The Ripple Effect

chapter one

THE RIPPLE EFFECT

Alexandra said she'd come to me because of a quiz in a women's magazine. "I know this sounds ridiculous," she said, "but I was in the pediatrician's waiting room, and there was a copy of some magazine, and I took a quiz in it called 'How Satisfied Are You?'"

She paused, waiting for me to ask the obvious question.

"So," I said, "how satisfied are you?"

"Apparently not very," she said. "My score was a 65. The high end of 'Average.' Not even the low end of 'Above Average.'" She smiled self- deprecatingly. "You'd think they might at least grade on a curve."

"Do you really think a quiz in a magazine can reveal your overall emotional state?" I asked.

"No," she said. "That's not what bothered me."

"So what did bother you?"

"I think the quiz was right. Just sitting there, taking a magazine quiz in a pediatrician's waiting room, I really felt average. Mediocre."

"Why don't you tell me some more details about yourself," I suggested. "Forget for the moment about whether or not you really are 'satisfied' or 'average.' Just tell me what's been going on in your life."

Over the coming weeks, that's just what Alexandra did. She described herself as "just this side of 40," a "workaholic" who actually loves what she's addicted to. She met her husband in a business course in college. Tom, like Alexandra, was a conscientious, success-oriented person who was happier talking about work than anything else. At the beginning of their relationship, she and Tom were a team in every way. Sometimes they would sit up in bed with a notebook open, brainstorming ideas for the small business they hoped to start one day. In the end all their hard work paid off. They got their business off the ground a few years after college, and it was successful. When the time came for them to think about starting a family, she figured they would just transfer their teamwork approach to that part of their life. Raising a child wouldn't be all that big a leap.

It wasn't, for Tom. As Alexandra told me, "He's basically able to take anything new that comes along and simply fold it into his life. A 7-£d screaming infant in the house? No problem!"

Right from the start she was overwhelmed. Alexandra was a perfectionist, used to controlling her world, but Caleb was a screaming, colicky mess in her otherwise well-ordered life. No matter what she did, she just couldn't seem to soothe him. For perhaps the first time in her life, Alexandra felt inadequate. That, she told me, is when she first noticed a change in herself. She had become, she said, "moody." Caleb had eventually stopped crying, but he had never stopped being what his pediatrician, his nursery school teacher and her friends called a "high-needs child"--intense, emotional, inflexible, and prone to wild swings of temper that left Alexandra confused about what to do and worried that she might never figure it out. Her "moodiness," she said, persisted to this day. Perhaps worst of all, it was a change that Tom had never noticed.

That's when Alexandra finally got around to talking to me about her sex life. The subject had been curiously absent from our conversations, but it was an absence that I found to be all too common in my practice. Women patients often wait as long as they can before they get around to discussing their sex lives--and the longer they wait, the more important it turns out to be.

In Alexandra's case, Tom's obliviousness to her change in mood became clear to her in bed. Practically every night when work was over and they'd tucked Caleb in, Tom would basically "leap" on her. "He's a guy," she figured. "It's in his blood."

Meaning: It wasn't in her blood. Alexandra had told herself that her decreasing interest in sex was "an aging thing," that desire goes down over the course of a marriage, and couples become best friends more than fiery lovers. They had the best marriage among their friends--everybody said so-- and that was enough for her. Sometimes it seemed to be enough for Tom, too. If he collapsed with a beer in front of SportsCenter instead of wanting to have sex, she found herself relieved and thinking to herself: "Whew--now I don't have to pretend tonight."

Alexandra didn't want to have to pretend, ever. When she thought back to the days when their lovemaking was long and robust and they seemed sexually indefatigable, when they were a "team" and open with each other about everything, she felt a pang of regret, and not a little guilt at having to deceive Tom now. One night when Tom curled up beside her in bed and planted a hand on her breast, she heard herself say, "We're not 22 anymore, in case you hadn't noticed."

He seemed wounded, not surprisingly. "I don't understand," he said. "Aren't you attracted to me, Alexandra?"

"Of course," she said. Maybe it was pity that motivated her, or guilt at having been so blunt and hurtful, but she began to backtrack. She said that all she meant was that they ought to be more realistic about what they expect from a marriage at this point in time. In her heart of hearts, she knew she had lashed out on purpose. Tom was able to roll with the ways Caleb had changed their lives, and he was better for it. He loved being a dad. She, on the other hand, had just never gotten her footing. She feared she was failing at everything: motherhood, career, and marriage. She felt guilty for not being able to accept Caleb for who he was, and at the same time she resented her son for taking her away from the work and the marriage that had sustained her for so many years. Tom said that he'd try to be more sensitive, and then they had sex. Afterward, when Tom was asleep, Alexandra lay in the darkness of the bed where they once made long to-do lists after a vigorous bout of lovemaking, and she thought about how she now had everything she wanted back then: a great husband, a beautiful child, a terrific career. She knew she couldn't fully enjoy her good fortune--not as long as the only way she was going to score 100 on a magazine quiz was if the subject was "How Fake Are You?"

Alexandra's situation was more common than you might imagine. Many women have come to see me because their partners want sex and they don't. Of course, Alexandra didn't think that was the reason she came to see me, but that information about her sex life turned out to be the key to our understanding of her whole life: of who she was, and who she could become.

Where does your sexual identity come from? How does it affect your life? These questions are crucial to understanding the woman you are, and understanding the woman you are is crucial to finding out how you can change into the woman you want to be. A powerful woman. A confident woman. A woman who would be able to score "Extremely" on a "How Satisfied Are You?" pop quiz.

