Who’s having sex? Who’s not?
And if not, why not?
No one hesitates to say to a friend, “I have a cough I’m concerned about,” “I’m not sleeping very well lately,” or, “I’m a little worried about my swollen ankles.” But when was the last time you admitted to a coworker, “My vagina smells funny,” or, “I have a terrible headache every time I have an orgasm,” or, “My vulvar itch doesn’t go away no matter how many times I get treated for a yeast infection”?
Exactly.
And because no one, no one, is talking about her sexual health, you would never know that 40 percent of your friends are likely to have experienced some sexual difficulty. You would think from what is presented in books and magazines, in films and TV shows, on the Internet and billboards, that the whole world is erotically charged and every single person (other than you) is having amazing, passionate sex and earth-shattering orgasms on a daily basis.
Even the postmenopausal character played by Meryl Streep in the movie Hope Springs, despite a sexual hiatus of years, was able to have fantastic sex without so much as a bottle of lubricant in sight. I can pretty much guarantee that every gynecologist (and about half the women) in the audience thought, Really? I don’t think so. Just because Meryl’s character’s relationship was suddenly passionate doesn’t mean her vagina and clitoris were cooperating.
Painful sex, difficult sex, and the lack of sex have always been at the top of the list of taboo topics for women. Many women can’t even comfortably say the word “vagina,” much less talk about a vagina that is dry, painful, bleeding, or the source of incredible agony—all conditions that make intercourse pretty much out of the question. Even really close girlfriends rarely have the courage to say, “Jenny, my vagina has been really dry lately. How’s yours?”
Women rarely even talk to their sexual partner or husband about this topic, not just because they are embarrassed, but because of the shame and fear associated with perhaps no longer being perceived as “sexy.” Indeed, in the 2013 Revive survey of sexual behavior among postmenopausal couples, 53 percent of women experienced at least one sexual problem, an astounding 61 percent hid their symptoms from their partner, and a shocking 73 percent admitted that they silently endured painful intercourse to please their partner. The other 40 percent solved the problem by simply avoiding sex altogether. The majority of women who used a vaginal product had a “secret ritual” behind a closed door to insert or apply it because they didn’t want their partner or husband to know they were not as naturally moist and sexy as when they were twenty.
What is this hiding really about?
Sexual Problems Are Even Taboo in the Doctor’s Office
In spite of the fact that almost 50 percent of women have sexual issues significant enough to interfere with or put a screeching halt to intercourse and intimacy, few doctors ask about this, and if the topic does come up, many doctors have very little to offer beyond, “Relax,” “Try some lubricant,” or even worse, “Don’t worry, it’s a natural part of aging.” Studies also confirm that it is the rare woman who brings it up to her doctor.
Dr. Streicher’s SexAbility Survey
Women were asked how often their doctor inquired about their sexual health:
26.2 percent said “routinely”
31.9 percent said “sometimes”
41.8 percent said “never”
My experience is different. Because I am a gynecologist who specializes in sexual health, I see women every day who specifically come to me to get treatment for painful intercourse or a lapse in libido. But even I see plenty of patients who have a hard time spitting out the real reason for their visit.
A typical scenario goes something like this: A patient comes in for her annual visit. Before the exam, we chat about her irregular periods, the occasional hot flash, and her daughter’s new boyfriend. I generally ask, “What’s going on in your sex life?”
All too often, the response is, “Sex life? I don’t have one.”
“Do you want to talk about it?”
She assuredly says, “No, that’s all right.”
So I move on to the breast exam, Pap, and pelvic. Before I leave the room, I ask, “Is there anything else you’d like to discuss?”
Then, with an embarrassed look on her face, she finally brings it up. “Is there anything you can do about my lack of libido? I really want my sex life back.”
I call this very common moment the “hand on the door question.” Those questions that women—regardless of their age—have been too uncomfortable, too defeated, to ask earlier.
Every year millions of women make that annual trek to their gynecologist’s office and usually leave without asking that question, even though it is on a lot of women’s minds. That “hand on the door question” is more often than not the reason the patient came to see me in the first place.
And even though most women are more comfortable discussing their sexual issues with me than with other doctors, I can count on one hand the number of patients who spontaneously tell me that it hurts when they masturbate or they are no longer able to have an orgasm. Sadly, for the majority of women, there is shame in admitting that they self-stimulate, enjoy orgasms, miss orgasms, and would like to have orgasms again.
