Dive Deeper with Leah Carey
I have been through the fire and come out the other side. Now I’m here to walk with you as you do the same.
I will help you take a stand for yourself, your desires, and YOUR PLEASURE.
Is it true that sex will become less fun – or even painful – after menopause? Is there any way to stop the changes that happen to our bodies as we get older?
You know that I rarely bring on experts, but today I have a special guest: MY OWN health care provider! She is an amazing human and she’s passionate about women’s health.
My favorite part of this episode: Maya’s theory on why women have so few fucks to give as they get into their 40s and 50s (hint: it has to do with their hormone levels).
You can find Maya at www.mayastrom.com.
Vulva and vaginal health during peri- and post-menopause
Making the adjustment from binary to non-binary language
Vaginal and anal dilators
Consent in a medical visit
How estrogen levels affect your sexual experience
Coconut oil and other lubricants
My favorite lubricant for sensitive skin: https://www.amazon.com/Personal-Lubricant-Sensitive-Isabel-Fay/dp/B00Q3GHPUS
More lube recommendations: https://www.youtube.com/watch?v=i_Ok69EI-ks
Dilator set (meant to be worn): https://www.sheboptheshop.com/wearable-5-piece-vaginal-dilator-set.html#partner=goodgirlstalk*
LEAH: Welcome to Good Girls Talk About Sex. I am sex educator and sexual communication coach, Leah Carey, and this is a place to share conversations with all sorts of women about their experience of sexuality. These are unfiltered conversations between adult women talking about sex. If anything about the previous sentence offends you, turn back now! And if you’re looking for a trigger warning, you’re not going to get it from me. I believe that you are stronger than the trauma you have experienced. I have faith in your ability to deal with things that upset you. Sound good? Let’s start the show!
LEAH: Hey, friends. You know I rarely bring on expert guests and the reason is that this show was created to feature your voices and stories, not professionals talking about how to give a better blowjob. But every once in a great while, I’ll bring on a women’s health provider who I know personally and who I trust to answer specific questions about vaginal and sexual health.
And today, I’m going to introduce you to my primary care provider, Maya Strom. And we’re going to talk about the hormonal and vaginal changes women go through during perimenopause and menopause.
I met Maya about a year and a half ago. I wanted to establish primary care with somebody new. And I had a whole range of providers through my life because I’ve moved around a lot. And as I thought back, I realized that the two who I felt the most safe with, the two who I trusted the most, were both APRNs, which stands for advanced practice registered nurse, which according to the internet means that they have a Master’s of Science and Nursing or a Doctor of Nursing Practice. For people outside the United States, I don’t know what the equivalent to an APRN is.
So, I went on a search for APRNs here in Portland. And to my great delight, I found Maya. It was obvious from the very first moment I met her that this was exactly the right fit for me. She’s smart. She’s gentle and she’s deeply caring. I feel so safe in her hands.
And as a side note, if you don’t have that type of relationship with your care provider, consider looking around. I know that not everybody has that privilege based on the incredibly fucked up insurance situation here in the United States, but if you have the ability to look for a different care provider, I hope that you will. You deserve to have a provider who you feel safe with and where you feel really seen and heard.
Anyway, so I’m at my first visit with Maya and she asked me where I was in terms of menses. I told her that I was starting to have some perimenopausal symptoms and asked a couple of questions about what to expect from my vulva and vagina over the next 10 years. After all, I spent four plus decades having terrible sex. Now, that I finally get to enjoy it, I want to maintain that for as long as possible through my 50s and 60s and even my 70s, if I can.
Maya started explaining some basic vaginal physiology to me and she included her theory about why so many women in their 40s and 50s stop giving a fuck. And that was the moment when I knew had to have her on the podcast.
Maya Strom is a family nurse practitioner with a Doctorate of Nursing Practice and she’s board-certified through the American Association of Nurse Practitioners. She practices under the name ila Health, that’s I-L-A Health in Portland, Oregon. Now, if you’re in Portland and suddenly have an intense interest in booking an appointment with Maya, you should know that at the time of this recording, her practice is full.
