In this week's podcast episode, we talked with Dr. Katherine Unverferth on Menopause, anxiety, and mental health. We covered the below topics:

• How do we define peri-menopause and menopause? 
• What causes menopause? 
• Why do some have more menopausal symptoms than others? 
• Why do some people report rapid rises in anxiety (and even panic disorder) during menopause. 
• Is the increase in anxiety with menopause biological, physiological, or psychological? 
• Why do some people experience mood differences or report the onset of depression during menopause? 
• What treatments are avaialble to help those who are suffering from menopause (or perimenopause) and anxiety and depression?

Welcome back, everybody. I am so happy to have you here. We are doing another deep dive into sexual health and anxiety as a part of our Sexual Health and Anxiety Series. We first did an episode on sexual anxiety or sexual performance anxiety. Then we did an episode on arousal and anxiety. That was by me. Then we did an amazing episode on sexual side effects of antidepressants with Dr. Aziz. And then last week, we did another episode by me basically going through all of the sexual intrusive thoughts that often people will have, particularly those who have OCD. 

This week, we are deep diving into menopause and anxiety. This is an incredibly important episode specifically for those who are going through menopause or want to be trained to understand what it is like to go through menopause and how menopause impacts our mental health in terms of sometimes people will have an increase in anxiety or depression.

This week, we have an amazing guest coming on because this is not my specialty. I try not to speak on things that I don’t feel confident talking about. This week, we have the amazing Dr. Katherine Unverferth. She is an Assistant Clinical Professor at The David Geffen School of Medicine and she also serves as the Director of the Women’s Life Center and Medical Director of the Maternal Mental Health Program. She is an expert in reproductive psychiatry, which is why we got her on the show. She specializes in treating women during periods of hormonal transitions in her private practice in Santa Monica. She lectures and researches and studies areas on postpartum depression, antenatal depression, postpartum psychosis, premenstrual dysphoric disorder—which we will cover next week, I promise; we have an amazing guest talking about that—and perimenopausal mood and anxiety disorders. I am so excited to have Dr. Unverferth on the show to talk about menopause and the collision between menopause and anxiety. You are going to get so much amazing information on this show, so I’m just going to head straight over there. Again, thank you so much to our guest. Let’s get over to the show.

Kimberley: Welcome. I am so honored to have Dr. Katherine Unverferth with us talking today about menopause and anxiety. Thank you for coming on the show.

Dr. Katie: Of course. Thanks for having me.

HOW DO WE DEFINE PERI-MENOPAUSE AND MENOPAUSE? 

Kimberley: Okay. I have a ton of questions for you. A lot of these questions were asked from the community, from our crew of people who are really wanting more information about this. We’ve titled it Menopause and Anxiety, but I want to get really clear, first of all, in terms of the terms and whether we’re using them correctly. Can you first define what is menopause, and then we can go from there?

Dr. Katie: Definitely. I think when you’re talking about menopause, you also have to think about perimenopause. Menopause is defined as the time after the final menstrual period. Meaning, the last menstrual period somebody has. It can only be defined retrospectively, so you typically only know you’re in menopause a year after you’ve had your final menstrual period. But that’s the technical definition—after the final menstrual period, it’s usually defined one year after. Perimenopause is the time leading up to that where people have hormonal changes. Sometimes they have vasomotor symptoms, they can have mood changes, and that period typically lasts about four years but varies. I think that people often know that they’re getting close to menopause because of the perimenopausal symptoms they might be experiencing.

Kimberley: Okay. How might somebody know they’re going into perimenopause? I think that’s how you would say you go into it. Is that right? 

Dr. Katie: Yeah. You start experiencing it there. I don’t know if there’s a specific term. 

Kimberley: Sure. How would one know they’re moving in that direction? 

Dr. Katie: Typically, we look for a few different things. One of the earliest signs is menstrual cycle changes. As someone enters perimenopause, their menstrual cycle starts to lengthen, whereas before, it might have been a normal 28-day cycle. Once it lengthens to greater than seven days, over 35 days, we would start to think of someone might be in perimenopause because it’s lengthened significantly from their baseline before. 

Other symptoms that are really consistent with perimenopause are vasomotor symptoms. Most women who go through perimenopause will have these. These are hot flashes or hot flushes—those are synonyms for the same experience—and night sweats. Hot flashes, as the name describes what it is, they last about two to four minutes. It’s a feeling of warmth that typically begins in the chest or the head and spreads outward, often associated with flushing, with sweating that’s followed by a period of chills and sometimes anxiety. The night sweats are hot flashes but in the middle of the night when someone is sleeping, so it can be very disruptive to sleep. That combination of the menstrual cycle changes plus these vasomotor symptoms is typically how we define perimenopause or how we diagnose perimenopause. Once someone is later in perimenopause, when they’re getting closer to their final menstrual period, often they’ll skip menstrual cycles altogether, so it might be 60 days in between having bleeding. Whereas before, it was a more regular period of time.

I think one of the defining features too is hormonal fluctuations during those times. But interestingly, there’s not much clinical utility to getting the blood test to check hormone levels because they can vary wildly from cycle to cycle. Overall, what we do see is that certain hormones increase, others decrease, and that probably contributes to some of the symptoms that we see around that time as well.

Kimberley: Right, which is so interesting because I think that’s why a lot of people come to me and I try to only answer questions I’m skilled to answer. Those symptoms can very much mimic anxiety. I know we’ll get into that very soon, but that’s really interesting—this idea of hot flashes. I always remember coming home to my mom from school and she was actually in the freezer, except for her feet. It was one of those door freezers. So, I understand the heat that they’re feeling, this hot flash, it’s a full body hot flash stimulant like someone may have if they’re having a panic attack maybe. 

Dr. Katie: Exactly. There are lots of interesting studies really looking at the overlap of menopausal panic attacks and hot flashes too. There’s a lot of this research that’s really trying to suss out what comes first in perimenopause because we know that anxiety predisposes someone to hot flashes and it can predispose someone to panic attacks, which is interesting. It seems like there’s this common denominator there. But I think that that’s a really interesting thing that hopefully we’ll get into this overlap between the two.

WHAT AGE DOES SOMEONE GET PERIMENOPAUSE AND MENOPAUSE?

Kimberley: I’m guessing this is something I’m moving towards as well. What age groups, what ages does this usually start? What’s the demographics for someone going into perimenopause and menopause?

Dr. Katie: The average age of menopause is 51, and then people spend about four years in perimenopause. Late 40s would be a typical time to start perimenopause. Basically, any age after 40, when someone’s having these symptoms, they’re likely in perimenopause. If it happens before the age of 40 where someone’s having menstrual cycle abnormalities and they’re having these vasomotor symptoms, that might be a sign of primary ovarian insufficiency. It used to be called premature ovarian failure, but that would be a sign that they should probably go see a doctor and get checked out. If it’s after 40, it’s very likely that they’re having perimenopausal symptoms.

Kimberley: Okay. What causes this to happen? What are the shifts that happen in people’s bodies that lead someone into this period of their life?

Dr. Katie: I think there are a lot of things that are going on. I think it’s really important to emphasize that menopause is a natural part of aging. That this isn’t some abnormal process. Nothing is wrong. It’s a natural part of aging. It can still be very uncomfortable, I think. But basically, over time, a woman’s eggs decline and the follicles that help these eggs develop also develop less. There’s this decline in the functioning of the ovaries. There are a few reasons this might be. There are some studies that show that blood flow to the ovaries is reduced as a result of aging, so maybe that makes them function a little bit less. The follicles that remain in the ovaries are probably aging, and then the follicles, which are still there, also might not be the healthiest of follicles, which is why they weren’t used earlier. 

There’s this combination of things that leads to these very significant hormonal changes that start around perimenopause. The first of these is an increase in follicle-stimulating hormone. Follicle-stimulating hormone is released by the pituitary and encourages the ovaries to develop follicles. That increases over time because the follicles aren’t developing in the same way. It’s like the pituitary is trying harder and harder to get them to work. At the same time as these, as the follicles and ovaries are aging, what we see is that the ovaries produce less estrogen and progesterone overall. But there’s still these wild fluctuations that are happening. FSH is going up, but it’s fluctuating up; estrogen and progesterone are going down, but they’re fluctuating down. It’s these really big shifts that seem to cause a lot of the symptoms that we associate with this time.

WHY DO SOME HAVE MORE MENOPAUSAL SYMPTOMS THAN OTHERS? 

Kimberley: Is there a reason why some people have more symptoms than others? Is it your genetic component or is there a hormonal component? What’s your experience?

Dr. Katie: I think there are lots of different reasons and we probably need more research in this area. There are definitely genetic components that influence it. For example, we know that women who have family members who went through menopause earlier are likely to go through menopause themselves earlier. There’s some genetic thing that’s influencing the interplay of factors. I think we know that there are certain lifestyles. There are certain behaviors, like certain behaviors in someone’s life that can influence, I think, their symptoms. We know that smoking, obesity, having a more sedentary lifestyle can impact vasomotor symptoms. I think some really interesting research looks at the psychological influences here. We know that women who have higher levels of neuroticism, when they go through perimenopause, have more anxiety and mood changes associated with it. People who have higher levels of somatic anxiety, coming into this perimenopausal transition, can also have a tougher time. I think that makes sense when we think about someone with somatic anxiety. They’re going to be very, very attuned to these small changes in their body. During perimenopause, there are these huge changes that are happening in your body. That can trigger, I think, a lot of anxiety and a focus on the symptoms. 

I think with vasomotor symptoms specifically, like hot flashes and hot flashes specifically, night sweats, not quite as much, we know that there are these psychological characteristics that probably perpetuate and worsen hot flashes. When someone has a hot flash, it’s certainly uncomfortable for most people. But the level of distress can be very different. They’ve looked at the cognitions that occur when people have hot flashes and at some point, people believe like, “Oh, this is very embarrassing, this is very shameful.” That doesn’t help them process it. They might believe, “This is never going to go away. I can’t cope with it.” That’s also not going to help. I think that’s really a target for cognitive behavioral therapy to help people during this time.

Kimberley: It just makes me think too, as somebody who has friends going through this, and you can please correct me, what I’ve noticed is there’s also a grief process that goes along with it too, like it’s another flag in terms of being flown, in terms of I’m aging. I’ve also heard, but maybe you have more to say about people feeling like it makes them less feminine. Is that your experience too, or is that just my experience of what I’ve heard?

