A Perfect Moment

This week a heterosexual couple in my office were discussing the possible use of testosterone for the female in the couple. She had gotten the blood tests that I had requested for total testosterone (TT) and sex hormone binding globulin (SHBG). I plugged her results into an online calculator. And, as I suspected, she had low levels of free testosterone (a key hormonal level when identifying the possible causes of low sexual desire in both men and women).

I had recommended that she consider using Testim, a product that has been designed for males, since it comes in little tubes that can be re-closed and used over a ten-day period, the approximate starting dose for female supplementation with this product. By contrast, males would use one tube per day, a dose ten-fold of that for women.

My client had many excellent questions, including one that stemmed from her checking the Testim website and noting their statement about the product being for use by males only.

I have medical colleagues who have been using this product for female patients for about five years with no adverse results. Their testosterone supplementation has been monitored by their physician -- including checking on symptom relief and doing periodic blood tests.

This type of prescribing is called off-label. It means using a prescribed substance that is originally intended for one purpose for another medical concern. Examples of this include Propecia for hair loss and SSRI-type antidepressants for slowing down rapid ejaculation.

We were wrapping things up with a "plan." She was to purchase the female condom and make an appointment with her nurse practitioner for the trial of Testim. Her nurse practitioner had mentioned that she had a few samples of Testim. We didn't know how many "a few" was. My client inquired about whether having only two Testim tubes would offer her a result or even any change.

I replied that the two tubes would not offer sufficient supply to be absorbed and counter balance her high level of SHBG. I added that if her nurse practitioner was willing to prescribe, she should move forward with the Testim.

Then, I parenthetically mentioned that a local pharmacy called Priceless which I had recently recommended to her was going out of business. So I wasn't sure where would be the best place to purchase it if insurance did not cover it.

My client then replied, "I checked with Costco, and found that it was actually cheaper than Priceless, by $20-$30."

I answered, "Oh, at one time Costco was higher than Priceless. That sounds great. When you really get down to it, a prescription of Testim is 30 tubes, which is approximately 300 days. It equals out to less than $1 per day...and if that provides what you need to have a functional sex life it's..."

Then her husband interrupted with just one word, "Priceless." It was a great laugh and a perfect moment.

Related Topics:

• What to Do at the Pharmacy: 7 Tips
• WebMD Video: Compound Pharmacy

Technorati Tags: sexuality, testosterone

When the Little Head is Thinking Better Than the Big One

For several months, I have been working with a man who was engaged to be married to his fiancée. They were in sex therapy because she was unwilling to go forward with the wedding until he was able to ejaculate in her vagina during intercourse. This had not happened yet for them, though he had done so with some other women.

He had not had many long-term relationships in his life and there had been some casual partners. In his main long-term relationship, he'd been unable to ejaculate at first, but after about four sexual experiences together things changed and there was no problem. She turned out not to be the right partner for him despite their sexual compatibility.

He had met his fiancée online and they began dating. She had many attractive features and was very appealing physically. She was about ten years younger and in her mid-twenties -- and still living at home.

My client abided by his fiancée's father-imposed curfew of 9 p.m., but over time, he began to have some misgivings about the level of independence that his intended bride would truly have, even once they were married. He had discussed this with her, but she did not see the situation similarly.

After several months of therapy that included low-dose use of Wellbutrin to facilitate orgasm for my client, they seemed no closer to reaching her requirement for marriage. So the wedding date was cancelled. They tried to continue to date and be sexual, but she dropped it down to about one date per week -- still with the 9 p.m. curfew.

My client's sexual response still did not change, despite addressing several issues that may have contributed to a lifelong pattern of being somewhat less likely to have an orgasm than many men.

Then, in one appointment that he attended alone, it all came tumbling out. He realized that his penis, the "little head," was thinking much better than the "big head" that had wanted to marry her. By not reaching orgasm, he was preventing himself from stepping into a very strict patriarchal in-law family structure -- and from all descriptions, probably a wise move for him.

Sometimes sexual dysfunctions have an unseen purpose that permit people to make better choices for themselves. This isn't the first time that I've seen this happen -- and I am sure that it will not be the last time.

Related Topics:

• The Dating Game: When Should You Have Sex?
• Your Guide to the Sexual Response Cycle

Technorati Tags: sexual health, relationships, sexual dysfunction, health-and-wellness

How Tension and Relaxation are Important to Women's Orgasms

About 10% of women have never had an orgasm -- either with a partner or during masturbation. So quite a few of them have found their way into my therapy practice. Many come to their first appointment with some confusion about issues involved when learning to become orgasmic.

One key issue is learning to develop a balance between relaxation and tension during sexual activity. But, how can a woman be both tense and relaxed at the same time?