But she does keep a waiting list and it’s right on her website. So, go to www.mayastrom.com and get yourself on the waiting list. And when you do meet her, tell her you heard her on Good Girls Talk About Sex. I am so pleased to introduce Maya Strom!
Maya, I am so excited to talk to you today. I’ve been looking forward to this for a while. So, the people know who you are, this is Maya Strom, family nurse practitioner. You have a Doctorate in Nursing Practice and you work here in Portland, Oregon practicing at ila Health. That’s I-L-A Health. And you would not be allowed to confirm this, but I can confirm that you are my healthcare practitioner.
LEAH: Which is how we came to have a conversation during my first visit with you a few months ago about female health, about female reproductive health specifically. And as much as I know about the communication aspect of sex and the consent aspect of sex, I don’t know a ton about the physical and the physiology piece of women’s health. And you told me so much stuff I had never heard before. So, I am so excited for you to share that with my listeners, so welcome.
MAYA: Thank you. I’m excited to talk about it. Any opportunity I have to talk about sex and perimenopausal and menopausal health, I really appreciate the opportunity. Thank you.
LEAH: Awesome. Yeah. So, first my question is what is your interest in this? How did you get interested in this particular aspect of medicine?
MAYA: I’ve always been interested in working with women, people who specifically identify as women back since I was probably 20 years old. So, I have a history of being in the Peace Corps and a place called Vanuatu, which is in the South Pacific. And I had an opportunity to do work on some reproductive health education while I was there and it really sparked my interest in working specifically around issues of reproductive health like reducing transmission of HIV and sexually-transmitted infections and also talking to young people about pregnancy prevention.
And when I came home from the Peace Corps, I was pretty determined that I wanted that as my career. That was what I wanted to do. At the time, when I was 20, I wanted to work as a midwife and thought that that would be my avenue into working in reproductive health education and pregnancy prevention and reproductive rights and all of those things.
LEAH: You said that you have a specific interest with women, and then you revised that to say people who identify as women. So, does that mean people who have vaginas or people who identify as female?
MAYA: Both. I will say that the majority of my practice are people who have vaginas and I love working with all people. I often work with a lot of people who are non-binary and have vaginas. And I really enjoy working with that population as well. I do trans medicine as well, transgender medicine as well.
But I’m now 44 years old and grew up in this very binary culture of speaking about men and women. And I’m trying to be more conscious with my language and I’m trying to start consciously being less binary in the way that I speak because I want to be inclusive. And I also see everybody basically. But my experience for the last 20+ years has mostly been with people who identify as women and who have female reproductive parts.
LEAH: Okay, yeah. I very much identify with what you’re talking about. I’m a couple years older than you, but grew up in that same obviously binary gender is male and female. And now that I’m working in this space, it’s really important to be inclusive. And sometimes, I get caught up in my language. I’m like, “Ah.” The way that I just asked you that question was not nearly as smooth as it was inside my head.
MAYA: Right. Yeah, absolutely. And I feel like it’s not fluent. So, I’m constantly pausing to adjust or think about it. And it’s interesting because I have a 12-year-old daughter who has been one of my biggest teachers around that. She identifies as she/her/they and she is constantly reminding me not to misgender people and to use they/them pronouns if I don’t know to identify people by their names. And so, that’s been a real helpful daily reminder to have my 12-year-old who is fluent in non-binary language be a teacher.
LEAH: Yeah, I love that. Okay. So, now, there are two conversations that really stayed with me or two topics that really stayed with me after our conversation in your office. So, I want to start there and see where else the conversation goes.
The first was about maintaining the elasticity and health of the skin in the genital area for women as we age and as we enter into the menopausal years. And you said some things I hadn’t heard before. So, I’ll just open it to you because I’m not exactly sure the right question to ask.