Dr. Katie: No, I agree. I think in my clinical experience, people go through it in a lot of different ways. I think that there is this grief. I think it can bring out a lot of existential anxiety. It is a sign that you are getting older. This can bring up a lot of these questions like, who am I? What’s my purpose? Where am I going? But I think it’s really important to remind women that we’re not defined by our reproductive functioning. I think that that’s something that people forget. Were you less of a woman when you were 15 or when you were 10 maybe and you hadn’t gone through puberty? You’re still the same person. But I do think that there’s a lot of cultural stress around this, and I think there are a lot of complexities around the way society sees aging women. I think that those are cultural issues that need to be fixed, but not necessarily a problem within the woman themselves.

WHAT CAUSES MENOPAUSE AND ANXIETY SYMPTOMS? 

Kimberley: That’s really helpful to know and understand. Okay, let’s talk about if I could get a little more understanding of this relationship with anxiety. Maybe you can be clearer with me so that I understand it. Is it more of what we’re saying in terms of like, it’s the chicken and the egg? Is that what you mean in terms of people who have anxiety tend to have more symptoms, but then those symptoms can create more anxiety and it’s like a snowball? Or is that not true for everybody? Can you explain how that works?

Dr. Katie: With regard to the perimenopausal period, what I think researchers are trying to figure out is, do vasomotor symptoms, like hot flashes, lead to anxiety and panic, or do anxiety and panic worsen the vasomotor symptoms? We don’t have a lot of information there. Part of it is because it’s difficult to study. Because when you’re doing symptom checklists, there’s a lot of overlap between a hot flash and a panic attack. It’s just been difficult, I think, to suss out in research. I think what we do know is there was one study that showed that people who have higher levels of anxiety are five times more likely to report hot flashes than women with anxiety in the normal range. Whether or not the anxiety is necessarily causing it, I do think that there’s probably some perpetuation of like, I think that the anxiety is perpetuating the hot flashes, which perpetuates the anxiety. We just don’t know exactly where it starts. 

MENOPAUSE & PANIC ATTACKS 

But I mean, if we just think about it for a second, if we think about what’s common between them, I think that both panic attacks and hot flashes have a quick onset. They have a spontaneous onset, a rapid peak, they can be provoked by anxiety, they can include changes in temperature, like feelings of heat and sweating. They can have these palpitations, they can have this shortness of breath, nausea. And then it’s very common that panic is reported during hot flashes, and hot flashes can be reported during panic. I think there’s this interplay that we’re trying to figure out. I think what’s interesting too is that common antidepressants can treat both panic and hot flashes, which is not something that probably everybody knows. There are probably different reasons that they’re treating each of them, but it is still just this other place where there is this overlap. 

Kimberley: Okay. That’s really interesting. One thing that really strikes me is I actually have a medical condition called postural orthostatic tachycardic syndrome (POTS), and you get really dizzy. I’m an Anxiety Specialist, so I can be good at pulling apart what is what, but it is very hard. You have to really be mindful to know the difference in the moment because let’s say I have this whoosh of dizziness. My mind immediately first says I’m having a panic attack, which makes you panic. I’m assuming someone with that whoosh of maybe a hot flash has that same thing where your amygdala, I’m guessing, is immediately going to be like, “Yeah, we’re having a panic attack. This is where we’re going.” That makes a lot of sense to me.

Now, some people also have reported to me that their anxiety has made them-- and again we have to understand what causes what, and we don’t understand it, but how does that spread into their daily life? What I’ve heard is people say, “I don’t feel like I can leave the house because what if I have a hot flash, which creates then a panic attack,” or “It’s embarrassing to have a hot flash. You sweat and your clothes are all wet and so forth.” Do you have a common example of how that also shows up for people? 

Dr. Katie: Yeah. I think that what you were alluding to is this behavioral avoidance that can happen. We can see that with panic attacks where people sometimes develop agoraphobia, fear of being in certain places. Sometimes they don’t want to leave their home. I think with hot flashes, we do also see this behavioral avoidance when people especially tend to find them very distressing. They catastrophize it when they happen. They worry about social shaming. That avoidance, I think, the way that we understand anxiety is that if you have an anxiety and then you change your behaviors as a result of that anxiety, that tends to perpetuate the anxiety. That’s one of the targets of cognitive behavioral therapy for hot flashes, is really trying to unwind some of this behavioral avoidance. Also, we know that temperature changes can trigger hot flashes. Unfortunately, it looks like strong positive and strong negative emotion can trigger hot flashes, just feeling any end of the spectrum. There are certain other triggers that can trigger hot flashes. I think that it’s just this discomfort and this fear of having a hot flash that I think really generalizes the anxiety during this time. 

HORMONES, ANXIETY, & MENOPAUSE

There’s also this interesting hormonal component too that’s being studied as well. We’ve talked a little bit about progesterone. But in reproductive psychiatry, we really focus on this metabolite of progesterone called allopregnanolone. I think this is interesting because allopregnanolone is a metabolite of progesterone. We know that progesterone is going like this, up and up and down during this time. Allopregnanolone works on this receptor that tends to have very calming effects. Other things that work at this receptor are benzodiazepines like Xanax and Ativan or alcohol. It has this calming effect. But when it’s going like this, it’s calming and then it’s not, and then it’s calming and then it’s not, up and down rollercoaster. There’s some thought that that specifically might contribute to anxiety during this time. It can be more generalized. It’s not always just related to hot flashes, even though we’ve been more specific on that. It can be the same as anxiety at any point in anyone else’s life, like ruminative thoughts, worry, intrusive thoughts, just this general discomfort. I think this is a really exciting area of research where we’re looking at ways to modulate this pathway to help women cope better. There are studies looking at progesterone metabolites to see if they can be helpful with mood changes during this time.

Kimberley: Interesting. Let’s work through it. As a clinician, if someone presents with anxiety, what I would usually do is do an inventory of the behaviors that they do in effort to reduce or remove that anxiety or uncertainty that they feel. And then we practice purposely returning to those behaviors. Exposure and so forth. From what you understand, would you be doing the same with the hot flashes or is there a balance between, there will be sometimes where you will go in purposely or go out and live your life whether you have a hot flash or not? How do we balance that from a clinical standpoint? Even as a clinician, I’m curious to know. As a clinician, what would I encourage my client to do? Would it be like our normal response of, “Come on, let’s just do it, let’s face all of our fears,” or is there a bit of a balance here that we move towards?

Dr. Katie: It’s more of a balance. I think one of the important things is that what you want to do-- I think the focus is on the cognition here a little bit. I’m not familiar and I don’t think that exposure to hot flashes is intentionally triggering hot flashes repeatedly, like sometimes we do in panic disorders is part of this. What I understand from the protocol is that it’s really looking at the unhelpful cognitions that relate to menopause, aging, and vasomotor symptoms. This idea of like, everybody is looking at me when I’m having a hot flash, this is so shameful. Or maybe it goes further, like no one will like me anymore. Who knows exactly where it can go? We know that when people have cognitive distortions, it’s not really based on rational thinking.

I think other part is you work on monitoring and modifying hot flash triggers, so it feels more in your control like temperature changes and doing those things. I think other things that you do is there’s some evidence for diaphragmatic breathing to help with the management of hot flashes. You teach someone those skills. I think your idea is you want to get them back out there and living their life despite the hot flashes, and also just education. This isn’t going to last forever. Yes, this is uncomfortable, but everybody goes through this. This is a normal part of aging. Also encouraging them to seek treatment if they need it. In addition to therapy, we know that there are medications that can help with this. If the hot flashes are impacting their life in a significant way or very distressing to them, go see a reproductive psychiatrist or go see an OB-GYN who can talk to you about the different options to really treat what’s coming up.

Kimberley: Right. That’s helpful. I want to quickly just add on to that with your advice. I think what you’re saying is when we come from an anxiety treatment model, we are looking at exposure, but when it comes to someone who’s going through this real life, like their actual symptoms aren’t imagined, they’re there, it’s okay for them to modify to not be going to hot saunas and so forth that we know that they’re going to be triggered, but just to do the things that get them back to their daily functioning, but it is still okay for them. I think what I’m trying to say is it’s still okay for them to be doing some accommodation of the symptoms of perimenopause, but not accommodation of the anxiety. Is that where we draw the line?

Dr. Katie: I think that’s a really good way of explaining it.

DEPRESSION AND MENOPAUSE

Kimberley: All right. The other piece of this is as important, which is how depression impacted here. Can you share a little bit how mood changes can be impacted by perimenopause? 

Dr. Katie: Definitely. We know that there’s a significant increase in not only the onset of a new depression, but also recurrence of prior depressive episodes during perimenopause. It’s probably related to the changing levels of hormones, but also, I think what we’ve alluded to and what we have to acknowledge is there are big life changes that are happening around this time as well. I think cultural views of aging, I think a lot of times people have changes in their relationships, their partners. Their libido can change. There’s so many moving parts that they think that also contributes to it. 

But specifically with regard to perimenopausal depression, we categorize this in the reproductive subtype of depression. At these different periods of hormonal transition, certain women are prone to have a depressive episode. We know that that’s true during normal cycling. For example, premenstrual dysphoric disorder or PMDD is a reproductive subtype of depression. People sometimes get depressed in those two weeks before their period and then feel fine during the week of their period or the week after. During the luteal phase, they experience depression. We know that that group of women also is at increased risk for perinatal depression, so depression during pregnancy and postpartum. And then that same group is also at risk for perimenopausal depression. What we know is that a subset of women is probably sensitive to normal levels of changing hormones, and that for them, it triggers a depressive episode. 

One of the biggest risk factors for depression during perimenopause is a prior history of depression. Unfortunately, the way depression works is that once you have it, you’re more likely to have it in the future. For people who have had depression in their life or have specifically had depression around these times of hormonal transition, it’s probably just important to keep an eye on how they’re doing, make sure they have appropriate support, whether that’s from a therapist or a psychiatrist, and monitor themselves closely.

Kimberley: Okay. This is really helpful to know. We know that people with anxiety tend to have depression as well. Have you found those who’ve had previous depression or previous anxiety also have coexisting in terms of having those panic attacks and depression at the same time?

Dr. Katie: That’s interesting. I haven’t read any research on that. It wouldn’t surprise me. But I think at least for research purposes, they’re separating it. I think clinically, of course, we can see it being all mixed together. But for research, it’s depression or panic and they keep those separate.

Kimberley: Right. One thing that just came to me in terms of just clarifying too is, I’m assuming a lot of people who have health anxiety are incredibly triggered during perimenopause as well, these symptoms that are unexplained but explained. But I’m wondering, is that also something that you commonly see in terms of they’re having these symptoms and questioning whether it means something serious is happening? Has that been something that you see a lot of?