A lot more is broken here than vaginas.
The whys and why-nots of who’s sexually active, who’s not, and who cares are incredibly complex. At the risk of oversimplifying, I can say that it almost always comes down to two questions: is there the opportunity, and is there pleasure?
There are really three groups of women:
• Women who enjoy a great deal of gratification from self-stimulation and/or partnered sex
• Women for whom there is little or no pleasure in sexual activity and for whom sex represents an obligation exclusively for the purpose of procreation and fulfillment of their marital or relationship expectations
• Women for whom sex represents intimacy and relationship far more than physical release and for whom the cuddling is great, the act itself is superfluous, and the orgasms are generally absent
I, of course, maintain that all women can and should enjoy sex. But sadly, once a medical barrier presents itself, women who never particularly enjoyed sex are often relieved to have a legitimate excuse to cross intercourse and sexual activity off their “to-do” list. Being nonsexual becomes the new normal. And women who enjoyed sex, when faced with a medical barrier, are, if not devastated, at a minimum saddened by the loss.
Here’s what this book is intended to do: give you the information you need about how your body is working or not working to decide yourself what needs fixing.
Big Pharma to the Rescue?
Nevertheless, our reluctance to talk about sexual health is changing. It used to be that I was one of the few people to talk about problems with vaginas in public (my family is used to it), but now there are ads everywhere—in magazines, on radio and TV, online—all touting solutions for sexual pain or low libido. Those ads inevitably have pictures of sad-looking midlife couples lying on opposite sides of the bed.
What is emerging is a push to give women permission to address sexual dysfunction too. Of course, this change is not driven by gynecologists like me who have been trying to start the conversation for years, but by the pharmaceutical industry, which appreciates the magnitude of female sexual dysfunction in women and knows there is a lot of money to make from vaginas that have lost the ability to have pleasurable, slippery intercourse. But because the topic is still a cultural taboo, and the majority of women are not asking for or getting the help they need, companies are now spending millions in marketing dollars to encourage women to talk to their doctors about getting a prescription or, in the case of products that don’t require a prescription, go shopping.
This is not a bad thing, nor is this a new phenomenon. For the guys this happened years ago. Indeed, it was the pharmaceutical industry that gave men the “permission” and the language to talk about their sexual problems. Without a doubt one of the most brilliant marketing successes of the 20th century was the introduction of the phrase “erectile dysfunction.” That’s right—marketing gurus, not medical doctors, popularized the term that is now part of the popular lexicon. Prior to 1998, men who were unable to maintain an erection suffered from impotency. Think about it. It’s bad enough to have a penis that won’t cooperate, but then to have a diagnosis that implies you are also weak, incompetent, and powerless is too much to expect any man to deal with. What self-respecting guy is going to say to a woman, “Sorry, honey, not tonight, I’m impotent”?
A guy who was impotent didn’t just have a medical problem. He was a personal failure. No way was he going to make an appointment to discuss his impotency with his medical doctor. The poor guy had to suffer in silence.
Suddenly, in 1998, the impotent man disappeared. Enter the man with erectile dysfunction, or ED. The man with ED was handsome, successful, and sexy. The man with ED was so powerful that he could even run for president—he’d lose (remember Bob Dole?), but he could still run. So who commercialized the term “erectile dysfunction”? The people who had a lot to gain from men admitting they had a problem. I think you know where I’m going.
Yes, it was the inventors of Viagra who also popularized the term ED. And I give them a lot of credit. Pfizer launched Viagra and at the same time launched a marketing campaign that redefined impotency as erectile dysfunction. Not only was the condition normalized, but the marketing campaign gave men the language to talk to their doctors about it so they could comfortably ask for a prescription.
And now it is starting to happen for the women.
Because the reality is that for every man who suffers from erectile dysfunction, there is a woman who suffers from sexual dysfunction. Women who suffer from painful sex, who have no libido, or who are unable to have an orgasm are just as common as men with erectile dysfunction.