The type of tension that helps reach orgasm is muscle tension (myotonia, the scientific language for the same thing). Many women who have not yet had an orgasm have the mistaken impression that they should relax and "just lay there." They've heard that relaxation during sex is important. But it turns out that muscle tension is very often necessary to have an orgasm. So many women learn to have their first orgasm by incorporating a fair amount of leg, abdominal and buttock tension. Sometimes even the muscles of the feet can be tensed in a productive way. And some women tense their upper body as well.

Only a very small percentage of women experience no body tension as they approach the release of orgasm. Interestingly, there are muscle contractions that occur in the lower pelvis that are a key part of the experience of orgasm. The same muscles that you squeeze in order to stop the flow of urine midstream contract automatically during orgasm.

This group is called the pubococcygeus muscle group and a conscious contraction of that group is called a "Kegel exercise." Many women contract these muscles during their sexual experiences in order to help build up their arousal. Contractions (or tensing) of the various muscles bring more blood to that area of the body. One important aspect of arousal is increased blood flow to the genital area (called vasocongestion in scientific terms).

So, where's the relaxation part of this equation? In the brain. By suggesting that a woman "relax," what is meant is that during sex it's best for her not to be worrying, questioning herself, or getting ahead of where she actually is in the process of building sexual arousal. The main task is to be focused primarily on the feeling of the sensations of the stimulation.

To help keep this type of relaxation going, I recommend using the "silent radio technique." You may have seen one of these in post offices or other public places in which long lines can form. Their purpose is to keep people's hostility at a low level despite long waits. Think of a Times Square sign in which words stream into view from the left-hand side of a rectangular black box, travel to the right edge, and then disappear off the screen. The ones I've seen have horoscopes, sports scores, news highlights and such.

When using it during sex, some women find it helpful to put a repetitive mantra such as "I can take as long as I want" or "This really feels great" on their mental silent radio. It keeps the brain occupied -- but with a thought that will foster sexual arousal rather than with one that decreases arousal.

So one aspect of learning to be orgasmic involves these two suggestions that, on the surface, seem to be contradictory, but when employed tend to help make substantial progress toward the desired outcome.

Related Topics:

• WebMD Video: For Women: Loss of Libido as You Age
• WebMD Video: Exercises for Better Sexsion

Technorati Tags: orgasm, masturbation, sexual satisfaction, health-and-wellness

"Coming Out" to Others and "Coming In" to Self

Last year I had quite a few parents bring their teenage sons to me for therapy to help them figure out their sexual orientation. Some parents brought their daughters too, but for some reason, not as many last year. For young male or females, managing the fact that they are not attracted to members of the other sex is a multifaceted process. It is not a single "event." It involves the development of their unique self and maintaining relationships with others. Most people have heard of a gay male or lesbian "coming out," but what's necessary first is the "coming in" to oneself.

What does this involve? It begins with the awareness of their minority sexual orientation. There is about a two-year period of time for many youth during which they self identify as non-heterosexual -- but they tend to keep this information to themselves.

Youths assume that they are heterosexual -- so does most everyone else. But, as they begin to realize that they are different, they must try to rectify in their minds these two sets of feelings. It can lead to some convoluted thoughts like, "I think I am normal, but I have feelings that are not normal. These feelings must be wrong...Maybe I don't really have these feelings."

Research suggests that on the average, youth are about ten when they first realize that they are not heterosexual. They are nearly thirteen when they have their first same-sex crush. At about fourteen, they label themselves as gay or lesbian. At sixteen they tend to disclose their orientation to a friend and about eighteen when they tell their parents. (These statistics come from research by D'Augelli, Hershberger and Pilkington, 1989, "Lesbian, gay and bisexual youth and their families: Disclosure of sexual orientation and its consequences," American Journal of Orthopshychiatry)

Youths are more likely to come out to peers before they come out to their families and a same-age peer is often the first choice. This experience can lead to further coming out or shutting the process down if it goes badly.

It is stressful to hide sexual orientation from one's family. But coming out to parents can be even more stressful. The majority of teens report that they come out to their mothers first, but they avoid telling if they suspect that they will be rejected. Youths from minority cultures often get an additional load because when they come out to their parents there can be repercussions because of ties that their family may have to their religious, racial, or ethnic communities. Some get stuck having to choose between being a sexual minority and an ethnic minority -- which may mean losing access to their cultural connections. Some even try to protect their families from shame by distancing themselves from the community and their family.

When teens do come out to their families, their internal motivations stem from several sources: trying to be honest, reducing the strain of deceiving others, increasing confidence, rising self-acceptance, and often anger.

As it stands, teens who are not heterosexual, for the most part, cannot rely on their parents to offer them support, accept their identity, or nurture it. So, they withdraw. Last year was an exceptional year. Each parent that I met was doing exactly that -- supporting their child. I look forward to meeting many of the same kind of parents this year.

Related Topics:

• Gay, Lesbian and Bisexual Adolescents
• Your Kids: Accept Them as They Are

Technorati Tags: parenting, coming out, sexuality, gay, lesbian, homosexual, bisexual, same sex, teen, health-and wellness