Dr. Katie: Definitely. I think the first time someone has a hot flash, it can be extremely distressing. It’s a very uncomfortable sensation. I think there are other changes that happen during perimenopause that, of course, I think, raise concern. We know that in addition to night sweats, people can just have general aches and pains. They can have headaches. Cognitive complaints can be very common during this time. Just this feeling of brain fog, not feeling as sharp as one used to be. They can have sleep disturbances, which can of course worsen the anxiety and the cognitive complaints, and the depression. I think there can be a myriad of symptoms. Other distressing symptoms, I’m not sure if they necessarily-- I think if you know what’s going on, it’s not quite as distressing, but there can be these urogenital symptoms, like vaginal dryness, vaginal burning. There can be recurrent UTIs, there can be difficulty with urination. There are this constellation of symptoms that I’m sure could trigger health anxiety in people, especially if they have preexisting health anxiety.

WHAT TREATMENTS ARE AVAIALBLE TO HELP THOSE WHO ARE SUFFERING FROM MENOPAUSE (OR PERIMENOPAUSE) AND ANXIETY AND DEPRESSION? 

Kimberley: Yeah, absolutely. Someone’s listened to this episode so they’re at least informed, which is wonderful. They start to see enough evidence that this may be what is going on for them. What would be the steps following that? Is it something that you just go through and like a fever, you just ride it out kind of thing? Or are there medications or treatments? What would you suggest someone do in the order as they go through it?

Dr. Katie: I think it depends on what’s going on and how they’re experiencing it. If this is distressing, life interfering, if they’re having trouble functioning, they should absolutely seek treatment. I think there are a few different things they can do depending on what’s going on. For depression and anxiety, medications are the first line. Antidepressants would still be the first-line therapy there. There’s some evidence for menopausal hormone therapy, but there’s not really enough. There is evidence for menopausal hormone therapy, but it’s not currently first line for depression or anxiety. If someone had treatment-resistant depression that came up in the perimenopausal transition, I think it’s reasonable to consider menopausal hormone therapy. But currently, menopausal hormone therapy isn’t really recommended for that. 

If someone is having distressing vasomotor symptoms with night sweats and recurrent hot flashes or hot flushes during the day, menopausal hormone therapy is a very good option. That is something to consider. They could go talk to their OB-GYN about it. Certain people will be candidates for it and other people might not. If you think it might be something you’re interested in, I recommend going and speaking to your OB-GYN sooner rather than later. 

Antidepressants themselves can also help with vasomotor symptoms as well. They can specifically help with hot flashes and night sweats. If someone has depression and anxiety and hot flashes and night sweats, antidepressant can be a really good choice because it can help with both of those. There was a really interesting study that compared Lexapro to menopausal hormone therapy for hot flashes, for quality of life, for sleep, and for depression. Essentially, both of them helped sleep quality of life in vasomotor symptoms, but only the Lexapro helped the depression. It really just depends on what’s going on. 

I think another thing that we’ve also talked about is therapy. This can be a big life transition. I think really no woman going through menopause is the same. Some people have toddlers. Some people have grown children who have just left their home. Some people are just starting their career. Some people are about to retire. Relationships can change. I think that it’s really important to take what’s going on in the context of a woman’s life. I think therapy can be really helpful to help them process and understand what they’re going through.

Kimberley: Right. You had mentioned before, and I just wanted to touch on this, vaginal drying and stuff like that, which I’m sure, again, a reason for this series is just how much sexual intimacy and so forth can impact somebody’s satisfaction in life or functioning or in relationships. Is that something that is also treatable with these different treatment models or is there a different treatment for that? 

Dr. Katie: With menopausal hormone therapy, when someone has hot flashes or these other symptoms that we were talking about, not the urogenital ones, they need to take systemic menopausal hormone therapy. They basically need estrogen and progesterone to go throughout their body. When someone is just having these urogenital symptoms, they can often use topical vaginal estrogen. It’s applied vaginally. That can be really helpful for those symptoms as well. I think if that’s something that someone is struggling with that they want treatment for, it’s very reasonable to go talk to their OB-GYN about it because there are therapies that can be--

Kimberley: Right, that’s like a cream or lotion kind of thing. 

Dr. Katie: Exactly. 

Kimberley: Interesting. Oh wow. All right. That is so helpful. We’ve talked about the medical piece, the medication piece. A lot of people also I see on social media mostly talk about these more-- I don’t want to use the word “natural” because I don’t like that word “natural.” I don’t even know what word I would use, but non-medical--

Dr. Katie: Like supplements or--

Kimberley: Yeah. I know it’s different for everyone and everyone listening should please seek a doctor for medical advice, but is that something that you talk about with patients or do you stick more just to the things that have been researched? What are your thoughts?

Dr. Katie: I think that supplements can be helpful for some people. I don’t always find that they’re as effective as medications. If someone is really struggling on a day-to-day basis, I do think that using treatments that have more evidence behind them is better. I think that there are some supplements that have a little bit of evidence, but I do think that they come with their own risks. Because supplements aren’t regulated by the FDA and things like that, I don’t typically recommend them. I think if someone is interested in finding a more naturopathic doctor who might be able to talk to them about those things is reasonable. 

Kimberley: Super helpful. Is there anything that you feel like we haven’t covered or that would be important for us to really drill home and make sure we point out here at the end before we finish up?

Dr. Katie: I think we’ve covered a lot. I think that the most important thing that I really want to stress is this is a normal part of aging. This is not a disease; this is not a disease state. Also, there are treatments that can be so effective. You don’t have to struggle in silence. It is not something shameful. There are clinicians who are trained, who are able to help if these symptoms are coming up. Just not being afraid to go and talk about it and go reach out for help. I think that that can be so helpful and really life-changing for some people when they get the right treatment.

Kimberley: Right. Thank you. Where can we hear about you, get in touch with you, maybe seek out your services?

Dr. Katie: You can find me online. I have a website. It’s just www.drkatiemd.com. It’s D-R-K-A-T-I-E-M-D.com. You can follow me on Instagram on the same. If you’re interested to see more of my talks and lectures, I often post those on my LinkedIn page. You can follow me on LinkedIn. I think if you are personally interested in learning more about menopause, there’s a really great book by an OB-GYN, her name is Dr. Jen Gunter, and it’s called The Menopause Manifesto. For anybody who really wants to educate themselves about menopause and understand more about what’s going on in their body and their treatments, I really recommend that book.

Kimberley: Amazing. That’s so good to have that resource as well. Thank you. I’m really, really honored. I know you’re doing so many amazing things and running so many amazing programs. I’m so grateful for your time and your expertise on this.

Dr. Katie: Of course. I’m so glad that you’re doing a podcast on this. I think this is a topic that we really need more information and education out there.

Kimberley: Yeah. Thank you.

Welcome. This is Week 4 of the Sexual Health and Anxiety Series. I have loved your feedback about this so far. I have loved hearing what is right for you, what is not right for you, getting your perspective on what can be so helpful. A lot of people are saying that they really are grateful that we are covering sexual health and anxiety because it’s a topic that we really don’t talk enough about. I think there’s so much shame in it, and I think that that’s something we hopefully can break through today by bringing it into the sunlight and bringing it out into the open and just talking about it as it is, which is just all good and all neutral, and we don’t need to judge.

Let’s go through the series so far. In Episode 1 of the series, we did sexual anxiety or sexual performance anxiety with Lauren Fogel Mersy. Number two, we did understanding arousal and anxiety. A lot of you loved that episode, talking a lot about understanding arousal and anxiety. Then last week, we talked about the sexual side effects of anxiety and depression medication or antidepressants with Dr. Sepehr Aziz. That was such a great episode. This week, we’re talking about sexual intrusive thoughts. 

The way that I structured this is I wanted to first address the common concerns people have about sexual health and intimacy and so forth. Now I want to talk about some of the medical pieces and the human pieces that can really complicate things. In this case, it’s your thoughts. The thoughts we have can make a huge impact on how we see ourselves, how we judge ourselves, the meaning we make of it, the identity we give it, and it can be incredibly distressing. My hope today is just to go through and normalize all of these experiences and thoughts and presentations and give you some direction on where you can go from there. Because we do know that your thoughts, as we discussed in the second episode, can impact arousal and your thoughts can impact your sexual anxiety. 

SEXUAL OCD OBSESSIONS

Let’s talk a little bit today about specific sexual intrusive thoughts. Now, sexual intrusive thoughts is also known as sexual obsessions. A sexual obsession is like any other obsession, which is, it is a repetitive, UNWANTED—and let’s emphasize the unwanted piece—sexual thought. There are all different kinds of sexual intrusive thoughts that you can have. For many of you listening, you may have sexual intrusive thoughts and OCD that get together and make a really big mess in your mind and confuse you and bring on doubt and uncertainty, and like I said before, make you question your identity and all of those things. 

In addition to these intrusive thoughts, they often can feel very real. Often when people have these sexual intrusive thoughts, again, we all have intrusive thoughts, but if they’re sexual in nature, when they’re accompanied by anxiety, they can sometimes feel incredibly real, so much so that you start to question everything. 

SEXUAL SENSATIONS

Now, in addition to having sexual intrusive thoughts, some of you have sexual sensations, and we talked a little bit about this in previous episodes. But what I’m really speaking about there is sensations that you would often feel upon arousal. The most common is what we call in the OCD field a groinal response. Some people call it the groinal in and of itself, which is, we know again from previous episodes that when we have sexual thoughts or thoughts that are sexual in nature, we often will feel certain sensations of arousal, whether that be lubrication, swelling, tingling, throbbing. You might simply call it arousal or being turned on. And that is where a lot of people, again, get really confused because they’re having these thoughts that they hate, they’re unwanted, they’re repetitive, they’re impacting their life, they’re associated with a lot of anxiety and uncertainty, and doubt. And then, now you’re having this reaction in your body too, and that groinal response can create a heightened need to engage in compulsions. 

As we know—we talk about this in ERP School, our online course for OCD; we go through this extensively—when someone has an obsession, a thought, an intrusive thought, it creates uncertainty and anxiety. And then naturally what we do is we engage in a compulsion to reduce or remove that discomfort to give them a short-term sense of relief. But then what ends up happening is that short-term relief ends up reinforcing the original obsession, which means you have it more, and then you go back through the cycle. You cycle on that cycle over and over again. It gets so big. It ends up impacting your life so, so much.

INTRUSIVE SEXUAL URGES

Now, let’s also address while we’re here that a lot of you may have intrusive sexual urges. These are also obsessions that we have when you have OCD or OCD-related disorders where you feel like your body is pulling you towards an action to harm someone, to do a sexual act, to some fantasy. You’re having this urge that feels like your body is pulling you like a magnet towards that behavior. Even if you don’t want to do that behavior, or even if that behavior disgusts you and it doesn’t line up with your values, you may still experience these sexual OCD urges that really make you feel like you’re on the cusp of losing control, that you may snap and do that behavior.