Guys Have ED, Women Have GD
So while the guys had the language and the permission for years, women are just now finally getting permission to talk about sexual dysfunction. The language, though, is still an obstacle. The medical term for thin, dry vaginal tissue is “vaginal atrophy.” But like being impotent, no women (even if they are familiar with the term) want to have vaginal atrophy! Talk about a buzz kill. “Honey, my vagina is atrophied, wasting away. Minimized. Sick. I can’t have sex tonight. Or ever.”
Since the pharmaceutical marketing gurus haven’t come up with a term to replace “vaginal atrophy,” I decided to coin the term GD, for “genital dryness,” to describe the changes that occur not only around the time of menopause but from a number of other medical conditions as well, including diabetes, heart disease, cancer treatments, and more—all of which you will learn about in the pages ahead.
Your physician may not know the term GD (not yet anyway), but he or she will understand what you mean when you say you have “genital dryness” and you need a solution. You also need a solution to the many other conditions that can affect your sexual health and therefore your right to experience pleasurable sex, a healthy libido, and a gratifying orgasm!
How Many People Are Really Having Sex?
Let’s go back to one of my original questions: how many people in this country are routinely sexually active and how often? These are not easy numbers to come by. Most studies are based on surveys and past recollection as opposed to a camera in every bedroom in America. In addition, in the scientific literature, sexual activity is often defined only as heterosexual vaginal-penile intercourse. (As discussed in chapter 2, that is not the case with many, if not most, men and women.)
One of the largest and most interesting surveys looking at frequency of sexual activity was conducted by the sociologists Dr. Pepper Schwartz and Dr. James Witte, who surveyed more than 100,000 individuals from around the world about every detail of their romantic lives for their 2013 book The Normal Bar. Their sample included women from across racial, ethnic, and educational lines. Roughly half the respondents were 45 or older, but the results included all ages (18 and up) combined. Among their sample, Schwartz and Witte found that:
7.5 percent had sex daily
40 percent had sex three to four times a week
27 percent had sex three to four times a month
8 percent had sex once a month
13 percent had sex rarely
4.5 percent never had sex
Since frequency is known to decrease as age and medical issues intervene, as expected, the numbers look very different when divided by age. A telephone survey of 2,000 US women between the ages of 18 and 94 was conducted in 2003 by randomly dialing individuals and inquiring about their sexual activity, including oral (active or receptive), vaginal, or anal intercourse, in the past three months. (One has to wonder about who would give this information to a stranger over the phone.) The percentage of sexually active women overall was 53 percent, and the results broke down by age as follows:
66 percent of women ages 18 to 29 years
70 percent of women ages 30 to 39 years
65 percent of women ages 40 to 49 years
46 percent of women ages 50 to 59 years
20 percent of women ages 60 to 94 years
Clearly something is happening at age 60, and it’s not good. But is it simply age? Or is it other variables that go along with age, such as lack of a partner or medical illness?
In the most comprehensive study of sexual activity in older adults, published in the New England Journal of Medicine in 2007, Dr. Stacy Lindau conducted extensive face-to-face interviews with 3,000 men and women between the ages of 57 and 85 and reassuringly found that most of them had remained sexually active into their sixties. Nearly half continued to have sex (not necessarily intercourse) regularly into their early seventies, but women were far more likely than men to not be sexually active, either because they had no partner or because sexual activity was no longer pleasurable. Here’s a breakdown of the numbers:
Ages 57 to 64
62 percent of women reported sexual contact
15 percent rated sex as “not at all important”
Ages 65 to 74
40 percent of women reported sexual contact
25 percent rated sex as “not at all important”
Ages 75 and Older
17 percent of women reported sexual contact
41 percent rated sex as “not at all important”
Of the women who stated that sex was no longer important, 48 percent were in the “not sexually active” group. This study was important because it looked not only at age but at medical illness as a predictor of sexual activity and found that, while sexual activity did decline with age, the drop was much more significant in people with medical problems. In other words, healthy old people are far more likely to have sex than sick old people. In fact, among healthy adults who were sexually active, about two-thirds had sex at least twice a month into their seventies, and more than half continued at that pace into their eighties.
How Real Is Sexual Dysfunction? Very.
