Female Pelvic Pain and Its Relationship to Emotions & Trauma

Dr. Adriana Martí

When sex hurts, experts still have tons of unanswered questions. Since we don’t have much accurate data on the various conditions that make intercourse painful, women often suffer in silence.

To help sort this out, Dr. Diana Wiley, a sex therapist, and Dr. Adriana Martí, a pain psychologist, had an informative conversation.

Dr. Martí uses the biopsychosocial model, which has emerged as the most comprehensive framework for understanding pain. Coming from a family of physicians, Dr. Marti understood the value of treating the physical body, but she also saw where the biomedical model falls short. That insight led her to embrace integrative, mind-body approaches to care especially for those living with chronic illness or pain.

The level of a patient’s anger has been shown to be an important predictor of chronic pain symptoms, and cultivating compassion has been shown to positively influence how we process emotions, thus reducing the tendency toward negativity, including anger.

Psychological or emotional factors are often involved. Stress, anxiety, depression, guilt, a history of sexual abuse, an upsetting pelvic exam in the past, or relationship troubles can also be at the root of sexual pain. Some women experience vaginismus—an involuntary clenching of vaginal muscles that prevents penetration. Vaginismus is especially common among women who associate their vaginal area with fear or physical trauma.

Both the sex therapist and the health psychologist want to include the patient’s partner at some point in the therapeutic process. For many couples who have been dealing with a confusing, undefined issue, there is a buildup of resentment and anger. Men often fear hurting their partner. Pleasure can become pain. It is so easy for couples to blame each other and lose sight of the fact that the real problem is a physiological condition, not their partner.

Dr. Martí also notes the cultural piece: the expectations related to the family. How does the family relate to pain? In one case, the mother and the grandmother both had pelvic pain. Sometimes the woman gets sucked into the “sick role,” which has the benefit of lowered expectations from the patient, but is ultimately not emotionally healthy.

Can pain be unlearned? A study led by Yoni Ashar, PhD, which was published in JAMA Psychiatry, was the first clinical trial of pain reprocessing therapy (PRT). PRT was developed by psychotherapist Alan Gordon to treat primary chronic back pain. Complete details can be found in his book, The Way Out: A Revolutionary, Scientifically Proven Approach to Healing Chronic Pain.

There are additional fixes, such as vaginal estrogen or other medicines or creams. Also, pelvic floor therapy (provided by a specially trained physical therapist) can help control vaginal muscles. “Down training” uses a combination of mindfulness, diaphragmatic breathing, meditation, stretching, and visualization to help calm the nervous system.  

The couple in therapy may be asked to do “outercourse” homework (non-penetrative sex). Some couples put too much focus on penetrative sex and neglect other fun, equally pleasurable sexual activities. Outercourse is a great option because it helps women forget there’s a goal, so they can just enjoy the feelings and sensations of the ride! It gets both people out of their brains and into their bodies.

Dr. Martí has a private practice where she works with individuals and couples in both English and Spanish. All sessions are done via telehealth. A fifteen-minute phone consultation is the no-charge first step!  www.martipsychologicalservices.com

ERECTILE DYSFUNTION: How It Happens, What Can Go Wrong, and Solutions

Dr. Paul Joannides is the author of Guide to Getting It On, now in its Tenth Edition. This is a well-known guide on sexuality which is used in college and medical school sex-ed courses in the U.S. and Canada. Please check out his comprehensive, informative website -- www.guidetogettingiton.com.   

Dr. Paul and Dr. Diana began with the biological/medical aspects of erectile dysfunction (ED). Dr. Paul reports that 50% of men have ED at 50 years of age. Research shows that more than 60% of men who suffered a serious heart attack experience erection problems more than two years prior to their heart attack. So why is ED the canary in the coal mine for serious health problems?

ED can result from vascular issues (heart disease, high blood pressure, etc.) or the cause can be nerve-based (Parkinson’s disease, multiple sclerosis, etc.). Metabolic Syndrome is often present: being overweight, low levels of good cholesterol, high blood sugar.  Also, gum disease caused by no flossing increases the chances of experiencing ED by some 300%. Other life-style issues are involved including lack of exercise, poor diet, and drinking too much (causing “whiskey dick”). Also, if a man under 40 experiences ED, he is seven times more likely to have a heart attack when he is older.