This is how impactful these sexual intrusive thoughts can be. This is how powerful they can be in that they can create these layers upon layers. You have the thoughts, then you have the feelings, then you have the sensations, you also have the urges. Often there’s a lot of sexual intrusive images as well, like you see in front of you, like a projector, the image happening or the movie scene playing out that really scares you, concerns you, and so forth. And then all of those layers together make you feel absolutely horrible, terrified, so afraid, so unsure of what’s happening in and of yourself. 

TYPES OF SEXUAL OCD OBSESSIONS

Let’s talk about some specific OCD obsessions and ways in which this plays out. Now, in the OCD field, we call them subtypes. Subtypes are different categories we have of obsessions. They don’t collect all of them. There are people who have a lot of obsessions that don’t fall under these categories, but these subtypes usually include groups of people who experience these subtypes. The reason we do that is, number one, it can be very validating to know that other people are in that subgroup. Number two, it can also really help inform treatment when we have a specific subtype that we know what’s happening, and that can be very helpful and reduce the shame of the person experiencing them. 

1. SEXUAL ORIENTATION OBSESSIONS OR SEXUAL ORIENTATION OCD

It used to be called homosexual OCD. That was because predominantly people who were heterosexual were reporting having thoughts or sexual intrusive thoughts about their sexual orientation—am I gay, am I straight—and really struggling with having certainty about this. Again, now that we’re more inclusive and that I think a lot more people are talking about sexuality, that we have a lot less shame, a lot more education, we scrapped the homosexual OCD or homosexual obsessions or subtype category. Now we have a more inclusive category, which is called sexual orientation OCD. That can include any body of any sexual orientation who has doubt and uncertainty about that. 

Now remember when we started, we talked about the fact that sexual intrusive thoughts are usually unwanted, they’re repetitive and they don’t line up with our values. What we are not talking about here is someone who is actually questioning their sexual orientation. I know a lot of people are. They’re really exploring and being curious about different orientations that appeal to them. That’s way different to the people who have sexual orientation OCD or sexual orientation obsessions. People with OCD are absolutely terrified of this unknown answer, and they feel an incredible sense of urgency to solve it. 

If you experience this, you may actually want to listen back. We’ve got a couple of episodes on this in the past. But it’s really important to understand and we have to understand the nuance here that as you’re doing treatment, we are very careful not to just sweep people under the rug and say, “This is your OCD,” because we want to be informed in knowing that, okay, you also do get to question your sexual orientation. But if it is a presentation of sexual orientation OCD, we will treat it like that and we will be very specific in reducing the compulsions that you’re engaging in so that you can get some relief. That is the first one. 

2. SEXUAL INTRUSIVE THOUGHTS ABOUT FAMILY OR SEXUAL INTRUSIVE THOUGHTS ABOUT INCEST

Incest sexual OCD or that type of subtype is another very common one. But often, again, one that is not talked about enough in fear of being judged, in fear of having too much shame, in fear of being reported. When people have these types of obsessions, they often will have a thought like, “What if I’m attracted to my dad?” Or maybe they’re with their sibling and they experience some arousal for reasons they don’t know. Again, we talked about this in the arousal and anxiety episode, so go back and listen to that if you didn’t. They may experience that, and that is where they will often say, “My brain broke. I feel like I had to solve that answer. I had to figure it out. I need to get complete certainty that that is not the case, and I need to know for sure.” 

The important thing to remember here is a lot of my patients, I will see and they may have some of these sexual intrusive thoughts, but their partners will say, “Yeah, I’ve had the same thoughts.” It’s just that for the person without OCD, they don’t experience that same degree of distress. They blow it off. It doesn’t really land in their brain. It’s just like a fleeting thought. Whereas people with OCD, it’s like the record got stuck and it’s just repeating, repeating, repeating. The distress gets higher. The doubt and uncertainty get higher. Therefore, because of all of this bubbling kettle happening, there’s this really strong urgency to relieve it with compulsions. 

3. SEXUAL INTRUSIVE THOUGHTS ABOUT GOD OR ABOUT A RELIGIOUS LEADER

This is one that’s less common, or should I say less commonly reported. We actually don’t have evidence of how common it is. I think a lot of people have so much shame and are so afraid of sinning and what that means that they may even not report it. But again, this is no different to having thoughts of incest, but this one is particularly focused on having sexual thoughts about God and needing to know what that means and trying to cleanse themselves of their perceived sin, of having that intrusive thought. It can make them question their religion. It can make them feel like they have to stop going to church. They may do a ton of compulsive prayer. They may do a ton of reassurance with certain religious leaders to make sure that they’re not sinning or to relieve them of that uncertainty and that distaste and distress. These are all very common symptoms of people who have sexual intrusive thoughts about God.

4. BESTIALITY OBSESSIONS

These are thoughts about pets and animals, and it’s very common. It’s funny, as we speak, I am recording this with a three-pound puppy sitting on my lap. We just got a three-pound puppy. It is a Malti-Poo puppy dog, and he’s the cutest thing you’ve ever seen. But it’s true that when you have a dog, you’re having to take care of its genitals and wipe it up and its feces and its urine and clean and all the things, and it’s common to have sexual intrusive thoughts about your pet or about your dog or your cat. Some people, again, with bestiality obsessions or bestiality OCD, have a tremendous repetitive degree of these thoughts. They’re very distressing because they love their dog. They would never do anything to hurt their dog, but they can’t stop having these thoughts or these feelings or these sensations, or even these urges.

Again, all these presentations are the same, it’s just that the content is different. We treat them the same when we’re discussing it, but we’re very careful with addressing the high level of shame and embarrassment, humiliation, guilt that they have for these thoughts. Guilt is a huge one with these sexual obsessions. People often feel incredibly guilty as if they’ve done something wrong for having these obsessions. These are a few. 

5. PEDOPHILIA OBSESSIONS

Now, for someone who has intrusive sexual thoughts and feelings and sensations and urges about children (POCD), they tend to be, in my experience, the most distressed. They tend to be, when I see them, the ones who come in absolutely completely taken over with guilt and shame. A lot of the time, they will have completely removed themselves from their child. They feel they’re not responsible. They won’t go near the parks. They won’t go to family’s birthday parties. They’re so insistent on trying to never have these thoughts. Again, I understand. I don’t blame them. But as we know, the more you try not to have a thought, what happens? The more you have it. The more you try and suppress a thought, the more you have it. That can get people in a very stuck cycle. 

SEXUAL OCD  COMPULSIONS

Let’s move on now to really address different sexual OCD compulsions. 

Now, for all sexual obsessions, or what I should say is, for all obsessions in general, there are specific categories of compulsions and these are things again that we do to reduce or remove the discomfort and certainty, dread, doubt, and so forth. 

1. Trigger Avoidance

This is where you avoid the thing that may trigger your obsession or thought. Avoiding your dog, avoiding your child, avoiding your family member, avoiding people of the sexual orientation that you’re having uncertainty about. 

2. Actual Sex Avoidance

We talked about that in the first episode. We talked a lot about how people avoid sex because of the anxiety that being intimate and sexual causes. 

3. Mental Rumination

This is a really common one for sexual intrusive thoughts because you just want to solve like why am I having it? What does it mean? You might be ruminating, what could that mean? And going over and over and over that a many, many time. 

4. Mental Checking

What you can also be doing here is checking for arousal. Next time you’re around, let’s say, a dog and you have bestiality obsessions, you might check to see if you’re aroused. But just checking to see if you’re aroused means that you get aroused. Now that you’re aroused, you’re now checking to see what that means and trying to figure that out and you’re very distressed. 

We can see how often the compulsion that the person does actually triggers more and more and more distress. It may provide you a moment or a fleeting moment of relief, but then you actually have more distress. It usually brings on more uncertainty. We know that the more we try and control life, the more out of control we feel. That’s a general rule. That’s very much the case for these types of obsessive thoughts. 

5. Pornography Use

A lot of people who have sexual orientation OCD in particular, but any of these, they may actually use pornography as a way to get reassurance that they are of a certain sexual orientation, that they are not attracted to the orientation that they’re having uncertainty about, or they’re not attracted to animals or God or a family member because they were aroused watching pornography. That becomes a form of self-reassurance. 

There’s two types of reassurance. One is reassurance where we go to somebody else and say, “Are you sure I wouldn’t do that thing? Are you sure that thing isn’t true? Are you sure I don’t have that? I’m not that bad a person?” The other one is really giving reassurance to yourself, and that’s a very common one with pornography use. 

SEXUAL INTRUSIVE THOUGHTS PTSD 

There are some sexual intrusive thought examples, including specific obsessions and subtypes, and also compulsions. But one sexual intrusive thought example I also wanted to address is not OCD-related; it’s actually related to a different diagnosis, which is called PTSD (post-traumatic stress disorder). Often for people who have been sexually assaulted or molested, they too may experience sexual intrusive thoughts in the form of memories or images of what happened to them or what could have happened to them. Maybe it’s often some version of what happened to them, and that is a common presentation for PTSD. If you are experiencing PTSD, usually, there is a traumatic event that is related to the obsession or the thoughts. They usually are in association or accompanied by flashbacks. There are many other symptoms. I’m not a PTSD specialist, but there’s a high level of distress, many nightmares. You may have flashbacks, as I’ve said. Panic is a huge part of PTSD as well. That is common. If you have had a traumatic event, I would go and see a specialist and help them to make sure that they’ve diagnosed you correctly so that you can get the correct care. 

SEXUAL INTRUSIVE THOUGHTS TREATMENT

If you have OCD and you’re having some of these sexual intrusive thoughts, the best treatment for you to go and get immediately is Exposure and Response Prevention. This is a particular type of cognitive behavioral therapy where you can learn to change your reaction, break yourself out of that cycle of obsessions, anxiety, compulsions, and then feed yourself back into the loop around and around. You can break that cycle and return back to doing the things you want and have a different reaction to the thoughts that you have.

PEOPLE ASK HOW TO STOP SEXUAL INTRUSIVE THOUGHTS? 

Often people will come to me and say, “How do I stop these sexual intrusive thoughts?” I will quickly say to them, “You don’t. The more you try and stop them, the more you’re going to have. But what we can do is we can act very skillfully in intervening, not by preventing the thoughts, but by changing how we relate and respond to those thoughts.” For those of you who don’t know, I have a whole course on this called ERP School. ERP is for Exposure and Response Prevention. I’ll show you how you can do this on your own, or you can reach out to me and we can talk about whether if you’re in the states where we’re licensed, one of my associates can help you one-on-one. If you’re not in a state where I belong, reach out to the IOCDF and see if you can find someone who treats OCD using ERP in your area. Because the truth is, you don’t have to suffer having these thoughts. There is a treatment to help you manage these thoughts and help you be much more comfortable in response to those thoughts. Of course, the truth here is you’re never going to like them. Nobody likes these thoughts. The goal isn’t to like them. The goal isn’t to make them go away. The goal isn’t to prove them wrong even; it’s just to change your reaction to one that doesn’t keep that cycle going. That is the key component when it comes to sexual intrusive thoughts treatment or OCD treatment. That’s true for any subtype of OCD because there are many other subtypes as well. 