Throughout this book we'll be looking at five ways women like you and me think of ourselves during sex, and how our sexual identities influence every other part of our lives. I call it "the ripple effect." Unlike Vegas, what happens in bed doesn't stay in bed. It emanates outward, in every direction, until it reaches the farthest shores of family, friendships, and work. It's always there; it's always everywhere. Touch the surface of your life and you'll feel it. Alexandra took a quiz in a magazine and felt it-- and didn't like what she felt.

The ripple effect can be a negative force, but it can also be a positive force. If your sexual identity is vital and powerful, then you'll feel that vitality and power throughout your life--a sense of control, of ownership, of confidence in who you are.

Some of this ripple effect is physical. You can think of sex as a chemical cocktail, since a number of hormones are released after sex and have beneficial effects. Oxytocin causes relaxation and feelings of love and bonding. Endorphins are the body's natural painkillers. Immunoglobulin A can help fight off colds. Many people find that after sex they fall asleep easily, and getting a good night's sleep has many health benefits.

You can think of active sex as an aerobic exercise. It's good for your heart. It tones your stomach, back, and buttock muscles. It relieves stress and--don't laugh--it gives your vagina a healthy workout.

Like other muscles, the vagina is a "use it or lose it" organ. The more you use your pelvic muscles, the more they stay in shape. The less you use them, the more likely they are to atrophy, until sex can actually become painful. (Pelvic muscles also affect bladder control; the better shape those muscles are in, the better your bladder control will be later in life or after having babies. Who wants to pee every time she sneezes or coughs?)

I'm pleased to say that women do seem to be giving their pelvic muscles a greater workout than ever before. According to a study conducted at the Institute of Neuroscience and Physiology at Gothenburg University in Sweden over a period of 30 years, the percentage of married women having sex at age 70 rose from 38 percent in 1971 to 56 percent in 2001. The percentage of women saying that they experienced orgasms during sex also rose dramatically. Probably this change in sexual activity is partly due to improvements in health and fitness, and probably it is partly due to the increasingly tolerant social attitudes toward sex that these seniors learned when they were young. Whatever the reasons, I like to think that these seniors are living proof of a vital lesson--one with a scientific basis: The more sex you have, the more you want to have sex.

Specifically, the more often you have an orgasm, the higher your overall level of sexual desire and arousal. One explanation (shown in small studies) may be that levels of testosterone--the hormone of desire--rise with frequent sexual activity. Which might lead you to ask: Why not just pump women full of testosterone and let 'er rip?

There are two good reasons. Such an approach would certainly increase a woman's desire, but it would also increase the potential for cardiovascular disease, facial hair, and a deep voice, as well as possibly breast cancer and stroke. In the United States testosterone has been deemed too risky in terms of the side effects to make it readily available, though in Europe the testosterone patch was approved in 2007. Some women do have a low testosterone level for their age or menopausal status, and they can indeed get medical help in the United States, but only to raise their testosterone to a normal--and safe--level. Even then the treatment includes increased levels of estrogen to balance the testosterone, since we don't know enough about the side effects of taking testosterone alone.

The second reason doctors wouldn't want to prescribe testosterone for most women is that such a treatment would be beside the point. It wouldn't address the issue that could really make a difference in a woman's life. Unlike men who use Viagra to correct erectile dysfunction or women who have naturally low testosterone levels, most women need to overcome a barrier that is not physical but psychological.

In one recent study, for instance, the sexual medicine group at Vancouver General Hospital in British Columbia found a distinct difference between what happens physically to women undergoing arousal and what they think is happening. Objectively, women watching pornography showed body changes signaling arousal--lubrication and bloodflow to the genitals. Subjectively, however, most of the women in the study said they did not feel aroused and were not turned on by the images. For men like Tom--which is to say, for men in general--what is physically happening during arousal and what they think is happening are pretty much the same thing. For women like Alexandra- -and for women in general--sexual satisfaction is much more heavily weighted toward the psychological than the physiological. Their bodies may be responding, but their brains aren't.

That's why the medications that researchers have been studying in the hopes of finding a female equivalent to Viagra would work their wonders by rewiring the brain, not by rerouting bloodflow to the genitals. I believe that even successfully rewiring the female brain would still be missing the point. It would still be a physiological solution. Despite its immediate benefits, it would still be an old-fashioned and ultimately ineffective approach. One that works from the outside in, rather than the inside out; that changes how you experience sex physically, not how you experience sex emotionally; that treats the symptom, not the cause. One that changes how you think, not what you think.

In this book we're going to do just that. We're going to focus on changing what you think about sex. I believe that only when you reunite your physical self with your mental self can you have a chance of becoming a whole self.

I can point to plenty of case histories from my own practice that support this belief. In fact, I'll be pointing to them throughout this book, just as I did with Alexandra and Tom at the beginning of this chapter. I can also point to persuasive medical research. A university group in Portugal, for instance, has been studying the relationship between women's thoughts and behavior during sex for years, and the results have been consistent: Women who have "dysfunctional beliefs" about sex are far more likely to have dysfunctional sex itself--lack of desire or sexual arousal or orgasm. Some examples of these dysfunctional beliefs--negative or nonerotic thoughts--might seem to be of a personal, individual nature: I am sexually incompetent; I am afraid of sex; I think nonmissionary or nonprocreative sex is "wrong." Some might involve body image or age-related issues: Women who are not attractive can't be sexually satisfied; as women age, they get less pleasure from sex; after menopause, women lose their sexual desire altogether. What all these dysfunctional thoughts have in common is that they arise from stories--not facts--these women have come to believe. Whether they originated in one woman's upbringing or our common culture, whether they involve one woman's sexuality or female sexuality in general, these stories feel true, but they're not.

A story doesn't have to render you sexually dysfunctional in order to take its toll. We're all at the mercy of the stories we believe about our sexuality. We've all altered our sexual selves to some extent to accommodate these stories. Each of us believes these stories because they feel true, but they're not.