For physical causes of ED, PDE-5 Inhibitors (Viagra, Cialis, etc.) help with the nitric oxide, relaxing the smooth muscle inside the penis, all in service of an erection. Another possible cause: too much tension held between the legs, in both men and women. Pelvic floor PTs often suggest that the patient stop doing Kegels because the muscles are too tight.

How about the psychological issues?  Quoting from Dr. Paul’s book: “Often, the biggest problem with ED isn’t the lack of erection. Rather, it’s a lack of playfulness and resourcefulness on the part of the man and woman when they are confronted with a hard-on that’s a no show.”

It takes most young men years, even decades, to leave penis-centric sex behind and understand the erotic value and pleasure of whole-body sensuality, rather just sticking it in. But few women appreciate how diminished men feel by ED. The couple needs to talk. Part of the problem is that men get less practice than women discussing their emotions, and when they do, they’re less skilled.

Dr. Diana discussed a case where the husband loses his erection during intercourse. The wife wondered if she did something wrong.  She asked, “What should I do when that happens?” Most erection problems are not caused by a partner doing something wrong but by feelings that the man has before or during sex. My advice: Don’t get pulled into a big drama about it. You want to respect your husband’s distress, of course, but you don’t have to agree that the sky is falling just because his penis does. They need to talk about how it feels, what she wants, what he wants, and what the options seem to be. The wife agreed this wasn’t much of a problem unless it’s made a problem by his turning away in frustration or anger.

Coping with age-related erection changes: forget quickies and spontaneous sex – schedule it; before making love, enjoy quality non-sexual time together: have fun; bathe or shower together beforehand; be patient with your penis. The latter is important and you can breathe deeply, kiss, cuddle, touch each other all over, savor novelty, enjoy vivid fantasies, and slow down with extended loveplay!

Do yourself a favor and get Dr. Paul Joannides’ book Guide to Getting It On.  It is a sensitive and playful guide; also funny, irreverent, intelligent and very honest … The very same qualities possessed by its author Paul Joannides! Furthermore, Dr. Diana knows him to be very kind and very sweet!

MENOPAUSAL HORMONE THERAPY, Part 2, with Dr. Rebecka Hoppins, ND, March 18, 2025

There is a large body of accumulated scientific research to support the thesis that Sexual Pleasure and Health are inextricably linked!   In Part 2, Dr. Becky, a Naturopathic Physician, and Dr. Diana a Sex Therapist, continued their conversation from January 28th. In Part 1, menopause myths were debunked, and menopausal women with low libido were offered some solutions.

Dr. Diana asked Dr. Becky How do you optimize a woman’s sexual health with the techniques of natural medicine?

Dr. Becky takes a broad, naturalistic, evolutionary overview of sex. She reminds us that in nature, sex is for reproduction, the survival of species. So broadly speaking, it makes sense that our bodies are wired to like it. Of course, that’s not the case for everyone – especially for many perimenopausal and menopausal women. She advises that when we feel healthy, balanced, safe and have resources, this is a good environment for offspring to survive/thrive. If we are stressed, malnourished, unsafe, etc., hormones shift to survival mode. Then the woman’s body is favoring the production of cortisol and adrenaline at the cost of the sex hormones progesterone, estrogen, DHEA, and testosterone. Fascinating fact: we literally make cortisol out of progesterone. What happens to highly stressed pregnant women? They are at a higher risk of miscarriage. After all, their progesterone is supposed to maintain the placenta and firmly hold the baby in the uterus, and this declines when cortisol goes up.

Stress may affect women even more when their sex/reproductive hormones decline. Blood flow diminishes. Vaginal health is often a problem, etc.

What does Dr. Becky look at? She addresses fatigue (adrenal function and other medical causes­), blood sugar/nutrition, physical causes of anxiety, and sleep health – to name just a few.   

The fascinating case of “Rachel”: her negative body image and her weight had led to obsessive negative self-talk. Dr. Becky’s Sage Clinic administers the GLP-1 (weight-loss) injections. Rachel’s mind became quiet – the chatter had stopped – as soon as it took effect!

There is so much more information in this podcast: Polarity Theory, the partnership environment, vasopressin vs oxytocin, inherited behaviors, sex demands from the male partner, narcissism and more!