That’s it, guys. I could go on and on and on and on about this, but I want to be respectful of your time. The main goal again is just to normalize that these thoughts happen. For some people, it happens more than others. The goal, if you can take one thing away from today, it would be, try not to assign meaning to the duration and frequency of which you have these thoughts. Often people will say, “I have them all day. That has to mean something.” I’m here to say, “Let’s not assign meaning to these thoughts at all. Thoughts are thoughts. They come and they go. They don’t have meaning and we want to practice not assigning meaning to them so we don’t strengthen that cycle.” 

I hope that was helpful for you guys. I know it was a ton of information. I hope it was super, super helpful. I am so excited to continue with this. 

Next week, we are talking about menopause and anxiety, which we have an amazing doctor again. I want to talk about things with people who are really skilled in this area. We have a medical doctor coming on talking about menopause and the impact of anxiety. And then we’re going to talk about PMS and anxiety, and that will hopefully conclude our sexual health and anxiety series. 

Thank you so much for being here. I love you guys so much. Thank you from me and from Theo, our beautiful little baby puppy. I will see you next week.

Hello and welcome back everybody. We are on Week 3 of the Sexual Health and Anxiety Series. At first, we talked with the amazing Lauren Fogel Mersy about sexual anxiety or sexual performance anxiety. And then last week, I went into depth about really understanding arousal and anxiety, how certain things will increase arousal, certain things will decrease it, and teaching you how to get to know what is what so that you can have a rich, intimate, fulfilling life. 

We are now on Week 3. I have to admit, this is an episode that I so have wanted to do for quite a while, mainly because I get asked these questions so often and I actually don’t know the answers. It’s actually out of my scope. In clinical terms, we call it “out of my scope of practice,” meaning the topic we’re talking about today is out of my skill set. It’s out of my pay grade. It’s out of my level of training. 

What we’re talking about this week is the sexual side effects of antidepressants or anxiety medications, the common ones that people have when they are anxious or depressed. Now, as I said to you, this is a medical topic, one in which I am not trained to talk about, so I invited Dr. Sepehr Aziz onto the episode, and he does such a beautiful job, a respectful, kind, compassionate approach to addressing sexual side effects of anxiety medication, sexual side effects of depression medication. It’s just beautiful. It’s just so beautiful. I feel like I want to almost hand this episode off to every patient when I first start treating them, because I think so often when we’re either on medication or we’re considering medication, this is a really common concern, one in which people often aren’t game to discuss. So, here we are. I’m actually going to leave it right to the doctor, leave it to the pro to talk all about sexual side effects and what you can do, and how you may discuss this with your medical provider. Let’s do it.

Kimberley: Welcome. I have been wanting to do this interview for so long. I am so excited to have with us Dr. Sepehr Aziz. Thank you so much for being here with us today.

Dr. Aziz: Thanks for having me.

Kimberley: Okay. I have so many questions we’re going to get through as much as we can. Before we get started, just tell us a little about you and your background, and tell us what you want to tell us.

Dr. Aziz: Sure. Again, I’m Dr. Sepehr Aziz. I go by “Shepherd,” so you can go ahead and call me Shep if you’d like. I’m a psychiatrist. I’m board certified in general adult psychiatry as well as child and adolescent psychiatry by the American Board of Psychiatry and Neurology. I completed medical school and did my residency in UMass where they originally developed mindfulness-based CBT and MBSR. And then I completed my Child and Adolescent training at UCSF. I’ve been working since then at USC as a Clinical Assistant Professor of Psychiatry there. I see a lot of OCD patients. I do specialize in anxiety disorders and ADHD as well.

Kimberley: Which is why you’re the perfect person for this job today.

Dr. Aziz: Thank you. 

WHAT ARE THE BEST MEDICATIONS FOR PEOPLE WITH ANXIETY & OCD (IN GENERAL)?

Kimberley: I thank you so much for being here. I want to get straight into the big questions that I get asked so regularly and I don’t feel qualified to answer myself. What are the best medications for people with anxiety and OCD? Is there a general go-to? Can you give me some explanation on that?

Dr. Aziz: As part of my practice, I first and foremost always try to let patients know that the best treatment is always a combination of therapy as well as medications. It’s really important to pursue therapy because medications can treat things and they can make it easier to tolerate your anxiety, but ultimately, in order to have sustained change, you really want to have therapy as well. Now, the first-line medications for anxiety and OCD are the same, and that’s SSRIs or selective serotonin reuptake inhibitors. SNRIs, which are selective norepinephrine reuptake inhibitors, also work generally, but the best research that we have in the literature is on SSRIs, and that’s why they’re usually preferred first. There are other medications that also might work, but these are usually first-line, as we call it. There are no specific SSRIs that might work better. We’ve tried some head-to-head trials sometimes, but there’s no one medication that works better than others. It’s just tailored depending on the patient and the different side effects of the medication.

SSRI’S VS ANTIDEPRESSANTS DEFINITION

Kimberley: Right. Just so people are clear in SSRI, a lot of people, and I notice, use the term antidepressant. Are they synonymous or are they different?

Dr. Aziz: Originally, they were called antidepressants when they first were released because that was the indication. There was an epidemic of depression and we were really badly looking for medications that would work. Started out with tricyclic antidepressants and then we had MAOIs, and then eventually, we developed SSRIs. These all fall under antidepressant treatments. However, later on, we realized that they work very well for anxiety in addition to depression. Actually, in my opinion, they work better for anxiety than they do for depression. I generally shy away from referring to them as antidepressants just to reduce the stigma around them a little bit and also to be more accurate in the way that I talk about them. But yes, they’re synonymous, you could say. 

BEST MEDICATION FOR DEPRESSION

Kimberley: Sure. Thank you for clearing that up because that’s a question I often get. I know I led you in a direction away but you answered. What is the best medication for people with depression then? Is it those SSRIs or would you go--

Dr. Aziz: Again, these are first-line medications, which means it’s the first medication we would try if we’re starting medication, which is SSRIs. Other medications might also work like SNRIs again. For depression specifically, there are medications called serotonin modulators that are also effective such as vortioxetine or nefazodone, or vilazodone. But SSRIs are generally what people reach for first just because they’ve been around for a long time, they’re available generic, they work, and there’s no evidence that the newer medications or modulators work better. They’re usually first line.

Kimberley: Fantastic. Now you brought up the term “generic” and I think that that’s an important topic because the cost of therapy is high. A lot of people may be wondering, is the generic as good as the non-generic options?

Dr. Aziz: It really depends on the medication and it also depends on which country you’re in. In the US, we have pretty strict laws as to how closely a generic has to be to a regular medication, a brand name medication, and there’s a margin of error that they allow. The margin of error for generics is, I believe, a little bit higher than for the brand name. However, most of the time, it’s pretty close. For something like Lexapro, I usually don’t have any pressure on myself to prescribe the brand name over the generic. For something like other medications we use in psychiatry that might have a specific way that the brand name is released, a non-anxiety example is Concerta, which is for ADHD.

This medication uses an osmotic release mechanism and that’s proprietary. They license it out to one generic company, but that license is expiring. All those patients who are on that generic in the next month or two are going to notice a difference in the way that the medication is released. Unless you’re a physician privy to that information, you might not even know that that’s going to happen. That’s where you see a big change. Otherwise, for most of the antidepressants, I haven’t noticed a big difference between generic and brand names.  

Kimberley: Right. Super helpful. Now you mentioned it depends on the person. How might one decide or who does decide what medication they would go on?

Dr. Aziz: It’s really something that needs to be discussed between the person and their psychiatrist. There are a number of variables that go into that, such as what’s worked in a family member in the past, because there are genetic factors in hepatic metabolism and things like that that give us some clue as to what might work. Or sometimes if I have a patient with co-occurring ADHD and I know they’re going to be missing their medications a lot, I’m more likely to prescribe them Prozac because it has a longer half-life, so it’ll last longer. If they miss a dose or two, it’s not as big of a deal. If I have a patient who’s very nervous about getting off of the medication when they get pregnant, I would avoid Prozac because it has a long half-life and it would take longer to come off of the medication. Some medications like Prozac and Zoloft are more likely to cause insomnia or agitation in younger people, so I’ll take that into consideration. Some medications have a higher likelihood of causing weight loss versus weight gain. These are all things that would take into consideration in order to tailor it to the specific patient.

Kimberley: Right. I think that’s been my experience too. They will usually ask, do you have a sibling or a parent that tried a certain medication, and was that helpful? I love that question. I think it informs a lot of decisions. We’re here really. The main goal of today is really to talk about one particular set of side effects, which is the sexual side effects of medication. In fact, I think most commonly with clients of mine, that tends to be the first thing they’re afraid of having to happen. How common are sexual side effects? Is it in fact all hype or is it something that is actually a concern? How would you explain the prevalence of the side effects?

Dr. Aziz: This is a really important topic, I just want to say, because it is something that I feel is neglected when patients are talking to physicians, and that’s just because it can be uncomfortable to talk about these things sometimes, both for physicians and for patients. Oftentimes, it’s avoided almost. But because of that, we don’t know for sure exactly what the incidence rate is. The literature on this and the research on this is not very accurate for a number of reasons. There are limitations. The range is somewhere between 15 to 80% and the best estimate is about 50%. But I don’t even like saying that because it really depends on age, gender, what other co-occurring disorders they have such as depression. Unipolar depression can also cause sexual dysfunction. They don’t always take that into account in these studies. A lot of the studies don’t ask baseline sexual function before asking if there’s dysfunction after starting a medication, so it’s hard to tell. What I can say for sure, and this is what I tell my patients, is that this sexual dysfunction is the number one reason why people stop taking the medication, because of adverse effects. 

WHAT MEDICATIONS ARE MORE PRONE TO SEXUAL SIDE EFFECTS? 

Kimberley: Right. It’s interesting you say that we actually don’t know, and it is true. I’ve had clients say having anxiety has sexual side effects too, having depression has sexual side effects too, and they’re weighing the pros and cons of going on medication comparative to when you’re depressed, you may not have any sexual drive as well. Are some medications more prone to these sexual side effects? Does that help inform your decision on what you prescribe because of certain meds?

