For Women Only
A Revolutionary Guide to Reclaiming Your Sex Life
By Jennifer Berman, Laura Berman, Elisabeth Bumiller
Henry Holt and Company Copyright © 2005 Jennifer Berman, M.D., and Laura Berman, Ph.D.
All rights reserved.
Our Approach to Women's Sexual Health
When Nicole arrived at our clinic early one December morning with complaints that she had no interest in sex, we could see how nervous she was. But then, almost every woman who walks through our door is a little frightened at first. It's the normal reaction, since sex is not normally addressed openly in any setting, much less a doctor's office. Our immediate task is to put our patients at ease. They're always relieved to learn that many other women share the very same problems, that they're not abnormal or alone. A lot of women will tell us that they are embarrassed that their sexuality is so important to them, and that they feel they aren't entitled to feeling sexual because they are older. The younger women often say they are unable or afraid to talk to their partners about their sexual problems. These attitudes reflect the long-standing pressure on women to acknowledge sex as a basic part of their lives but not to feel entitled to an optimum response.
Nicole, a 40-year-old bank loan officer from Kentucky, learned about us from an article in a women's magazine about female sexual dysfunction. Like a lot of our patients, she had finally decided that her problems were important enough to take time off from work and travel a long way to see us. "It's been pretty stressful," she told Laura. "I feel bad for my partner." Other patients are referred by their gynecologists, primary care doctors, or internists, or hear about the Berman Center and Female Sexual Medicine Center by word of mouth. Others are interested in trying Viagra, which we have successfully prescribed to a number of female patients. Some of those patients have taken part in our Viagra trial, one of the earliest studies of the drug's effects on women. (For the results of our Viagra study, and information about Jennifer's research on vaginal and clitoral tissue, see here at the end of this chapter.)
When Nicole had called to make her appointment, she spoke briefly to Laura. During these initial phone calls, many women break down and cry out of frustration from having dealt with this issue alone for so long. Others cry from relief that someone is finally listening to them. Nicole was more matter-of-fact. Laura asked her a little about herself and to describe her problem. Then, as Laura does with all of our patients, she told Nicole what to expect during her upcoming visit to the clinic: Nicole would first talk to Laura and then be evaluated by Jennifer. Following her medical evaluation, she would then undergo our physical testing in a private examination room. We explained that in order to fully evaluate her arousal problem, if one existed, and determine its cause (for example, hormone levels, low genital blood flow, decreased genital sensation, or low vaginal lubrication), we would need to evaluate her, as best we could, under conditions of sexual arousal. Her physiological sexual responses would then be measured. Although this situation does not reproduce what happens in the privacy of one's own home, it does provide us with a lot of useful information.
We evaluated Nicole over a period of two days. On the first day we evaluated her baseline sexual response without medication. On the second day, the evaluations were repeated after she took Viagra.
What happened after that, during Nicole's two days at our clinic, will tell you a lot about who we are and how we work. We also hope that Nicole's case, and those we've included here of two other patients, Maria and Paula, will clarify what our patients tell us is a professional, caring, and very positive experience.
The first thing Nicole did in our office was fill out several short questionnaires asking about her sexual functioning over the previous month. These forms, used by all of our patients, ask for basic medical and relationship information. They also ask them to rate their sexual desire, their ability to become aroused, their level of lubrication, any sensations they feel in their genital area during sex, any feelings of numbness, their ability to reach orgasm, whether they experience any pain during intercourse, how satisfied they are with their partner's stimulation, and their feelings of emotional intimacy during sex.
After Nicole completed the forms, she went in to see Laura for a 45-minute psychosexual evaluation. Laura used an assessment model she created called the Biopsychosocial Sexual Evaluation System (BSES), through which she is able to get an initial impression of not only the sexual history of the patient, but the source of the sexual function complaints as well. After these sessions, often the first time that the patient has talked to anyone at length about her difficulties, Laura can identify red flags that signal the need for further evaluation and potential treatment, either physical or emotional. A course of action, both medical and psychotherapeutic, can begin to be developed based on the findings.
