One very helpful way to start to address sexual pain is to consider the location of the pain.  Whether the pain occurs externally (the vulva or labia), internally (the vagina), or deep (cervix, uterus, or other internal organs) gives us many clues as to how to approach sexual pain.  Not all pain is of the same intensity, but rather than avoid the pain – finding the cause of the pain puts you that much closer to resolving it.

If the pain is occurring externally, a woman may experience discomfort of the labia or the areas to either side or just below the vaginal opening.  Occasionally, yeast infections can cause irritation, especially on the inside of the labia minora.  Pain to either side or just below the vaginal opening may be due to vulvodynia – a more complex condition that often is accompanied by weakness and/or tightness in the pelvic floor muscles.  Some women also experience a feeling of burning or uncomfortable stretching when attempting penetration, which could be due to changes in hormones, or sometimes even scar tissue from an episiotomy.  A decrease in free testosterone can also result in pain just at the opening of the vagina.

If the pain is experienced internally, the first thing to rule out is any type of infection.  Not all infections will cause sexual pain, but those that do, such as yeast infection or Trichomonas, are easily treated (don’t forget your partner needs treatment too).  Once the possibility of infection is ruled out, other causes of internal sexual pain can be explored.  Probably the most common is a decrease in estrogen as is found in menopausal women, or women just after childbirth.  The changes in hormone levels are reflected in the tissues lining the inside of the vagina.  Without the support of estrogen, penetration can produce irritation, burning, or even some minor bleeding.

Lastly, pain that is experienced deep inside is most likely related to one’s internal organs.  Endometriosis is a very common cause of sexual pain, especially during deep penetration.  Sometimes, women can experience pain during certain sexual positions if their uterus is tilted backwards (what is referred to as retroverted uterus), but usually finding a different position or angle of entry helps this situation.  Also, if there is inflammation in other pelvic organs such as an ovarian cyst (even a benign follicle during ovulation), these may cause some pain during penetration due to the closeness of these structures to the vaginal canal.

Too many times, women are embarrassed to address their sexual pain, so they put it off until it starts to affect their pleasure and desire for sex.  Also, not all doctors are created equal and there are some doctors who work very well with women that experience sexual pain, while others seem clueless, frustrated, and dismissive.  If you find yourself with one of these doctors, please move on to a more understanding and connected doctor.  Please do not delay in getting a proper examination if you have any unexpected bleeding, discharge, or changes in your skin.  Your sexuality is a vital part of you which does not deserve to be ignored or minimized.

Masturbation is a natural activity that is performed by certain species of animals, humans being one of them.  By using the term “side effects” I assume that you are referring to negative effects of masturbation.  When considering masturbation, as with most things, balance is the key.

Masturbation is an activity that some children stumble upon naturally, many teenagers perform daily, and adults may or may not engage in at different times in their life.   It is used to help relieve natural urges, experience pleasure, decrease stress, as a sleep aid, and as an adjunct to sexual activity shared between partners.  Negative effects could be experienced in both physical and mental realms if it is used in an unhealthy, unbalanced way.

Usually, masturbation does not produce any physical negative effects.  It is natural and the body is designed to not only sustain, but also enjoy this activity.  If, however, a person masturbates with excessive force, pressure, persistence, or using objects that could cause physical damage, the result could be bruising, lacerations, skin burns, etc.

Mentally, masturbation provides excitement, release of stress, and profound calm.  There is an increase of sex hormones for both men and women, as well as release of oxytocin which promotes feelings of security and bonding.  Of course, if there is no balance or if it is used in an unhealthy way, masturbation can produce feelings of guilt, feelings of emptiness, feelings of isolation, etc.

Masturbation has been a part of human history as long as we have been human, and it is a useful activity that provides many benefits to both the individual and relationships as well.  It is an enjoyable sexual activity that does not carry any risk for either pregnancy or sexually transmitted illness (unless body fluids are transferred to another person).  It is how you use it that determines whether it will have a negative or positive effect for you.  But that is true of everything in life – even food and water necessary to sustain us.

Compared to other mammals, humans with their obnoxiously-large cortex have the capacity to think a multitude of different thoughts, even in the midst of sexual intercourse. Your ego, which defines for you what sex should be and what it means to you at any given moment, has a way of overshadowing your body so that your attention may be taken up by your thoughts about sex rather than the sex itself. When this happens, your brain is not paying full attention to the sensations that your nerve endings are sending to it. In a way, part or most of the communication from your genitals to your brain is being ignored at that moment in order for the brain to concern itself with whatever the ego is preoccupied with at the moment.

