If most married couples could rewrite their nuptial vows, they might go something like this: . . . For better or for worse, for richer for poorer, in sickness and in health, to love and to cherish, through great sex and blah sex (and no sex), as long as we both shall live.
When put in realistic terms, long-term relationships don’t look so, uuhhhh . . . sexy.
Just ask Harriet and her husband Ozzie, who are married with two young children:
“For the first few years, the sex was phenomenal and nearly every day,” says Harriet. “But after the birth of the kids, sex hit the brakes. Now we have ‘date night’ because our lives are so hectic. And, it still doesn’t happen as automatic as it used to.”
Or, Lucy and Ricky who’ve been together for over two decades and haven’t had sex for over a year:
“I’m close to menopause and I just don’t feel like having sex,” confides Lucy. “Sometimes we ‘mess around’ but it’s usually when I feel like it. In the beginning, I was the one who was aggressive and he wasn’t but, I slowly lost interest. I’ve read a little about the hormone stuff for women, but haven’t done anything.”
And, then there’s Archie and Edith, who have been together nearly 20 years:
“I don’t know what’s wrong with me. I’ve just lost interest,” admits Archie. “I think it might have something to do withmy medication.”
“But,” smirks Edith, “you just started taking it.”
These real-life couples, whose names have been changed, are like many people in long-term relationships. They are interested in keeping sex satisfying but, as they point out, it’s not so easy.
For Better, For Worse
“Sex is more than intercourse,” says Evelyn Green, a licensed professional councilor and a certified sex therapist with Denver Sex Therapy. “Sex is the erotic component of a relationship and helps a couple to remain close. We need to begin to open up people’s definition of what it means to have sex. It’s much wider an activity than penetration and a lot more about intimacy.”
Green says sex should get better the longer a couple’s been together. “In a long-term relationship, you should be more intimate and revealing. And, you should know how to make love to your partner,” she says.
But, in truth, that’s not what happens. Couples report having sex less and they are less than satisfied. Green says some of the problem is based on expectation. It’s a fallacy to expect to have the same physical passion that seemed automatic in the beginning of the courtship. After that initial stage, she says, “You have to work at the relationship and having pleasure on purpose.”
Dr. Oscar Aguirre agrees. He is a urogynocologist and the medical director of Pelvic Specialty Care, The Center for Female Pelvic Medicine in Englewood, Colo. He also conducts clinical research in women’s health and has specifically researched female sexual dysfunction.
“People need to be mature enough to say, ‘a little tothe left, babe.’”
So how does a couple figure out if they are having enough sex? It’s not by keeping a tally.
“Don’t get caught up in the numbers. But, if the issue is distressing one of you, it can become a problem,” says Aguirre. “The key question is how is the relationship?”
Green says for most couples with “sex problems,” there is usually something else going wrong in the relationship. Sometimes people withhold sex to gain control, to punish each other, or because of resentment and anger. For these folks, she says they first need to strengthen the other aspects of the relationship – starting with communication and respect.
Clair confides that she and Cliff got help from a sex therapist a few years ago:
“We went because sex was happening less and less, until finally we went over a month without it,” says Clair. “There was a lot of distance between us and then my husband thought I was having an affair, which I wasn’t. The therapist helped us figure out why I was avoiding sex and him.”
Other couples may need a boost. Couples don’t have to settle for boring, unsatisfying sex. But, Green also says, “They shouldn’t expect every sexual encounter to be mind-blowing, fabulous sex.”
Sex therapists can help couples communicate and explore their individual, sexual-selves – learn what feels good, how they like to be touched, what turns them on, what position they prefer, and learn information about controlling orgasms, and why they should. The communication part is key but most couples don’t do it and it can be hard to in practice.
“How we are raised, our experiences, and other cultural influences shape our attitude and comfort with sexuality,” says Green. It is fairly common for women to have been taught to be chaste and there are people who have had negative experiences growing up, including sexual abuse.
A therapist can help people develop comfort and confidence on a sexual level and teach a couple how to talk and listen to each other.