When Laura first asked Nicole to describe as specifically as possible her problem and why she had come, Nicole responded that not only had she lost desire, but also that she had trouble with vaginal lubrication and could not reach orgasm when she did have sex. She traced her problems to laser surgery for skin cancer of the vulva that she had undergone three years earlier. Nicole told Laura that she had at one time enjoyed sex enormously — "I remember having orgasms and being real wet" — but since her cancer surgery "it hasn't been anything like it was before." Nicole also told Laura that she was on Paxil, an SSRI (selective seratonin reuptake inhibitor) antidepressant, which can cause a loss of libido, vaginal dryness, and difficulty in reaching orgasm. (For more about the effects of antidepressants on sexual function, see chapter 4.)
Because early childhood experiences can impact on sexuality later in life, Laura next asked Nicole about her early childhood and adolescence, her attitudes toward sex when she was growing up, her parents' attitudes, and her past sexual experiences. Like many of the women we see, Nicole said she had been raised to believe that premarital sex was wrong, and that her brother had always told her that "if you had sex, a guy wouldn't respect you." She first had intercourse at the age of 19 with a boyfriend and described the experience as physically painful, although she began to enjoy sex a few years later with a different partner. She apologetically said that sex was always easier for her after a few drinks — "I move better, probably, and I'm looser" — and that in general it was hard to let herself go without alcohol. Nicole also told Laura that she had tried masturbation, but had never used it to reach orgasm, and was afraid to try a vibrator. "I always heard if you used a vibrator," she said, repeating something we hear all the time, "that you wouldn't want a man." Other women worry — wrongly — that they will become dependent on a vibrator or be unable to become aroused or reach orgasm without it.
Nicole's words were strikingly but typically full of self- reproach. She was blaming herself for her problems. It didn't help that they were also upsetting her relationship with her partner. "A lot of times I don't reach orgasm, which makes him feel inferior," she said. Her partner, Nicole said, was now having trouble getting an erection or maintaining one. But she also admitted that she sometimes resented him for expecting that it was "my job" to arouse him. "Sometimes I really don't like to work to get it hard," she said. At one point, as Nicole cataloged her problems with her partner, she quietly wept.
Afterward, Laura recounted the session to Jennifer and summarized the important psychological factors and problems with the relationship that could be contributing to Nicole's problem. Then Nicole met with Jennifer for a medical evaluation, which included a full gynecological and urological exam. Jennifer checked the internal and external structures, including the clitoris, which is usually omitted during pelvic exams. Through this process she can rule out obvious gynecological problems. Jennifer asked Nicole questions about her present problem, past surgeries, past illnesses, ob-gyn history, family history, and the depression she was being treated for with Paxil. Nicole told Jennifer that she had a long history of bladder infections, which may also have interfered with her interest in sex since these infections cause pain and irritation in the urethra.
What followed is the physiologic part of our testing. As Nicole lay on the examination table, Jennifer inserted a small flexible pH probe, about the width of a cocktail stirrer, into Nicole's vagina to measure her vaginal pH. Our nurse-assistant then recorded a reading of 4.6 on Nicole's chart, considered in the normal range for a premenopausal woman (4.5 to 5.1; pH rises in menopausal women who are not on estrogen). After that, Jennifer measured Nicole's clitoral and labial sensation using a biothesiometer, which is an instrument that detects sensitivity to low- and high-frequency vibration. This provides information about the sensory nerves to the genital area. Nicole's clitoral and labial sensation were low. Next, Jennifer inserted a small balloon device into Nicole's vagina and very slowly inflated it, asking Nicole to tell her when she felt the first sensation of pressure and then when it became uncomfortable. This was to measure Nicole's vaginal compliance, or the ability of the vagina to relax and lengthen. That was normal.
Finally, Jennifer placed the ultrasound probe, about the size of a wooden matchstick, against Nicole's clitoris and labia. The probe allowed Jennifer to see a complete picture on a television screen of the clitoral and labial anatomy, as well as the blood flow to Nicole's clitoris, labia, and urethra. Next, a tampon-sized probe was inserted into her vagina to measure blood flow to the vagina and uterus. Surprisingly, given her surgery and what she had told Laura, Nicole had very good blood flow to all parts of her genital area.
After that, Nicole was given a vibrator and a pair of 3-D surround sound video glasses. These glasses allow for uninterrupted erotic visual stimulation. Nicole was to watch an erotic video, designed and produced for women, through the glasses and stimulate herself in private with the vibrator for 15 minutes. Before leaving the room, Jennifer told her that the goal was to become maximally aroused so that we could get the best measurements.