So imagine that you are having sex or getting sexual contact from your partner, but your brain isn’t fully paying attention. You’re going to miss the full experience of that touch, that kiss, that stroke, that pressure, that wetness. This is particularly problematic for people having difficulty with desire or arousal. If their brain is not recognizing the signals of arousal that the body is trying to send, it doesn’t really register.

How this might happen in sex could be seen in those people preoccupied with a judgment about sex or perhaps a concern about their body. In this case, your focus is taken away from the tactile sensations that you are having over your skin, your genitals, your entire body so that the message is ignored by your brain and you miss out on recognizing that moment of pleasure. The more your brain is preoccupied with other thoughts, the less pleasure it can register. Even more distressing is that when the brain is preoccupied with thoughts that are anxiety provoking (“I don’t like my body”, “Maybe my partner is not really enjoying themselves.”), it stops sending signals back to the genitals that are needed for lubrication or for an erection, etc.

There is a remedy, however, which is to slow down the activity and focus on the tactile sensations that you are experiencing. You will increase your pleasure when your brain is allowed to focus on each touch, each movement, and the way your body responds. Focusing on the present moment during your sexual contact will also increase the experience of the pleasure as the brain filters out distractions to focus fully on the communication from the your erogenous zones and genitals. Feeling more during sex by slowing down the action and focusing on sensation is to take a play out of the Neo-tantric playbook and get closer to sexual spirituality and ecstatic consciousness.

After puberty, testosterone levels are usually at their highest, driving competitiveness, aggression, and sexuality.  It seems that almost anything from nervousness, to excitation, to daydreaming, to boredom can trigger an erection.  For many teenage guys, masturbating daily or even several times a day is common without untoward consequences.

Then we cut to a sexual situation.  Maybe there is the expectation of having sex with a partner that is very attractive and exciting, so much so that a guy becomes anxious about his ability to please his partner.  If his anxiety starts to overshadow his excitement, he may not be able to keep an erection or even get one at all.  Once the anxiety becomes the predominating thought, not only does it flood the system with adrenaline, but it leaves little room for real erotic thoughts that drive arousal.

What kind of response a guy gets to his level of arousal can also greatly influence the level of his erection or ability to maintain it.  A strong, judgmental, hysterical, or demanding attitude on the part of his partner is not only insensitive, but works directly against his arousal and can make the situation even worse.  The more that a guy can continue to focus primarily on what he finds exciting without getting pressure from his partner or from his own performance anxiety, the better the chance that he will have in getting an erection that he is pleased with and keeping that erection.

When anxiety takes hold, the best tactic is to redirect one’s thoughts to whatever activity or stimulus is pleasurable and erotic in the moment.  Don’t worry about what will happen 5 minutes from now since you are only in control of the present.  Similarly, don’t continue to beat yourself up about past disappointments, because those moments have passed and you have the ability to shape each moment differently.  Instead, pick the first thing that is the most erotic for you and let yourself completely focus on this.  Sex is much better when it is a “want to” and not a “have to.”

Sex surrogates are people specifically trained to help others work on issues of sex and sexuality. Their activities can range from touching and holding exercises to different sexual activities with the goal of helping their clients work through any difficulties. Many people assume that it is just paying for a sexual partner, but there is so much more that goes into sex surrogacy. In fact, many surrogates never even have sexual intercourse with their clients, instead having therapeutic effect with just conversation, touching and holding, and emotional connection.

As you can imagine, sex surrogacy is not without controversy. Most states consider it tantamount to prostitution and therefore have not legalized the practice. The IPSA is currently the only place in the country where surrogates can be trained and certified. It is currently very difficult to regulate, and with the short period of time involved in training, it is difficult for mental health professionals to be assured that a surrogate is psychologically and emotional appropriate with a client. Also, it is up to the individual surrogate to be free of any communicable diseases.

Conceptually, the idea of a sex surrogates helps solve multiple problems – dealing with anxiety in the moment and the experience of a knowledgeable and encouraging partner who is not judgmental or gives destructive criticism. The real question is does this translate into better sex with a partner? Can the client transfer this behavior, feeling, and response to the experience of sex with their partner once the work with the surrogate is done? This will probably vary from person to person and their own level of anxiety and block. Although society and medicine is placing more and more importance on the individual’s sexual health and acknowledging how satisfying sex contributes to quality of life and even to increased life span, it seems like some time before we will have legalization, standardization, and regulation of sex surrogates. It will also require a great deal of open-mindedness from a great many people.