Dr. Aziz: Yeah. I mean, the SSRIs specifically are the ones that are most likely to cause sexual side effects. Technically, it’s the tricyclics, but no one really prescribes those in high doses anymore. It’s very rare. They’re the number one. But in terms of the more commonly prescribed antidepressants and anti-anxiety medications among the SSRIs and the SNRIs and the things like bupropion and the serotonin modulators we talked about, the SSRIs are most likely to cause sexual dysfunction.

Kimberley: Right. Forgive me for my lack of knowledge here, I just want to make sure I’m understanding this. What about the medications like Xanax and the more panic-related medications? Is that underneath this category? Can you just explain that to me?

Dr. Aziz: I don’t usually include those in this category. Those medications work for anxiety technically, but in current standard practice, we don’t start them as an initial medication for anxiety disorders because there’s a physical dependency that can occur and then it becomes hard to come off of the medication. They’re used more for panic as an episodic abortive medication when someone is in the middle of a panic attack, or in certain cases of anxiety that’s not responding well to more conventional treatment, we’ll start it. We’ll start it on top of or instead of those medications. They can cause sexual side effects, but it’s not the same and it’s much less likely. 

SEXUAL SIDE EFFECTS OF MEDICATION FOR MEN VS WOMEN 

Kimberley: Okay. Very helpful. Is it the same? I know you said we don’t have a lot of data, and I think that’s true because of the stigma around reporting sexual side effects, or even just talking about sex in general. Do we have any data on whether it impacts men more than women?

Dr. Aziz: The data shows that women report more sexual side effects, but we believe that’s because women are more likely to be treated with SSRIs. When we’re looking at the per capita, we don’t have good numbers in terms of that. In my own practice, I’d say it’s pretty equal. I feel like men might complain about it more, but again, I’m a man and so it might just be a comfort thing of reporting it to me versus not reporting. Although I try to be good about asking before and after I start medication, which is very important to do. But again, it doesn’t happen all the time.

Kimberley: Yeah, it’s interesting, isn’t it? Because from my experience as a clinician, not a psychiatrist, and this is very anecdotal, I’ve heard men because of not the stigma, but the pressure to have a full erection and to be very hard, that there’s a certain masculinity that’s very much vulnerable when they have sexual side effects—I’ve heard that to be very distressing. In my experience. I’ve had women be really disappointed in the sexual side effects, but I didn’t feel that... I mean, that’s not really entirely true because I think there’s shame on both ends. Do you notice that the expectations on gender impacts how much people report or the distress that they have about the sexual side effects? 

Dr. Aziz: Definitely. I think, like you said, men feel more shame when it comes to sexual side effects. For women, it’s more annoyance. We haven’t really talked about what the sexual side effects are, but that also differs between the sexes. Something that’s the same between sexes, it takes longer to achieve orgasm or climax. In some cases, you can’t. For men, it can cause erectile dysfunction or low libido. For women, it can also cause low libido or lack of lubrication, which can also lead to pain on penetration or pain when you’re having sex. These are differences between the sexes that can cause different reporting and different feelings, really.

Kimberley: Right. That’s interesting that it’s showing up in that. It really sounds like it impacts all the areas of sexual playfulness and sexual activity, the arousal, the lubrication. That’s true for men too, by the sounds of it. Is that correct? 

Dr. Aziz: Yeah. 

Kimberley: We’ve already done one episode about the sexual performance anxiety, and I’m sure it probably adds to performance anxiety when that’s not going well as well, correct?

Dr. Aziz: It’s interesting because in my practice, when I identify that someone is having sexual performance anxiety or I feel like somebody, especially people with anxiety disorders, if I feel like they have vulvodynia, which means pain on penetration—if I see they have vulvodynia and I feel that this is because of the anxiety, oftentimes the SSRI might improve that and cause greater satisfaction from sex. It’s a double-edged sword here.

COMMON SEXUAL SIDE EFFECTS OF ANTIDEPRESSANTS

Kimberley: Yeah. Can you tell me a little more about What symptoms are they having? The pain? What was it called again?

Dr. Aziz: Vulvodynia.

Kimberley: Is that for men and women? Just for women, I’m assuming.

Dr. Aziz: Just from vulva, it is referring to the outside of the female genitalia. Especially when you have a lack of lubrication or sometimes the muscles, everyone with anxiety knows sometimes you have muscle tension and there are a lot of complex muscles in the pelvic floor. Sometimes this can cause pain when you’re having sex. There are different ways to address that, but SSRIs sometimes can improve that. 

Kimberley: Wow. It can improve it, and sometimes it can create a side effect as well, and it’s just a matter of trial and error, would you say?

Dr. Aziz: It’s a delicate balance because these side effects are also dose-dependent. It’s not like black or white. I start someone on 5 milligrams, which is a child’s dose of Lexapro. Either they have sexual side effects or don’t. They might not have it on 5, and then they might have it a little bit on 10, and then they get to 20 and they’re like, “Doctor, I can’t have orgasms anymore.” We try to find the balance between improving the anxiety and avoiding side effects.

SEXUAL SIDE EFFECTS TREATMENT

Kimberley: You’re going right into the big question, which is, when someone does have side effects, is it the first line of response to look at the dose? Or how would you handle a case if someone came to you first and said, “I’m having sexual side effects, what can we do?” 

Dr. Aziz: Again, I’m really thorough personally. Before I even seem to start a medication, I’ll ask about libido and erectile dysfunction and ability to climax and things like that, so I have a baseline. That’s important when you are thinking about making a change to someone’s medications. The other thing that’s important is, is the medication working for them? If they haven’t seen a big difference since they started the medication, I might change the medication. If they’ve seen an improvement, now there’s a pressure on me to keep the medication on because it’s working and helping. I might augment it with a second medication that’ll help reverse the sexual side effects or I might think about reducing the dose a little bit while maintaining somewhere in the therapeutic zone of doses or I might recommend, and I always recommend non-pharmacological ways of addressing sexual side effects. You always do that at baseline.

Kimberley: What would that be?

Dr. Aziz: There’s watchful waiting. Sometimes if you just wait and give it some time, these symptoms can get better. I’m a little more active than that. I’ll say it’s not just waiting, but it’s waiting and practicing, whether that’s solo practice or with your partner. Sometimes planning sex helps, especially if you have low libido. There’s something about the anticipation that can make someone more excited. The use of different aids for sex such as toys, vibrators, or pornography, whether that’s pornographic novels or imagery, can sometimes help with the libido issues and also improve satisfaction for both partners. The other thing which doesn’t have great research, but there is a small research study on this, and not a lot of people know about this, but if you exercise about an hour before sex, you’re more likely to achieve climax. This was specifically studied in people with SSRI-related anorgasmia.

Kimberley: Interesting. I’m assuming too, like lubricants, oils, and things like that as well, or?

Dr. Aziz: For lubrication issues, yes. Lubricants, oils, and again, you really have to give people psychoeducation on which ones they have to use, which ones they have to avoid, which ones interact with condoms, and which ones don’t. But you would recommend those as well.

Kimberley: Is it a normal practice to also refer for sex therapy? If the medication is helping their symptoms, depression, anxiety, OCD, would you ever refer to sex therapy to help with that? Is that a standard practice or is that for specific diagnoses, like you said, with the pain around the vulva and so forth?

Dr. Aziz: Absolutely. A lot of the things I just talked about are part of sex therapy and they’re part of the sexual education that you would receive when you go to a sex therapist. I happen to be comfortable talking about these things, and I’ve experienced talking about it. When I write my notes, that would fall under me doing therapy. But a lot of psychiatrists would refer to a sex therapist. Hopefully, there are some in the town nearby where someone is. It’s sometimes hard to find someone that specializes in that.

Kimberley: Is there some pushback with that? I mean, I know when I’ve had patients and they’re having some sexual dysfunction and they do have some pushback that they feel a lot of shame around using vibrators or toys. Do you notice a more willingness to try that because they want to stay on the meds? Or is it still very difficult for them to consider trying these additional things? Are they more likely to just say, “No, the meds are the problem, I want to go off the medication”?

Dr. Aziz: It really depends on the patient. In my population that I see, I work at USC on campus, so I only see university students in my USC practice. My age group is like 18 to 40. Generally, people are pretty receptive. Obviously, it’s very delicate to speak to some people who have undergone sexual trauma in the past. Again, since I’m a man, sometimes speaking to a woman who’s had sexual trauma can be triggering. It’s a very delicate way that you have to speak and sometimes there’s some pushback or resistance. It can really be bad for the patient because they’re having a problem and they’re uncomfortable talking about it. There might be a shortage of female psychiatrists for me to refer to. We see that. There’s also a portion of the population that’s just generally uncomfortable with this, especially people who are more religious might be uncomfortable talking about this and you have to approach that from a certain angle. I happen to also be specialized in cultural psychiatry, so I deal with these things a lot, approaching things from a very specific cultural approach, culturally informative approach. Definitely, you see resistance in many populations.

Kimberley: I think that that’s so true. One thing I want to ask you, which I probably should have asked you before, is what would you say to the person who wants to try meds but is afraid of the potential of side effects? Is there a certain spiel or way in which you educate them to help them understand the risks or the benefits? How do you go about that for those who there’s no sexual side effects, they’re just afraid of the possibility?

Dr. Aziz: As part of my practice, I give as much informed consent to my patients as I can. I let them know what might happen and how that’s going to look afterwards. Once it happens, what would we do about it if it happened? A lot of times, especially patients with anxiety, you catastrophize and you feel this fear of some potential bad thing happening, and you never go past that. You never ask yourself, okay, well now let’s imagine that happens. What happens next? I tell my patients, “Yeah, you might have sexual dysfunction, but if that happens, we can reduce the medications or stop them and they’ll go away.” I also have to tell my patients that if they search the internet, there are many people who have sexual side effects, which didn’t go away, and who are very upset about it. This is something that is talked about on Reddit, on Twitter. When my patients go to Dr. Google and do their research, they often get really scared. “Doctor, what if this happens and it doesn’t go away?” I always try to explain to them, I have hundreds of patients that I’ve treated with these medications. In my practice, that’s never happened. As far as I know from the literature, there are no studies that show that there are permanent dysfunctions sexually because of SSRIs. 

Now, like I said, the research is not complete, but everything that I’ve read has been anecdotal. My feeling is that if you address these things in the beginning and you’re diligent in asking about the side effects of baseline sexual function beforehand and you are comfortable talking with your patients about it, you can avoid this completely. That’s been my experience. When I explain that to my patients, they feel like I have their back, like they’re protected, like I’m not just going to let them fall through the cracks. That has worked for me very well.

Kimberley: Right. It sounds like you give them some hope too, that this can be a positive experience, that this could be a great next step.

Dr. Aziz: Yeah, absolutely.