After 15 minutes, Jennifer returned and asked Nicole how she was doing. Nicole had not had an orgasm, but shyly said she had enjoyed the vibrator. "I think I need to get one," she said. Jennifer then repeated the three-part exam. Nicole's lubrication and pelvic blood flow had increased significantly poststimulation. Her vaginal elasticity also increased, but her genital sensation did not significantly improve.
After Nicole dressed, we talked with her in our office, where she asked the single most common question in our practice: "Do you think it's in my head?" Laura told her it was absolutely not, but that it was probably her head and body working against each other. Although Nicole did not have any severe anatomic abnormalities, the Paxil she was taking can be associated with sexual function problems. In addition, her previous genital surgery most likely affected the sensory nerves to her labia and minor branches of the clitoris, making it difficult for her to become maximally aroused and have an orgasm. Nicole also had emotional and relationship issues, which in turn made her physical problems worse — a vicious cycle. On an emotional level, the surgery she had had for her vulvar cancer was particularly traumatic. Any woman who faces a life-threatening illness like cancer, particularly in her genital area, is going to feel differently about herself and her body. Nicole seemed to have some negative body image issues from her surgery, which had been mildly disfiguring, and also some fear during sex. Her partner's functioning contributed to her problem.
On Nicole's next visit, she received a single dose of Viagra, the brand name of the drug sildenafil, one hour prior to her evaluation. As we had suspected it might, Nicole's pelvic blood flow tripled poststimulation and her genital sensation increased. She had an orgasm in our clinic, one of her first in years. The Viagra, which increased genital blood flow and sensation, combined with stimulation from the vibrator and the erotic video, seemed to help her overcome the loss of sensation and arousal as a result of her surgery and the SSRI she was taking. She left the clinic with a prescription for Viagra, which she now takes on a regular basis. She was also encouraged to explore the emotional aspect of her problem and was referred to a trained sex therapist in her hometown for further treatment.
Virtually all of our cases at the Berman Center and Female Sexual Medicine Center include some combination of medical, emotional, and relationship problems. It's like a pie chart, but the pieces of the pie are distributed differently. We'll see a woman whose primary problem is medical or physiologic, but because she's experiencing a long-standing problem, it's affecting the way she feels about her body and herself. As a result, her relationship is often in crisis, which makes the physical problems much worse. We've learned that it's very difficult for a woman to separate her sexuality from the context in which she experiences it — that is, in her relationship with her partner. This emphasizes the point that the most important sex organ in the human body is the brain. However, we've learned that physical problems can affect the mind, which in turn affects happiness and sexual satisfaction, and vice versa.
We've had tremendous success using sildenafil for women like Nicole, but it's important to point out that many patients don't even make it to the prescription. Sometimes the diagnosis is a relationship problem, communication difficulties, or a partner who either doesn't know what to do to stimulate her sexually or has sexual function problems of his or her own. We've also learned that even if the problem is purely medical or physiological, medications like it do not always work.
Rebecca was an attractive 42-year-old real estate agent from Cleveland, Ohio. When she came to the Berman Center, she had never had an orgasm and also complained of low libido. During her assessment with Laura, Rebecca revealed that she was recently separated from her second husband, Joe, after nearly seven years of marriage. She had initiated the separation because she no longer felt any passion towards him. They basically led parallel lives with little contact or quality time together. Rebecca said her husband regularly pursued activities that excluded her and kept him away from home. She didn't feel valued or cared for by him. As a result of her loneliness in the relationship, Rebecca even found herself in an Internet affair with a man she met online six months before. They had never made contact in person, but Rebecca's feelings for her "cyberfriend" were becoming stronger than the feelings she had for her husband, which caused her finally to ask for the separation.
Rebecca was given a complete physical exam after her therapy session with Laura. Ultrasound and sensory testing revealed no physical problems with her sexual response. Her hormonal levels were normal and there were no signs she was in peri-menopause. It was clear that her current problems with low sexual desire and difficulty reaching orgasm were not rooted in medical causes. Laura believed that getting to the real source of Rebecca's lack of passion would explain why she was vulnerable to searching for romance outside of her relationship. (Continues...)
Excerpted from For Women Only by Jennifer Berman, Laura Berman, Elisabeth Bumiller. Copyright © 2005 Jennifer Berman, M.D., and Laura Berman, Ph.D.. Excerpted by permission of Henry Holt and Company.
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