There is a movement, more political than scientific, that asserts that sexual dysfunction in women does not exist but is in fact a “normal” experience made medical by profit-motivated pharmaceutical companies. As a physician and a woman, I find this argument offensive. The notion that pain, an inability to have an orgasm, and loss of libido are not “real” conditions but are manufactured so that pharmaceutical companies can sell drugs is clearly entertained by people who have never spent time in my office. Not to mention that they give pharmaceutical companies way too much credit. Sexual problems in women have been recognized by the medical community as specific conditions for over thirty years, long before Big Pharma entered the picture of what happens in people’s bedrooms. The potential negative impact of this movement is huge and could destroy women’s hard-won entitlement to have their experience validated. Female sexual dysfunction deserves appropriate research and treatment options. Hypoactive sexual desire syndrome (low libido) is not the pharmaceutical equivalent of a Hallmark holiday manufactured to sell more greeting cards any more than Viagra was developed to treat fake erectile dysfunction.
So yes, in spite of the fact that the pharmaceutical companies are motivated by profits, their research and development of new drugs have validated that female sexual health problems are real and desperately deserving of the attention they are finally getting.
Although it is true that the majority of women with sexual problems are in midlife or beyond, the problem is not limited to the over-40 crowd. For some women, the problems started with their first sexual encounter. Others did not have issues until something like pregnancy, medication, illness, or surgery sabotaged their sex life.
The Benefits of Having Sex
I am obviously a consistent proponent of trying to make sex an active part of your life. However, I would be remiss as a physician if I didn’t share a bit of healthy skepticism about the ever-expanding list of purported physical, psychological, and social benefits of good sex. So here goes. Let’s take a look at why people have sex to begin with—starting, of course, with the fact that it’s supposed to feel good. There are three main reasons why people have sex:
Pleasure: People like to do things that feel good. The release of endorphins and neurotransmitters, the physical pleasure, and the intimacy and connection that occur with sexual activity all result in pleasure. The biological reason that sex feels good is so people will have sex a lot and procreate.
Partner: People have sex because it enhances their relationship with their partner. Biologically, of course, partnered sex is necessary for procreation.
Procreation: So yes, procreation is biologically why people have sex. Period. From an evolutionary viewpoint, it also makes sense for healthy people to procreate, which is why people who are sick, weak, or dying (the biologically unsuitable) are less likely to be sexually active.
While everyone agrees that healthy people have more sex, on the flip side, does having sex make you healthier? Google “health benefits of sex” and you will learn that regular sex prevents cancer, boosts your immune system, improves heart health, cures arthritis, eliminates PMS, lowers blood pressure, eliminates headaches, prevents wrinkles, makes your hair thicker, whitens your teeth . . . the list goes on and on.
There is no doubt that pleasurable sexual activity has psychological benefits, but when it comes to physical benefits, which of the many claims out there has an actual scientific basis? What’s cause and what’s effect? Does having a lot of sex make your heart healthier? Or is it just that people who have better heart health have more sex? Correlation and causation are not the same thing, so let’s separate the hype from the facts.
Sex Promotes Weight Loss?
There is no question that having sex burns more calories than, say, sitting in front of the television and eating Twizzlers. But do women who have regular sex actually lose weight? Sex burns around five calories a minute. Most people have sex for about ten to fifteen minutes. Tops. The average person burns around two hundred calories a week having sex, less than the number of calories in the two glasses of wine you drank before you had sex. Don’t cancel the gym membership.
Sex Reduces Pain?
Sexual activity releases endorphins. High endorphin levels are associated with less pain. There are many claims that increased endorphins from sexual activity relieves headache pain, back pain, muscle pain, you-name-it pain. There are actually very few scientific studies that look at pain reduction as a direct result of sexual activity. One study conducted at the Headache Clinic at Southern Illinois University did find that half of female migraine sufferers reported relief after orgasm. So much for the “I have a headache” excuse.
Sex Reduces Menstrual Cramps?
This claim is based on pain reduction from increased endorphins along with the uterine contractions that occur with orgasm. Uterine contractions get the menstrual blood out faster. Shorter periods reduce the amount of time you are in pain. While there are a lot of anecdotal reports of pain-free periods as a result of sexual activity, there are no scientific studies that prove this to be true.
Sex Eases Depression?