Kimberley: Thank you for bringing up Dr. Google, because referring to Reddit for anything psychologically related is not a great idea, I will say. Definitely, when it comes to medications, I think another thing that I see a lot that’s interesting on social media is I often will get dozens of questions saying, “I heard such and such works. Have your clients taken this medication? I heard this medication doesn’t work. What’s your experience?” Or if I’ve told them about my own personal experience, they want to know all about it because that will help inform their decision. Would you agree, do not get your information from social media or online at all?

Dr. Aziz: I have patients who come to me and they’re like, “My friend took Lexapro and said it was the worst thing in the world, and it may or not feel any emotions.” I’m explaining to them, I literally have hundreds of patients, hundreds that I prescribe this to, and I go up and down on the dose. I talk to them about their intimate lives all day. But for some reason, and it makes sense, the word of their friend or someone close to them, really, carries a lot of weight. Also, I don’t want to discount Reddit either, because I feel like it’s as a support system and as a support group. I find other people who have gone through what you’ve gone through. It’s very strong. Even pages like-- I don’t want to say the page, but there’s a page that’s against psychiatry, and I peruse this page a lot because I have my own qualms about psychiatry sometimes. I know the pharmaceutical companies have a certain pressure on themselves financially, and I know hospitals have a certain pressure on themselves. I get it. I go on the page and there’s a lot of people who have been hurt in the past, and it’s useful for patients to see other people who share that feeling and to get support. But at the same time, it’s important to find providers that you can trust and to have strong critical thinking skills, and be able to advocate for yourself while still listening to somebody who might have more information than you.

Kimberley: I’m so grateful you mentioned that. I do think that that is true. I think it’s also what I try to remember when I am online. The people who haven’t had a bad experience aren’t posting on Reddit. They’re out having a great time because it helped, the medication helped them, and they just want to move on. I really respect those who have a bad experience. They feel the need to educate. But I don’t think it’s that 50% who gave a great experience are on Reddit either. Would you agree?

Dr. Aziz: Right. Yeah. The people who are having great outcomes are not creating a Reddit page to go talk about it, right?

Kimberley: Yeah. Thank you so much for answering all my questions. Is there a general message that you want to give? Maybe it’s even saying it once over on something you’ve said before. What would be your final message for people who are listening?

WHEN SSRIs IMPACTS YOUR SEX LIFE: ADVICE FROM DR AZIZ

Dr. Aziz: I just want to say that when SSRI’s impact your sex life, it’s really important for psychiatry, and especially in therapy, that you feel comfortable sharing your experiences in that room. It should be a safe space where you feel comfortable talking about your feelings at home and what’s going on in your intimate life and how things are affecting you. Your feelings, positive or negative towards your therapist or your psychiatrist, whether things they said made you uncomfortable, whether you feel they’re avoiding something, that room should be a safe space for you to be as open as possible. When you are as open as possible, that’s when you’re going to get the best care because your provider, especially in mental health, needs to know the whole picture of what’s going on in your life. Oftentimes, we are just as uncomfortable as you. And so, again, a lot of providers might avoid it because they’re afraid of offending you by asking about your orgasms. As a patient, you take the initiative and you bring it up. It’s going to improve your care. Try not to be afraid of bringing these things up. If you do feel uncomfortable for any reason, always let your provider know. 

I always tell my patients, I have a therapist. I pay a lot of money to see my therapist, and sometimes I tell him things I hate about him. He’s a great therapist. He’s psychoanalytic. Every time I bring something up, he brings it back to something about my dad. He’s way older than me. But he’s a great therapist. Every time I’ve brought something like that up, it’s been a breakthrough for me because that feeling means something. That would be my main message to everyone listening.

Kimberley: Thank you. I’m so grateful for your time and your expertise. Really, thank you. Can you tell us where people can get in touch with you, seek out your services, read more about you?

Dr. Aziz: Sure. I work for OCD SoCal. I’m on the executive board, and that’s the main way I like to communicate with people who see me on programs like this. You can always email me at S, like my first name, Aziz, that’s A-Z-I-Z, @OCDSoCal.org. If you’re a USC student, you can call Student Health and request to see me at the PBHS clinic. That’s the Psychiatry and Behavioral Health Services clinic on campus at USC.

Kimberley: They’re lucky to have you.

Dr. Aziz: Thank you.

Kimberley: Yes. I love that you’re there. Thank you so much for all of your expertise. I am so grateful. This has been so helpful.

Welcome back, everybody. We are on Episode 2 of the Sexual Health and Anxiety Series. Today, I will be the main host and main speaker for the episode, talking about arousal and anxiety. This is a topic that goes widely misunderstood, particularly in the OCD and anxiety field where people are having arousal that they can’t make sense of. It’s also very true of people with PTSD. They’re having arousal that makes no sense to them, that confuses them, that increases anxiety, increases shame, increases guilt, and from there, it all becomes like a huge mess to them. It becomes incredibly painful, and it’s just so messy they can’t make sense of it. 

My hope with this episode is to help you understand the science behind arousal and the science behind arousal and anxiety so that you can move forward and manage your anxiety around arousal and manage your shame and guilt and sadness and grief around arousal, and have a better relationship with your body and with yourself and your soul.

Now, these are more difficult conversations. I have talked about them in the past, and so I want you just to go into this really, really gentle, really open with con compassion and kindness, and curiosity. Your curiosity is going to help you immensely as you move through this series, as you move through some of the difficult conversations we’re going to have, maybe a little bit embarrassing, humiliating, and so forth. Even me telling my kids that I’m so excited, I’m doing a series on sexual health, they’re like, “Mom, you can’t talk about that to other people.” I’m like, “Yes, I can. We’re going to talk about it. Hopefully, when you’re old enough, you’ll be able to listen to this and you’ll be so glad that we’re having conversations around this and taking the shame and stigma, and misinformation out of it.”

I’m going to go straight into the episode. This is our episode on understanding arousal and anxiety. We are going to come on next week talking about an entirely different subject about sexual health and intimacy, sex and anxiety, and arousal and anxiety. I am so excited. Stick around. Enjoy every bit of it. Take as many notes as you can, but please, please be kind to yourself. Let’s get to the show.

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ANXIETY AND AROUSAL

Let’s get into the episode. Let me preface the episode by, we’re talking about anxiety and arousal. If I could have one person on the podcast, it would be Emily Nagoski. I have been trying to get her on the podcast for a while. We will get her on eventually. However, she’s off doing amazing things—Netflix specials, podcasts, vet documentaries. She’s doing amazing things. Hopefully one day. But until then, I want to really highlight her as the genius behind a lot of these concepts. 

Emily Nagoski is a doctor, a psychology doctor. She is a sex educator. She’s written two amazing books. Well, actually three or four, but the ones I’m referring to today is Come As You Are. It’s an amazing book, but I’m actually in my hand holding The Come As You Are Workbook. I strongly encourage you after you listen to this podcast episode to go and order that book. It is amazing. It’s got tons of activities. It might feel weird to have the book. You can get it on Kindle if you want to have it be hidden, but it’s so filled with amazing information and I’m going to try and give you the pieces that I really want you to take away. If you want more, by all means, go and get the workbook. The workbook is called The Come As You Are Workbook: A Practical Guide to The Science of Sex. The reason I love it is because it’s so helpful for those who have anxiety. It’s like she’s speaking directly to us. She’s like, “It’s so helpful to have this context.”

Here’s the thing I want you to consider starting off. A lot of people who have anxiety report struggles with arousal. We’re going to talk about two different struggles that are the highlight of today. Either you have no arousal because of your anxiety, or you’re having arousal at particular times that concern you and confuse you, and alarm you. You could be one or both of those camps. Let’s first talk about those who are struggling with arousal in terms of getting aroused. 

The thing I want you to think about is, commonly, this is true for any mental health issue too. It’s true for depression, anxiety disorders, eating disorders, dissociative disorders—all of them really. But the thing I want you to remember, no matter who you are and what your experience is, even if you have a really healthy experience of your own sexual arousal and you’re feeling fine about it, we all have what’s called inhibitors and exciters. Here is an example: An inhibitor is something that inhibits your arousal. An exciter is something that excites your arousal. 

Now, you’re probably already feeling a ton of judgment here like, “I shouldn’t be aroused by this, and I should be aroused by this. What if I’m aroused by this and I shouldn’t be,” and so forth. I want us to take all the judgment out of this and just look at the content of what inhibits our arousal or excites our arousal. Because sometimes, and I’ll talk about this more, it’s for reasons that don’t make a lot of sense, and that’s okay.

SEXUAL INHIBITORS AND SEXUAL EXCITERS

Let’s talk about a sexual inhibitor—something that pumps the brakes on arousal or pleasure. It could be either. There’s exciters, which are the things that are really like the gas pedal. They just really bring on arousal, bring on pleasure, and so forth. 

We have the content. The content may be, first, mental or physical, and this includes your health, your physical health. For me, I know when I am struggling with POTS, arousal is just barely a thing. You’re just so wiped out and you’re so exhausted and your brain is foggy, and it’s just like nothing. That would be, in my case, an inhibitor. I’m not going to talk about myself a lot here, but I was just using that as an example. You might say your anxiety or your obsession is an inhibitor. It pumps the brakes on arousal. It makes it go away. Worry is one. It could also be other physical health like headaches or tummy aches or, as we said before, depression. It could be hormone imbalances, things like that. It’s all as important. Go and speak with your doctor. That’s super important. Make sure medically everything checks out if you’re noticing a dip or change in arousal, that’s concerning you. 

The next one in terms of content that may either excite you or inhibit you is your relationship. If your relationship is going well, you may or may not have an increase in arousal depending on what turns you on. If your partner smells of a certain smell or stench that you don’t like, that may pump the brakes. But if they smell a certain way that you do really like, and really is arousing to you, that may excite your arousal. It could also be the vibe of the relationship. A lot of people said, at the beginning of COVID, there was a lot of fear. That was really, really strong on the brakes. But then all of a sudden, no one had anything to do, and there was all this spare time. All of a sudden, the vibe is like, that’s what’s happening. Now, this could be true for people who are in any partnership, or it could be just you on your own too. There are things that will excite you and inhibit your arousal if you’re not in a relationship as well, and that’s totally fine. This is for all relationships. There’s no specific kind. 

Setting is another thing that may pump the brakes or hit the gas for arousal, meaning certain places, certain rooms, certain events. Did your partner do something that turned you on? Going back to physical, it could also depend on your menstrual cycle. People have different levels of arousal depending on different stages of their menstrual cycle. I think the same is true for men, but I don’t actually have a lot of research on that. But I’m sure there are some hormonal impacts for men as well.