You have to claim great sex, again and again, over the course of your life. It won’t grow and blossom without your long-term commitment. You need good information, the kind you will find in this podcast. Great sex is a natural outgrowth of great health, and the two flourish in tandem!  If you have problems in either realm, seek out the help of Dr. Becky Hoppins at the Sage Integrative Medical Clinic in Edmonds, WA. She is brilliant, well informed, and approachable. Listen to both shows and you will be convinced!

Menopausal Hormone Therapy

Sex and the older woman used to be considered an oxymoron, rarely mentioned in the same breath. Finally, menopause is having big media moments, including a just-published book, Dare I Say It – Everything I Wish I’d Known About Menopause, by Naomi Watts.

Nearly thirty years ago, I was fortunate to be in the right place at the right time. I was living in Honolulu and hosted a radio show “Fifty-Plus and Fabulous – A Show About Successful Aging.” One of my guests was a medical doctor specializing in longevity. As I was then just beginning menopause, he suggested bioidentical hormone replacement therapy (BHRT), which included regular doses of estradiol (Bi-Est), progesterone, and testosterone. As a result, I’ve enjoyed “postmenopausal zest” for all these years! Going from fertile to menopausal, I was closed for business—but open for pleasure!

My guest, Dr. Rebecka Hoppins, is a board-certified naturopathic physician and a 2005 graduate of Bastyr University near Seattle. She has 20 years of clinical experience with a particular focus on hormone balancing. She is deeply passionate about educating her patients regarding the effects of hormone dynamics in our day-to-day activities and the impact they have on every aspect of our lives: relationships, work, mental health, home life, and bigger health issues. You can reach her at the Sage Integrative Medical Clinic – www.sagemedclinic.com .

Dr. Becky shared her personal perimenopausal management. She reports, “I come from a history of women with significant PMS and menopausal symptoms. Since I’ve been practicing hormone balancing in clinic for 20 years, I don’t get symptoms as long as I follow my own rules!”

She and I had an informed conversation debunking these three common myths about menopause:

And, of course, many menopausal women find that their sex drive diminishes or disappears. What can you do to enjoy sex more? Dr. Becky suggests topical estrogen, adrenal balancing, managing stress—and picking the right partner. Both of us agree that nothing is going to be helpful if you don’t like your partner! We also discussed how estrogen helps with orgasm, and how a vibrator can become an important aid to enhancing a woman’s capacity to achieve orgasm. The more a woman practices on her own and teaches her partner what she likes, the easier it is for her to reach climax.

Dr. Becky is a delight and so well informed.  Please listen!  You will learn a lot!

A Tribute to Dr. Ruth Westheimer (1928-2024), Who Taught America How to Talk about Sex

Dr. Ruth talked publicly about sex more than anyone else. Ever.

She was my inspiration to do media work. In 1980 I began listening to her radio call-in show “Sexually Speaking.” In 1982 I watched her first appearance on The Tonight Show Starring Johnny Carson Show, a footstool under her feet because she was 4-foot 7. She spoke openly and with enthusiasm about sex – including masturbation. In those days, public discussion of sex was shrouded in prudishness.

She often said, “When it comes to sex, the most important 6 inches are the ones between the ears.”

My guest, Dr. Mark Schoen, founder of Sex Smart Films, is both smart and sexy! He has Dr. Ruth clips on Sex Smart Films. And he knew her before she became famous! At NYC’s Columbia University, she asked him to put her in one of his sex education films, which were used in sex education classes. His explicit films were always made to educate, not to titillate. Mark declined her request, fearing that her heavy German accented English would not appeal to viewers. Fast forward 19 years when Dr. Mark was producing sex ed films for the Sinclair Institute. They wanted her in one of their sex ed films. When he called Dr. Ruth to ask, she replied, “Mark, call my agent!” By then she was too expensive for the Sinclair budget.

Dr. Mark and I discussed many aspects of her remarkable life.

Her sense of purpose came from her history. Her parents died in the Holocaust. Dr. Ruth observed, “There were 1,500,000 Jewish children killed during World War II. I was spared because I was sent to Switzerland. People like me have an obligation to make a dent in society. I did not know that my eventual contribution to the world would be to talk about orgasms and erections, but I did know I had to do something for others to justify being alive.”  She understood that sex was a portal to living a happier life and that she was motivated by tikkun olam – Hebrew for making the world a better place. Dr. Ruth said, “You can take horrible experiences you will never forget, but you can use the experiences to live a productive life.” And she had fun being Dr. Ruth!  She described herself as being like a German doll: you knock it down and it bounces back. Ahh, resilience!