Myth – You can’t get pregnant the first time you have sex or anytime during your period.
Truth – Although it’s much more unlikely to be fertile during your menstrual period, it’s not a definite. Many women have very irregular ovulations which could result in pregnancy if they have unprotected sex. Either way, use a condom to protect against pregnancy and any STIs. And you absolutely can get pregnant the first time you have sex! Don’t let anyone fool you.

Myth – If a guy can’t get an erection with a woman, it means he is not attracted to her.
Truth – Erectile difficulties is not an absolute sign that the man is not interested. In fact, the more important that woman is to him, the more attractive she is to him, or the more he wants to have sex with her – then the more anxiety he usually experiences resulting in difficulty getting or keeping his erection. Relax and keep focusing on the erotic.

Myth – If a woman cannot reach orgasm with intercourse, there is something wrong with her.
Truth – Most women (in fact about 70-75% of women) cannot reach orgasm with vaginal intercourse alone. Most women need to have some clitoral stimulation in order to reach her peak and most sexual positions do not allow for that. Finding ways to still get the clitoral stimulation – whether from a hand, a vibrator, or the ability to grind against her partner’s body – would be needed to help these women reach orgasm during intercourse.

Myth – If a guy can’t last in bed like the guys do in porn, then he has premature ejaculation.
Truth – Premature ejaculation has a pretty small window of time to orgasm coupled with a lack of ability to control it. When a guy gets optimal stimulation, the average lasting time is about a minute and a half. This means that if he thrusts continuously and gets proper stimulation, he is going to reach orgasm pretty quickly. A guy like this is normal and needs to learn instead that he can slow down, stop, or change the movement so that he doesn’t reach orgasm more quickly than he (or his partner) would like.

I invite you to check out my eBooks: A Man’s Guide to Male Sexual Issues, and A Woman’s Guide to Male Sexual Issues.

In the last 20 years, SSRIs have become the first choice of treatment for depression as well as anxiety, panic, and OCD.  And they are prescribed not only by psychiatrists, but also by Family Medicine Practitioners, Internists, Cardiologists, Gynecologists, and Neurologists.  Although transient GI side effects such as nausea and soft stools are very common, as are the longer term side effects of insomnia, fatigue, and constipation, the benefits of treatment usually outweigh the risk of these side effects.

In many cases, these medications are extremely necessary and I am certainly not recommending that people stop taking their medications.  Nor am I recommending that a person go without proper treatment that they may need simply because of side effects.  What I am recommending is that people understand the effects of medications so that they can plan around it.  Such is the case for men taking SSRIs who might be planning on conceiving with their partner.

It has been shown that SSRIs can significantly lower levels of testosterone and estrogen after just 5 weeks of taking the medications.  Other studies have demonstrated a decrease in sperm motility and viability during treatment with SSRIs that started to improve within a few weeks of stopping the medication.  But a new study recently demonstrated actual changes in a man’s sperm after being treated with an SSRI after 3 months.  Specifically, researchers found that concentration (amount), motility (ability to move properly), and morphology (normal shape) all fell more than 50% at the end of the three month period, and these effects were seen in 100% of the men treated.  This is considered a significant decrease that could place some men into the ‘infertile’ range.

Although small changes appeared after the first month of treatment, it wasn’t until after the third month that the numbers really started to drop.  Researchers note that this would be a logical finding since sperm production takes about 64 days, therefore sperm changes would be most evident after the two and a half month mark.  What is worrisome to me is that in questioning other colleagues of mine, it does not seem that these side effects are common knowledge, yet these medications are continued to be prescribed in increasing quantities.  Now SSRIs are also being used to help some men overcome premature ejaculation with good results.  As the use of these medications continues to increase, a serious discussion about side effects needs to take place, especially in men planning on starting a family so that they can plan accordingly if they should have any difficulty conceiving.

Thanks for your great question.  I have to ask – To what are you comparing your amount of ejaculate?  What makes it seem as though it’s not very much?  If you are comparing yourself to what you see in porn, you better stop right there and think again.  Too many people compare themselves to porn and somehow it doesn’t sink in that IT’S A MOVIE and some aspects of it are FAKE.  A mixture of cornstarch and water to simulate semen can even be used to heighten the effect, especially for shots to the face.  And remember, that in a movie, a shot can be edited anyway you like – made to look like it’s lasting longer or whatever.

Most people have difficulty judging the exact volume of their ejaculate, especially when it’s spread out or partly soaked up in a napkin or tissue.  On average, guys ejaculate about 1 teaspoon-worth of semen in one ejaculation – about 5 mL – which is not a large amount.   The amount (volume) of ejaculate will be a little more if it’s been awhile since you ejaculated and less if you ejaculated recently.