“People need to be mature enough to say, ‘a little to the left babe,’” says Green. “The key is not to talk about ‘sex problems’ in a sexual situation and to be frank about what’s happening or not happening for you. It’s also better to ask for help rather than to criticize.”
In Sickness & In Health
In addition to behavioral reasons for a couple’s sex decline, there are also physiological conditions that impact sex and the libido.
There are several causes of female sexual dysfunction including low libido (medically termed “hypoactive sexual desire disorder”), difficulty with orgasm, pain with intercourse, female sexual arousal disorder, and low self-esteem because of appearance and self-image, says Dr. Aguirre.
As a urogynocologist, he treats women with anatomical gynecologic issues including pain with sex, gynecological conditions such as endometriosis and vaginismus, and painful bladder syndrome/interstitial cystitis. He also performs sexual enhancement surgeries and cosmetic enhancement procedures.
For many women, the most common problem is low libido. Aguirre says, “Low libido can typically be attributed to three things – medications such as birth control pills, antidepressants, anti-hypertension meds; medical conditions such as a thyroid problem or depression; and low testosterone because of oral contraceptive pills or menopause caused naturally or surgically induced.”
Aguirre says a testosterone patch for women is on the horizon. Aguirre has conducted clinical research on the patch and says it has “significant proof of improvement in the frequency of sex, sexual thoughts, and orgasm.” However, the patch has yet to be approved by the Food and Drug Administration (FDA). In 2004, the FDA rejected the experimental patch as a treatment for women with sexual difficulties on safety grounds citing concerns about its long-term effects and risk of cardiovascular disease and breast cancer. Aguirre says more test results will be available this year.
“A low libido is not an automatic reason to give someone testosterone,” says Dr. Christopher Blicharski, an endocrinologist with Denver Endocrinology Diabetes & Metabolism in Lone Tree. But, if people suspect it is hormonally-related or that they have a thyroid or diabetes disorder, especially if they have a family history of the same, then they should see an endocrinologist.
“Hormones are complicated, particularly in women. Women have at least 600 different estrogen-type hormones.”
Endocrinologists treat medical disorders affecting the glands. Glands are the organs that make hormones and hormones control reproduction, metabolism, growth and development.
One local woman in her thirties tried a male-testosterone gel, prescribed by her primary doctor, to up her libido:
“It helped, no doubt about it! But, after meeting with an endocrinologist who talked to me about the side effects and risks, I went off it,” she says. “I went the natural route instead, reducing stress and getting more rest, which also helped.”
“Hormones are complicated particularly in women,” says Blicharski. “Women have at least 600 different estrogen-type hormones. There needs to be the right balance of estrogen and testosterone. It’s the ratio [of estrogen, progesterone and testosterone] and the interplay that control the libido.”
For menopausal Women taking Hormone Replacement Therapy (HRT), they generally experience an improvement in sexual interest, as well as general well-being. HRT may be taken via patches, pills, creams, IUDs, vaginal rings, gels, or, more rarely, by injection or pellets. However, Blicharski cautions that HRT is still controversial, because some research shows an increased risk for breast or uterine cancer with long-term use.
Another common glandular disorder affecting sexual health, particularly among women, is thyroid dysfunction. A “hyper” thyroid condition can cause a person to be very sexually aroused, while a “hypo” thyroid can cause disinterest. Although primary physicians can test for the disorder, Blicharski recommends individuals see an endocrinologist because of their expertise in diagnosing and treating the condition.
For men having difficulty developing or maintaining erections, diabetes could be the culprit. Blicharski estimates there are 40 to 60 million people who have not been diagnosed but who are in its early stages or who have full-blown diabetes. “So before men start taking Viagra for erection problems, diabetes should be ruled out,” he says.
. . . As Long As We Both Shall Live
Given all of the above, sex therapist Evelyn Green surmised the situation the most succinctly. “It’s a choice between bitterness and wisdom in life,” she says. “There are people who can help give a couple tools to work through these delicate issues to stay sexual and married.”
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