Dr. Ruth noted the importance of humor in teaching. I heard this first-hand in 1995 when I was part of a faculty which included her for a weekend sex conference in Washington D.C.. I spoke about my expertise: Sex & Aging. Meeting Dr. Ruth was a thrill!  She lectured that “if a professor leaves his students laughing, they will walk away remembering what they have learned.”

Westheimer promoted long-term relationships. Another quote: “I believe that the best sexual relations have to be in a loving relationship – not like in Hollywood, or your first love or the first night of sex, but in an enduring relationship, and realize how grateful we are that we have someone who cares for us.”

Old was not in her vocabulary. One of her 37 books was Dr. Ruth’s Sex After 50. She advised that if you are a senior and alone, buy a vibrator!

In her own very old age, she was named New York State's Honorary Ambassador to Loneliness. Her prescription for the lonely was the same as for the sexually frustrated: Be open. You have to feel your emotions. If you bottle the sadness in, the joy gets bottled right along with it.

R.I.P., Dr. Ruth, our beloved sex therapist known for her cheerful and insightful advice that educated millions about sexual health!

A Second Tribute to Candid Royalle, with Jamye Waxman

As sex therapists and longtime friends of Candida Royalle (actual name Candice Vadala), Jamye and Diana appreciate Candice’s thirst for self-knowledge. She wrote in 2013, “Still trying to unlock the key to myself.” She also wrote, “I will not let my past ruin my future.”  For decades Candice struggled to view herself through her own eyes, rather than through the eyes of some guy.

Jamye Waxman (www.waxmansextherapy.com) spoke in response to Dr. Diana’s questions: What was Candice to you? and What would you like to thank her for? As the “Godmother of Feminist Porn,” Candice—a real pioneer— was an inspiration for Jamye; also, a real friend and mentor. Jamye confesses that Candice believed in her before she could believe in herself! Diana and Jamye agreed that their late friend allowed others to shine! Jamye, for example, produced “Under the Covers” while Candice directed (the very last movie before her death in 2015).

Our discussion pivoted to pornography. Candice was disappointed by the new generation of mainstream porn: “The adult-porn industry is becoming a trash heap of over-the-top extremities of the most violating acts … Young men being brought up on this latest crop of meaningless mechanical crap are learning some terrible things about sex and women.” She wrote that in her diary in 2003.

Jamye fears that for our offspring, that we are fostering a phone-based childhood instead of a play-based childhood.

Because of phones, kids often have easy access to porn. For example, choking a partner may be normalized. (See the interview with Dr. Debbie Herbenick.)  Jamye’s concern is that things are being learned without being addressed. Candice foreshadowed that violence could become acceptable. It’s easy enough to go down a rabbit hole: vanilla sex scenes lead to kinky sex acts or violent ones.

In the early morning of September 7, 2015, Candice died of ovarian cancer at her Long Island home. The night before Diana wrote to her, in part: “To think that your vibrant, creative, beautiful life is about to end is devastating. It’s not fair. But your legacy is phenomenal! Through your movies, your book (How to Tell a Naked Man What to Do), and your media appearances, you have changed and improved many people’s sex lives and relationships. And, when folks can experience less shame and more enthusiasm regarding their sexuality … wow! … what a blessing!”

Diana and Jamye are glad Candice lived. She was a real blessing!

BTW, Check out Jamye’s column in PLAYGIRL. The one on attachment and relationships is compelling: https://playgirl.com/sex-talk/the-psychology-of-sex-lets-get-attached/ .

A Tribute to Candida Royalle & the Sexual Revolution with Veronica Vera

Diana Wiley and Veronica Vera were each longtime, close friends of Candida Royalle, a pioneer in producing female-friendly pornographic films. Both women were interviewed by Jane Kamensky, former professor of history at Havard and director of the Elizabeth Schlesinger Library on the History of Women in America, for her recently released biography: Candida Royalle & the Sexual Revolution – A History from Below.

