when the frustration level hits an unbearable high. The days when both partners were interested in sexual encounters are usually long gone.

The underlying reasons for why one partner may have lost interest in sex can be complex. I take a lot of time identifying and discussing each piece of the puzzle that contributes to a couple’s unique situation. The reasons can be related to the individual (examples are hormonal issues, medication side effects, body image concerns, aging related concerns, depression, sexual trauma, fear of loss of control, fear of pregnancy, lack of attraction to the partner, etc.), or they can be relationship factors (anger or marital conflict; fear of closeness, vulnerability or intimacy; or a passive aggressive solution to power imbalance). I challenge my clients to think about which ones are most important, and then address them first.

In order to talk about sexual desire, it is important to understand what the term really means. Back in the ’60s and ’70s, researchers developed a model of human sexual response that looked like this: Normal sexual response starts with sexual desire, and is followed by arousal, orgasm and resolution. The fact that sexual desire was the starting point became a general expectation, leading women and men who do not feel a strong level of sexual interest to wonder whether something might be wrong. In other words, they think that they should have a natural appetite or hunger for sex in order to be “normal.”

Several researchers eventually called for a model of human sexual response that was not primarily “genitally focused” but included emotional components as well. In particular, Dr. Rosemary Basson recently developed a model that is circular and where the starting point is a desire to feel close or committed to the partner, or feelings of being attracted or attractive, or a need to show love and affection. Note that the person may have little interest in sex at this stage. If the person is in this mood, she (or he) will then seek or be receptive to sexual stimulation. To give an example, imagine that it is late at night and a woman wants nothing more than to go to sleep, but she also wants to cuddle with her spouse. They start kissing, and perhaps he caresses her nipples, slowly (or quickly) causing her to become sexually aroused. It is not until now that her sexual desire becomes evident. Suddenly, she is aroused and wants more physical intimacy and sex.

The important thing to notice here is that for many women sexual arousal has to happen before they can feel a desire for sex. Therefore, I always tell clients that there is nothing wrong with having to work at feeling sexual desire. You do not need to have a strong urge for sex up front, as long as you can get to a point where you can trigger your appetite.

With this in mind, I can begin working with the individual, or even better with the couple, on how to create opportunities where the lower libido partner can access their potential for sexual desire.

Several researchers eventually called for a model of human sexual response that was not primarily “genitally focused” but included emotional components as well.

Annette Owens, MD, Ph.D., is certified by the American Association of Sexuality Educators, Counselors, and Therapists. She sees clients in her Charlottesville office (cvillewellness.com) and answers questions online at LoveandHealth.info and Sexual Health.com. She has co-edited the new four-volume book, Sexual Health (Praeger).