There’s also ludic factors, which are like fantasy, whether you have a really strong imagination that either pumps the brakes or puts the gas pedal in terms of arousal. It could be like where you’re being touched. Sometimes there’s certain areas of your body that will set off either the gas pedal or the brakes. It could be a certain foreplay. Again, really what I’m trying to get at here isn’t breaking it down according to the workbook, but there’s so many factors that may influence your arousal. 

SHAME AND SEXUAL AROUSAL

Another one is environmental and cultural and shame. If arousal and the whole concept of sex was shamed or booked down on, or people have a certain opinion about your sexual orientation, that too can impact your gas pedal and your brakes pedal. I want you to explore this not from a place of pulling it apart really aggressively and critically, but really curiously, and check in for yourself. What arouses me? What presses my brakes? What presses my gas? And just start to get to know that. Again, in the workbook, there’s tons of worksheets for this, but you could also just consider this on your own. Write it down on your own. Be aware over the next several days or weeks, just jot down in a journal what you’re noticing.

Now, before we move on, we’ve talked about a lot of people who are struggling with arousal and they’ve got a lot of inhibitors and brake pushing. There are the other camps who have a lot of gas pedal pushing. I speak here directly to the folks who have sexual obsessions, because often if you have sexual obsessions, the fact that your sexual obsession is sexual in nature may be what sets the gas pedal off, and all of a sudden, you have arousal for reasons that you don’t understand, that don’t make sense to you or maybe go against your values.

I’ve got a quote that I took from the book and from the workbook of Emily Nagoski. Again, none of this is my personal stuff. I’m quoting her and citing her throughout this whole podcast. She says: “Bodies do not say yes or no; they say sex-related or not sex-related.” Let me say it again. “Bodies do not say yes or no; they say sex-related or not sex-related.” This is where I want you to consider, and I’ve experienced this myself. Just because something arouses you doesn’t mean it brings you pleasure—main point. We’ve got to pull them apart.

SEXUAL OBSESSIONS & AROUSAL

Culture has led us to believe that if you feel some groinal response to something, you must love it and want more of it. An example of this is, for people with sexual obsessions, maybe they have OCD or some other anxiety disorder and they have an intrusive thought about a baby or an animal. Bestiality is another very common obsession with OCD, or could be just about a person. It could be just about a person that you see in the grocery store. When you have a thought that is sex-related, sometimes, because the context of it is that it’s sex-related, your body may get aroused. Our job, particularly if you have OCD, is not to try and figure out what that means, is not to try and resolve like, does that mean I like it? Does that mean I’m a terrible person? What does that mean? I want you to understand the science here to help you understand your arousal, to help you understand how you can now shift your perspective towards your body and your mind and the pleasure that you experience in the area of sexuality.

THE GROINAL RESPONSE

Let’s talk about the groial resopsne. Again, the body doesn’t say yes or no; they say either sex-related or not sex-related. Here’s the funny thing, and I’ve done this experiment with my patients before, if you look at a lamp post or it could be anything. You could look at the pencil you’re holding, and you think about, and then you bring to mind a sexual experience, you may notice arousal (or the groinal response). Again, it doesn’t mean that you’re now aroused by pencils or pens; it’s that it was labeled as sex-related. Often your brain will naturally press the accelerator. That’s often how I educate people, particularly those who are having arousal that concern it. It’s the same for a lot of people who have sexual trauma. They maybe are really concerned about the fact that they do have arousal around a memory or something, and then that concerns them, what does that mean about me? 

The thing to remember too is it’s not your body saying yes or no; it’s your body saying sex-related or not sex-related. It’s important to just help remind yourself of that so that you’re not responding to the content so much and getting caught up in compulsive behaviors. 

A lot of my patients in the past have reported, particularly during times when they’re stressed, their anxiety is really high, life is difficult, any of this content we went through, they may actually have a hard time being aroused at all. Some people have reported not getting an erection and then it completely going for reasons they don’t understand. I think here, we want to practice, again, non-judgment. Instead, move to curiosity. There’s probably some content that impacted that, which is, again, very, very normal. 

BETTER SEX THROUGH MINDFULNESS

I’m talking with patients. I’ve done episodes on this in the past and we’ve in fact had sex therapists on the podcast in the past. They’ve said, if you’ve lost arousal, it doesn’t mean you give up. It doesn’t mean you say, “Oh, well, that’s that.” What you do is you move your attention to the content that pumps the gas. When I mean content, it’s like touch, smell, the relationship, the vibe, being in touch with your body, bringing your attention to the dance that you’re doing, whether it’s with a partner or by yourself or whatever means that works for you. You can bring that back. Another amazing book is called Better Sex Through Mindfulness. It talks a lot about bringing your attention to one or two sensations. Touch and smell being two really, really great ones. 

Again, if your goal is to be aroused, you might find it’s very hard to be aroused because the context of that is pressure. I don’t know about you, but I don’t really find pressure arousing. Some may, and again, this is where I want this to be completely judgment free. There is literally no right and wrong. But pressure is usually not that arousing. Pressure is not that pleasurable in many cases, particularly when it’s forceful and it feels like you have to perform a certain way. Again, some people are at their best in performance mode, but I want to just remind you, the more pressure you put on yourself on this idea of ending it well, it’s probably going to make some anxiety. Same with test anxiety. The more pressure you put on yourself to get an A, the more you’re likely to spin out with anxiety. It’s really no different. 

Here is where I want you to catch and ask yourself, is the pressure I put on myself or is the agenda I put on myself actually pumping the brakes for me when it comes to arousal? Is me trying not to have a thought, actually in the context of that, does that actually pump the brakes? Because I know you’re trying not to have the thought so that you can be intimate in that moment and engaged in pleasure. But the act of trying not to have the thought can actually pump the brakes. I hope that makes sense. I want you to get really close to understanding what’s going on for you. Everyone is different. Some things will pump the brakes, some things will pump the accelerator. A lot of the times, thought suppression pumps the brakes. A lot of the times, beating yourself up pumps the brakes. A lot of the time, they’re more like goal, like I have to do it this way. That often pumps the brakes. Keep an eye out for that. Engage in the exciters and get really mindful and present. 

A couple of things here. We’ve talked about erections. That’s for people who struggle with that. It’s also true for women and men with lubrication. Some people get really upset about the fact that there may or may not be a ton of lubrication. Again, we’ve been misled to believe that if you’re not lubricated, you mustn’t be aroused or that you mustn’t want this thing, or that there must be something wrong with you, and that is entirely not true. A lot of women, when we study them, may be really engaged and their gas pedal is going for it, but there may be no lubrication. It doesn’t mean something is wrong in those cases. Often a sex therapist or a sex educator will encourage you to use lubrication, a lubricant. I’ve talked to clients and they’re so ashamed of that. But I think it’s important to recognize that that’s just because somebody taught us that, and sadly, it’s a lot to do with patriarchy and that it was pushed on women in particular, that that meant they’re like a good woman if they’re really lubricated. That’s not true. That’s just fake, false, no science, has no basis in reality. 

Now we’ve talked about lubrication, we’ve talked about erection. Same for orgasm. Some people get really frustrated and disheartened that they can’t reach orgasm. If for any reason you’re struggling with this, please, I urge you, go and see a sex therapist. They are like the most highly trained therapists. They are so sensitive and compassionate. They can talk with you about this and you can target the specific things you want to work on. But orgasm is another one. If you put pressure on yourself to get there, that pumps the brakes often. 

What I want you to do, and this is your homework, is don’t focus on arousal; focus on pleasure. Again, it’s really about being in connection with your partner or yourself. As soon as you put a list of to-dos with it is often when things go wrong. Just focus on being present as much as you can and in the moment being aware of, ooh. Move towards the exciters, the gas pedal things. Move away from the inhibitors. Be careful there. Again, for those of you who have anxiety, that doesn’t mean thought suppress, that doesn’t mean judge your thoughts because that in and of itself is an inhibitor often.

I want to leave you with that. I’m going to, in the future, do a whole nother episode about talking more about this idea of arousal non-concordance, which is that quote I used: “The bodies don’t say yes or no; they say sex-related or not sex-related.” I’ll do more of that in the future, but for right now, I want it to be around you exploring your relationship with arousal, understanding it, but then putting your attention on pleasure. Being aware of both, being mindful of both. 

I’m not a sex therapist. Again, I’m getting all of this directly from the workbook, but most of the clients I’ve talked to about this, and we’ve used some worksheets and so forth, they’ve said, “When I put all the expectations away and I just focus on this touch and this body part and this smell and this kiss or this fantasy, or being really in touch with your own body, when I just make it as simple as that and I bring it down to just engaging in what feels good, use it as a north star. You just keep following, that feels good. Okay, that feels good. That doesn’t feel so great. I’ll move towards what feels good”—moving in that direction non-judgmentally and curiously, they’ve had the time of their lives. I really just want to give you that gift. Focus on pleasure. Focus non-judgmentally and curiously, being aware of what’s current and present in your senses.

That’s all I got for you for today. I think it’s enough. Do we agree? I think it’s enough. I could talk about this all day. To be honest, and I’ve said this so many times, if I had enough time, I would go back and I would become a sex therapist. It is a huge training. Sex therapists have the most intensive, extensive training and requirements. I would love to do it. But one day, I’ll probably do it when I’m like 70. That will be awesome. I’ll be down for that for sure. 

I just love this content. Again, I want to be really clear, I’m not a sex therapist and so I still have tons to learn. I still have. Even with what we’ve covered today, there’s probably nuanced things that I could probably explain better, which is why I’m going to stress to you, go and check out the book.

I was thinking about this. Remember I just recently did the episode on the three-day silent retreat and I was sitting in meditation. I remember this so clearly. I’m just going to tell you this quick story. For some reason, my mind was a little scattered this day and something came over with me where I was like, “Wouldn’t it be wonderful if I didn’t just treat anxiety disorders but I treated the person and the many problems that are associated with the anxiety disorder? Isn’t that a beautiful goal? Isn’t that so? Because it’s not just the anxiety; it’s the little tiny areas in our lives that it impacts.” As soon as I finished the meditation, I went on to my organization board that I use online and it was like, “Arousal. Let’s talk about pee and poop,” which is one episode we recently did. “Let’s talk about all the things because anxiety affects it all.” We can make little changes in all these areas, and slowly, you get your life back. So, I hope this gives you a little bit of your sexual expression back, if I could put it into words. Maybe not expression, but just your relationship with your body and pleasure. 

I love you. Thank you for staying with me for this. This was brave work you’re doing. You probably had cringey moments. Hopefully not. Again, none of this is weird, wrong, bad. This is all human stuff. So, finish up. Again, go check out the book. Her name is Emily Nagoski. I’ll leave a link in the show notes. One day we’ll get her on. But in the meantime, I’ll hopefully just give you the science that she’s so beautifully given us.