The book is a sympathetic, clear-eyed profile of a woman who made female pleasure her business by starting her own production company, Femme Productions, in 1984.  Royalle (Candice Vadala, 1950-2015) prioritized women’s pleasure and orgasm in her films, while featuring a variety of sensual and sexual play.  She wasn’t interested in making the same, old, typical, boring, (male-focused) pornography.  

Veronica Vera (www.veronicaverawrites.com) wrote the column “Veronica Vera’s New York” that ran from 1985-1993. Veronica chronicled the sex world of which Candice was a star player. Veronica also founded CLUB 90, the first porn star support group with Candida Royalle, Veronica Hart, Gloria Leonard, and Annie Sprinkle. Fast forward to 2015, Veronica was the executor for Candice’s estate, and was instrumental in getting her archive of diaries, journals, and photos to Dr. Kamensky. Veronica knew Candice for about 35 years and loved her dearly.

Diana knew Candice for 28 years and also loved her deeply. They met at a sexology conference. Diana’s first impression was that of a radiant woman with a smile that said, “I love life, live it to the fullest, and adore adventures!” Yes, both women were open to adventures! They recognized that immediately as well as their sexual openness. Diana confessed, “My favorite thing is to go where I’ve never been. There is a scintillating thrill in new adventures!” She thought of herself as a girl of sparkle, shimmer, and shine – at least one in progress. That attitude played out when she worked as a showgirl in Miami Beach in the 70s (this job followed teaching school in Honolulu).

Chapter 25 of the book, “Sex in the 90s,” opens with a photo of Candice and Diana (page 351), who were about to go on the Jenny Jones TV talk show.  The topic: Candida’s explicit erotic films for couples to watch and how Diana used them in her therapeutic practice. Later, they envisioned “Case Studies: An Educational Line for Femme Films.”  They proposed a first volume on sex and aging, a research specialty of Wiley’s and a huge potential market.

One fan, a woman whose marriage benefited from watching Candida’s films, called her the Grace Kelly of Porn – a sophisticated and beautiful woman of incredible integrity, big enough to allow others to shine.

Candice’s quest for self-understanding as the center of a life well lived is evident in a 2013 journal: “Still trying to unlock the key to myself.”

Tune in for a fascinating podcast! And buy Jane Kamensky’s book … you’ll find yourself rooting for Candice Vadala!

Technology Changes Sex Education – What Parents Need to Know to Talk to Their Teens

Dr. Diana Wiley interviewed her amazing colleague Dr. Debby Herbenick, Provost Professor at the Indiana University School of Public Health, and Director of the Center for Sexual Health Promotion. Dr. Debby has just published her sixth book: Yes, Your Kid: What Parents Need to Know About Today's Teens and Sex. She is widely considered one of the country’s most credible sources of accurate scientific information when it comes to sexuality.

How did she come to write this book? As a sex researcher and educator, she knew parents needed sex education—in an updated version. So much has changed because of internet access. Also changed are the ways that teenagers and young adults are having sex. There are changing sexual norms. As a mom, Dr. Debby was compelled to write Yes, Your Kid.

It’s important to be an askable parent, a parent who is warm, approachable, and supportive. Often with religious/church influences, the parents themselves grow up in a culture of sexual shame and guilt. Silence is a message, too. Dr. Debby offers parents guides to opening up conversations with their children. The book offers good strategies for parents.

We talked about “The Rise of Rough Sex” (Chapter 7). Dr. Debby’s research has shown a rise in rough sex and even choking among teens. Forty percent of women ages 18 to 29 have been choked during sex. Choking is a form of strangulation; obviously, there are risks—even death, although rare. It everywhere now, even globally. It’s in mainstream pornography. It’s in lots of TikTok videos.

Parents, when confronted with this information will yell, “No Way!” Dr. Debby’s extensive research says, “Yes, it’s happening.”

Parents can step into conversations about rough sex, but also about consent, using condoms, and communication. Pleasure also needs to be considered. Who can enjoy getting it on with a lover who ignores the real risks of pregnancy and STIs? Feeling safe is crucial to the deep relaxation necessary for erotic pleasure!

To quote Debby Herbenick, PhD: “Let your teen know that you want them to have fulfilling relationships in life—and that may include sex if they want. Be that resource and safety net for them.”