High levels of dopamine are associated with decreased depression. Sexual activity increases dopamine. Depression (accompanied by low levels of dopamine) is associated with decreased sexual activity. So again, is it cause or correlation? One interesting study claims that the components of semen, including prostaglandins, testosterone, and oxytocin, are absorbed through the vaginal tissues and improve mood in women. Obviously, only women who do not use condoms potentially benefit from this effect. One can’t help but wonder if this hypothesis (never proven, by the way) was construed by a condom-hating scientist.
Sex Prevents Infection?
This one pops up a lot and is based on a small study that measured postcoital salivary levels of immunoglobulins, our body’s defense against infection. In that study, intercourse transiently boosted immunoglobulins by about 30 percent. As a result of that one tiny study, there are countless claims that sex fights off infection. So do people who have lots of sex have fewer colds? Who knows? This has also never been proven. Since kissing and heavy breathing tend to spread colds, it may be a wash. And we’re not even talking about STDs.
Sex Leads to Better Heart Health?
In one often-cited British study, men who had at least three orgasms per week had 50 percent fewer heart attacks than men who did not. The theory is that sex causes an increase in DHEA (didehydroepiandrosterone), which in turn helps circulation. Another is the assumption that the exercise of sex builds heart health. Having sex takes about the same amount of effort as climbing two to three flights of stairs. Now, if you were to climb about twenty flights of stairs and then have sex . . .
Sex Improves Sleep?
Orgasm causes a transient rise in prolactin and oxytocin, hormones that increase during sleep. But having higher prolactin levels during sleep is not the same thing as inducing sleep. In fact, it is sleep that induces elevated prolactin levels. This is a perfect example of upside-down science being used to make a point. An elevation in oxytocin is associated with emotional bonding and sexual pleasure, but it doesn’t directly help you fall asleep. The physical activity of sex may make you tired, but again, we’re talking two to three flights of stairs. Does sex make you feel relaxed and satisfied? I’ll go for that.
Sex Lowers the Risk of Cancer?
A 2004 study in the Journal of the American Medical Association showed that men who had at least twenty-one ejaculations a month had a significantly lower risk of developing prostate cancer than men who ejaculated fewer than seven times a month. The validity of this study has been questioned, particularly since the study was based on men’s recollections of how much sex they’d had at different times in their life, and as you know, men never exaggerate about how much sex they have. A 1989 French study showed that women who never had sex were three times as likely to develop breast cancer as women who regularly had sex.
Sex Prevents Incontinence?
Not only does a long session of sex supposedly tone your thighs and butt, but there are claims that strong orgasms, which induce pelvic floor contractions, may also help tone your pelvic floor, which in turn prevents incontinence. There is no question that a strong pelvic floor prevents involuntary loss of urine. But it is also known that women who are incontinent avoid having sex and are also likely to have difficulty reaching orgasm. (See chapter 15 on medical issues). So, does sex prevent incontinence, or do women who don’t leak urine just have more sex?
Sex Reduces Wrinkles?
Wrinkles are caused by loss of collagen. Estrogen increases collagen formation. In fact, women in the 1950s were encouraged to put estrogen cream on their face to keep their youthful appearance. But sexual activity doesn’t increase estrogen; estrogen increases the ability and desire to have sex. Are you confused? I’m confused. In the meantime, stick with your sunscreen, which is proven to prevent wrinkles.
Sex Prevents Tooth Decay?
Semen has calcium, zinc, and other minerals needed to fight tooth decay. Women who swallow semen should therefore have healthier teeth. This is a stretch. A very big stretch, unless you are using semen as toothpaste.
Sex Increases and Sustains Vaginal Lubrication and Elasticity?
This is the old “use it or lose it” issue, which happens to be very true. Regular intercourse increases blood flow to the vaginal walls, which in turn increases lubrication and elasticity. So, if things are working fine, having intercourse on a regular basis does help to sustain vaginal health. On the other hand, once the tissues are thin and dry, “using it” more times than not only causes more pain and more dryness. Fix it and then use it.
Sex Makes You Happier?
A National Bureau of Economic Research study calculated that regular sexual activity brings the same levels of happiness as earning an extra $100,000 annually. I can’t vouch for the $100,000 claim, but I can tell you that satisfying, pain-free sex does tend to make people happier.
Sex Prolongs Life?