A man’s body is constantly producing sperm and storing it up for ejaculation.  This gets mixed with fluid produced by the seminal vesicles and prostate.  Apart from frequency of ejaculation, the amount of time spent in sexual activity and the amount of arousal can also affect the volume of ejaculate.  The longer the build-up, arousal, and direct stimulation prior to ejaculation, the more volume of fluid can be produced to mix with sperm for ejaculation.  Some men also have noticed that this increase in ejaculate volume with longer stimulation also produces a waterier semen because of the increased fluid to sperm ratio.

So it stands to reason that if you are dehydrated, your volume will probably be less.  Other factors that affect it are getting proper amounts of zinc in your diet, getting good sleep, stress levels and your frequency of ejaculation.  Genetic factors and age also play a part, but those are not under your control.  Strengthening your PC muscles can produce stronger contractions on orgasm and help push out more fluid.  I explain how to strengthen your PC muscles by doing Kegel exercises in this article.  You can also check out my eBook, Penis Problems: A Man’s Guide.

Diabetes itself is not responsible for the damage done to the body.  Instead, it is the rise in blood sugar that comes from either insufficient insulin release (type 1) or a body’s resistance to the effects of insulin (type 2).  Type 2 begins as an adult and is almost always related to being obese or overweight for some time.  Often, it can be reversed if a person returns to a normal weight.  Many doctors are happy if they see their diabetic patients maintain their blood sugar under 150, or even 180 if they have had the disease for some time.  I believe that these levels permit slow degeneration of the tissues and nerves of the body which can severely affect one’s quality of life.  Ideally, a level between 80 – 125 is best.

Good sexual functioning depends on good blood flow and the ability to not only perceive sensations, but to have the organs and tissues respond to these sensations.  When a person’s blood sugar is high, cells cannot function properly and nerve endings become damaged.  This can cause numbness, or worse – uncomfortable tingling.  Having uncontrolled levels of blood sugar also causes damage to the blood vessels in the form of decreased ability to relax and contract when needed as well as increased atherosclerosis decreasing blood flow.

Ways that nerve damage manifests for someone with diabetes could be a decreased sensation in their genitals.  When this happens, it becomes more difficult to become aroused when touched or stroked.  Impaired blood flow commonly causes erectile dysfunction in men and lack of lubrication or difficulty reaching orgasm in women.  To make matters worse, patients with diabetes have a poorer response to medications for erectile dysfunction.

One of my goals is to inform people of how the choices they make today can affect their tomorrow.  Maintaining very careful control of one’s blood sugar can prevent this damage, but requires close attention to food choices, avoidance of sugar and simple carbohydrates, portion control, and complete compliance with diabetic medications.  The damage to one’s sex life can sneak up on you, but is very disheartening when it happens.  Prevention is key – before the damage is done.

Ever since we have been walking upright (maybe 6 million years now) our bodies have had increased stress in our pelvic floor because of the effects of gravity.  Even though pregnancy and childbirth has always placed a strain on this network of muscles, regular physical activity and walking on all fours gives other animals advantages to strengthen these muscles that humans do not have.  Added to this is the tendency of humans being not only sedentary, but also overweight.  All of these factors cause the muscles of the pelvic floor to weaken over time.

When there is pelvic floor dysfunction, there can be weakness, spasticity, or cramping and knotting up of the muscles.  This creates a situation where the muscles cannot work in coordination to do their function – be constricted when walking around to maintain continence, or relax when using the bathroom or engaging in sexual intercourse.  When weakness or dysfunction occurs, there can be pain during sex, pain sitting for long periods of time, back pain, constipation, difficulty with urination, or pain upon urination or ejaculation.

It’s estimated that perhaps up to 20% of people may have some pelvic floor dysfunction at some time in their lives.  Being overweight, not participating in regular exercise or stretching, and changes in collagen and connective tissue that can occur with pregnancy or menopause can increases the risk for developing pelvic floor dysfunction.  Kegel exercises are often recommended to increase tone of PC muscles, especially for women after childbirth.  But since these can worsen pelvic floor dysfunction, it is important to be evaluated for pelvic floor dysfunction if you have any pain or problems with urination, defecation, or sexual activity before starting Kegels.

An evaluation by either your gynecologist (women) or urologist (men) is in order if you feel you may have any of the symptoms mentioned above.  Physical therapy is usually quite successful in treating pelvic floor dysfunction, but as always – the sooner treatment begins, the sooner and easier it can be resolved.