ANDROPAUSE, sometimes called MALE MENOPAUSE

Though the potency crisis that hits many men in middle age has some obvious causes – age, alcohol, stress – the decline is hormonal and psychological as well. Men often won’t discuss it with their doctors, their wives, or their lovers.

Dr. Stephanie Buehler (www.LearnSexTherapy.com), heading up The Buehler Institute, joined the program once again. When men and women face the same passages with different needs and directions, how does the partnership survive? Dr. Stephanie and Dr. Diana talked about it all!  Women go through the process of menopause in different ways, but it’s almost a universal experience. Men are all different.

Often there are existential issues. For example: Does my life have meaning? What parts of myself have been neglected that I am now free to live out? Do I matter? The denial of aging can show up in a man’s embracing symbols of success and vitality. It may also contribute to men avoiding seeking help when they experience sexual issues as they age.

Women are often concerned about their partners. One of Dr. Diana’s clients said, “I have some menopausal symptoms – but the main problem is that my husband has more! He’s 52, withdrawn, moody, and angry that he’s aging and losing his hair. Also, he just doesn’t get aroused anymore. And I got tired of things not happening when I tried to get sex started. I always thought it was me. I stopped trying because I thought it was embarrassing to him.” These are not uncommon complaints from female partners.

The two sex therapists discussed typical psychological problems such as lethargy, depression, increased irritability, mood swings, and an overall lessening of a sense of well-being. As men move into their 50s and 60s, they may have intermittent problems in gaining and sustaining erections. They may also feel some slackening of sexual desire. And unless a man is in a good relationship with a supportive partner, the shock of all these changes can bring on a powerful psychological crisis, which can actually frighten a man into erectile dysfunction (E.D.). Still, they don’t talk about it. Men may have integrated this idea: “Your job as a male is to be strong.”

It’s important to underscore that there is a robust population of older men who survive this potential crisis with their egos and erectile abilities intact. In one large study, forty percent of these healthy males remained completely potent at age 70. A man’s general physical health picture is significant. Organic factors contribute to E.D. in up to 80 percent of men.

Dr. Stephanie points out that some female partners are not helpful, heaving insults like, “What’s wrong with you?”

Once again, USE IT or LOSE IT comes into play. And it requires a trusted partner, and some self-discipline around drinking, eating, exercise, and preventive health measures.

The two sex therapists also talked about alcohol, diet, and stress. The chronic use of alcohol can murder potency. Urologists report that when looking at the tissue from patients with chronic alcoholism, the nerve is killed inside the penis. Tom Lue, an internationally known expert on the treatment of male sexual dysfunction, notes “It’s almost impossible to revive. Usually, it takes 10 or 15 years of chronic heavy alcohol use to kill the nerve.”

In 1995 Dr. Diana spoke about aging and sexuality at a Washington, D.C. conference. The keynote speaker, Dr. William Masters (of Masters and Johnson), was asked his best advice for an older man who is worried he’s losing his potency. Dr. Masters was nearly 80 then, and his voice filled with tenderness: “Talk to your partner. Tell her you have these concerns. She’s probably concerned and afraid to tell you. Then talk to a competent sexologist about how to reactivate your bedroom scene.” Dr. Masters treated sexual dysfunction for nearly 50 years. He had a humble definition of good communication in a relationship: “It’s the privilege of exchanging vulnerabilities.”

The Scariest Halloween Goblin: Many young men get their sex education from porn!

Dr. Paul Joannides, author of Guide to Getting It On, now in its 10th Edition, is seriously concerned about how porn affects young men. A great deal of sexual misery stems from mistaken beliefs! There is very little competent sex education to help.

Dr Paul, realizing that many young men, teenagers included, are compulsive about video gaming, developed the website Real Dude Radio to reach this audience with accurate information about sex. This works because young people consume information differently, conditioned by the video gaming industry and porn. They need help with the distortions of pornography.

Real Dude Radio is very enlightening!

• For example check out “The Ultimate Guide to the Clitoris.” A woman needs to get the brain and the body on the same page! This guide is clear and practical.

Dr. Paul is also concerned with sextortion where young men are getting blackmailed for their dick pics that also reveal their face. See this recent article in the Washington Post: ‘IDK what to do’: Thousands of teen boys are being extorted in sexting scams

Listening to this podcast episode will enlighten and entertain you!