Do people who have sex live longer because they have sex, or are healthier people who are the most likely to live longer also more likely (and able) to have sex? A study in the British Medical Journal found that men who had sex less than once a month were twice as likely to die in the next ten years as those who had sex once a week. A 25-year study of 270 men and women age 60 to 96, conducted at Duke University, found that the more men had sex, the longer they lived. Women who said they enjoyed their sex lives lived seven to eight years longer than those who were not interested in having sex. Cause or correlation? In either case, it’s easy to make the argument that having good sex gives you an incentive to live longer.
So What’s the Verdict?
Call me a skeptic, but the jury is still out on most of these claims. However, it doesn’t matter. What is known is that sex is associated with the elevation of “feel-good” hormones and neurotransmitters, sex is not bad for you, and the correlation between good health and pleasurable sex is proven. Get your sexual health together and your general health is likely to benefit as well. Besides, sex feels good. And while the only biological reason to have sex is procreation, we live longer now, well beyond the years of childbearing. Therefore, sexual activity has taken on a different role: in short, sex enhances the quality of life.
So why then do women start avoiding sex?
It’s Not Always Physical
If you have painful sex—whether you have a partner, don’t have a partner, or don’t want a partner—you are likely to avoid situations that lead to sex. And while your ability to have pleasurable sex and the frequency of your sexual activity are influenced by your physical ability to do so, clearly there are many nonmedical considerations that impact your sexual activity as well. Before launching into the myriad of medical, physical, and hormonal issues behind sexual dysfunction (the next 15 chapters are devoted to those subjects!), let’s take a look at some of the nonmedical factors that negatively influence not just how good sex is but how frequent (or infrequent) it is.
Cultural Factors
Every society has behaviors that are unique to that culture, and sexual behavior is no exception. Homosexuality is acceptable in some cultures, but not in others. Women baring their breasts on the beach is the norm in France, while in some cultures even nudity in the bedroom isn’t allowable. Some cultural sexual behaviors, such as female genital mutilation, are not only hazardous to health, but can eliminate or reduce pleasure. Dry sex (preferred by men, not women!) in some cultures, as opposed to the American preference for slippery, lubricated intercourse, may also pose health risks for women beyond pain.
Sexual practices and attitudes vary not only from culture to culture but within cultures. In the United States, there are plenty of people who would never consider anything other than male-female intercourse in the missionary position, while their next-door neighbor routinely has mixed-gender threesomes that involve light bondage and strap-on dildos.
The Length of the Relationship
Even with a really strong couple, the longer the relationship the less frequent the sex. There are exceptions, of course, but virtually every study shows that new sex is not only hotter but also more frequent.
Partner Issues
Relationship issues aside, not having a partner, or a functional partner, is the most common issue for women. While erectile dysfunction is frequently discussed, another common problem that is talked about less is premature ejaculation.
Lack-of-partner issues are particularly common among aging women, since age disparities at the time of marriage leave women often outliving their husbands or having a significantly older husband. It is also a reality that divorced or widowed men are more likely to remarry than divorced or widowed women. Even when a functional partner is available, there may be a disconnect when it comes to sexual interest. Women are not the only ones who have varying levels of libido.
Age Issues
The perception that older people do not have sex is not based in reality. More than half of women continue to be sexually active after menopause. Having said that, even if there are no medical or partner issues, women’s interest in sex and the type and frequency of their sexual activity eventually decline as part of the normal aging process.
Religious Factors
Women from strict religious upbringings who have an engrained belief that premarital sex is evil are sometimes unable to shake that belief and continue to feel that sex is “wrong” even after they marry and are expected to become sexually active. While most religions encourage sexual activity (within marriage) for procreation, some place restrictions on either the type of sexual activity or the timing. Almost every religion forbids intercourse during menstruation. Why bother if the chance of pregnancy is almost nil?
Observant Jews take it a step further and forbid intimacy (including hand-holding, kissing, or touching of any sort) for days after the flow has stopped. My Orthodox friends tell me that this forced abstinence results in an anticipation that enhances enjoyment of sex. On the other hand, Orthodox Jews are not only permitted to be intimate but are obligated to have intercourse at certain times. Having sex on the Sabbath is a mitzvah—meaning that God gives you extra credit. As an extra perk for Jewish women, the traditional marriage contract states that a husband has the obligation to make sure his wife is sexually satisfied and cannot force her to have sex if she doesn’t want to.
For Muslims, pretty much anything goes as long as it’s in the marital bed, it’s not happening during menstruation, and it’s not sodomy. Islam actually sees sex (in the proper setting) as ibadah, or an act of worship. While modesty and chastity in public are the hallmarks of a Muslim woman, there is nothing wrong with that woman being active and responsive during sex. In fact, foreplay by both partners is strongly encouraged—those who skip straight to penetration are said to be behaving like animals.
Mormons are bound by the “law of chastity,” which says that they are “to stay morally clean in their thoughts, words, and actions.” But there aren’t many restrictions when it comes to what a Mormon couple can do after they tie the knot. And there’s no “till death do us part” in Mormon wedding vows: since Mormon marriages are “celestial,” they continue into the afterlife. Although Mormonism has been associated with polygamy in the past, this is now a touchy subject, and any Mormon who enters into a polygamous relationship will be excommunicated from the Church of Latter-Day Saints. There’s one loophole: a widowed man (but not a widowed woman) is allowed to marry again and thus have multiple wives—and sexual partners—in the afterlife. Now that would make for a very awkward celestial reunion.
For Catholics, sex is all about procreation, so using it for a reason other than that is considered a sin. That’s not to say that sex shouldn’t be pleasurable for Catholics, but that it should happen within marriage, without birth control, and definitely not with someone of the same sex. Masturbation is also a no-no. In fact, even if there is no chance of the woman getting pregnant (she is already pregnant, postmenopausal, etc.), Catholic men must only ejaculate into a woman’s vagina.
Excluding monks and nuns, the Buddhists get the gold ribbon for sexual leniency. After all, they are the inventors of tantric sex and sexual yoga, which, according to some Tibetan authorities, are necessary practices in order to attain Buddhahood (the state of complete enlightenment). Buddhism teaches that cravings—including sexual cravings—lead to suffering, so acknowledging those desires is strongly encouraged. The only restrictions are very vague: followers are to “refrain from sexual misconduct,” but what that actually means is open for interpretation. And there’s no mention of homosexuality in ancient Buddhist texts, so that’s up for interpretation too.
Having a History of Sexual Abuse
A history of rape or sexual abuse increases the likelihood that consensual sexual activity may be problematic, even if the issues surrounding the trauma have been resolved. The experience of early and repeated sexual abuse is highly associated with adult issues of low libido, low arousal, sexual pain, and inability to orgasm. One study showed that 75 percent of women with a history of coercion had sexual dysfunction.
Fear of Infection or Pregnancy
It’s hard to “let go” if you think you might get a sexually transmitted infection or are worried about becoming pregnant. Fear of pregnancy goes both ways: you may not want to get pregnant and are having sex without contraception, or you may desperately want to become pregnant and have not been able to.
Body Image and Self-Esteem Issues
He is not looking at your cellulite—he is too worried about the size of his penis—but you are. Studies consistently show that women who feel physically undesirable avoid sex. Even if there are underlying self-esteem issues that have nothing to do with body image, sexual intimacy may be problematic.
Stress
While men may try to convince women that sex is a stress reliever, that is generally not the case, and in fact the endless list of stresses—financial issues, work, caretaking of parents, unemployment, life—has a negative influence on frequency of sexual activity.
Sleep Patterns/Schedule
If your husband works nights and you work days, the likelihood of your having sex is going to decrease. Ditto if you get up at the crack of dawn to get an exercise session in before you get the kids up and off to school, run around like a crazy person all day, and then collapse into bed right after the dishes go into the dishwasher. Snoring that leads to separate bedrooms can also be a real sexual sabotage.
Privacy
If your kids are bursting into the bedroom unannounced every time they have a question (or more likely every time they hear the bed squeaking), it’s hard to be “in the moment.” This may also be an issue if you live in really cramped quarters.
So yes, cultural factors, religious beliefs, social issues, general health, and age all influence the frequency of sexual activity. More than any other factor, though, the frequency of sex is determined by pleasure. Most people don’t want to do things that don’t bring them pleasure.
If there is a physical, hormonal, or medical condition that has sabotaged your sex life, you are far from alone, and that is what the next 19 chapters are all about: comprehensive, up-to-date, accurate information about improving your SexAbility—minus the speculum, Pap smear, and stirrups.