MAYA: Sure, yeah. Often what happens, perimenopause, and this is the bell curve, but typically starts around age 45 and average age of menopause is 51. And menopause is defined by 12 months of not having a period. But there’s so many hormonal changes that happen during that time period. And a lot of people who have female hormones also start experiencing changes earlier than age 45 too. Sometimes, more subtle. And then, they become less subtle as they get closer to 50.
I talk about it as a reproductive hormonal evolution and that’s just something that I’ve come up with as a way of terming it. But what I find is that there’s the slow reproductive hormonal evolution that occurs in people that have female hormones starting from menarche or when they get their period through menopause.
And for the most part, these slow subtle changes and hormonal fluctuations and changes or shifting happens in these seven-to-ten-year increments, so that when you’re 30, your cycle really looks different than it did when you were 20. But you may not have noticed those changes as they were happening because they’re subtle. But then, there’s times in that reproductive evolution where things are sped up quite a bit and it’s no longer subtle. It’s pretty obvious.
MAYA: This is happening to me and I can feel it happening to me. And one of them is obviously during menarche during puberty when we’re getting our periods. It’s pretty obvious. There are some serious hormonal fluctuations happening at that point.
And then, the second is really during reproduction, breastfeeding if one choose to have babies. That’s a very sped up hormonal process that’s not subtle. And then, the last one is really at the end during perimenopause and menopause where again, that process is sped up. It’s not subtle anymore.
And so, people who identify as women or who have vaginas and vulvas start to feel a lot of changes during that time in perimenopause and menopause during that sped up process of hormonal fluctuations or the hormonal evolution.
And one of them is the estrogen starts decreasing. And as the estrogen starts decreasing, our vulvas and vaginas require estrogen, it brings blood flow, estrogen is a very sex-driven hormone. It helps drive our desire to want to have sex and ovulation obviously helps our desire to want to have sex.
And as ovulation starts to diminish or decrease or you start ovulating less or more irregularly, that can decrease our desire for sex. And also, the labia or the vulva starts to shift. And so, as you have less estrogen in the vulva, it can become thinner and drier, more likely to have little fissures or tears from penetrative intercourse and it can be very painful too.
I have had several patients describe it as feeling like shards of glass in their vagina. And if putting something in your vagina, it feels like glass, you don’t really want to do that again. That is very painful. And so, how can we support people who have vaginas, who want to have a healthy sex life or penetrative intercourse without having some of those symptoms?
LEAH: And so, specifically I remember you talking about coconut oil as an at-home thing.
MAYA: Yeah. There’s lots of ways that we can support our vulvas and vaginas. And I think that my practice is very holistic and integrative. And so, I’m trained very conventionally in the medical model, but my practice is a lot more expansive than that. And so, I tend to like to use things that are more natural. And so, one of the things is coconut oil. I’ve been doing this for so long, so I’ve had so many conversations with people about sex.
MAYA: And I love it and I love the opportunity, but there’s patterns in the conversations. You start seeing things anecdotally. You start having the same conversations over and over and over again. And one of the things that I do find is that people are not well educated about different types of lubricants.
And so, you or your partner just goes and finds a lubricant, just an over-the-counter drug store, but we don’t necessarily pay attention to the ingredients in the lubricants. And often, the ingredients in just your standard over-the-counter drug store, I don’t know if should say brand names, yeah.
LEAH: That’s fine.
MAYA: So, things like Astroglide or K-Y Jelly are not good especially for the perimenopausal and the menopausal vulva because the perimenopausal and menopausal vulva is super sensitive, way more sensitive than the blood-filled really plump estrogen-rich vulva.
And so, when you put these chemicals on the perimenopausal and menopausal vulva, the vulva that does not have as much estrogen, estrogen-depleted vulva, it can cause a lot of irritation and actually, it can contribute to dryness and painful intercourse, yeah. And so, it really depends on who you’re having sex with, how you’re having sex. You and I have talked about not all sex is penis in vagina sex. There’s lots of sex.
MAYA: And what you’re putting in your vagina, what you choose to put your vagina, whether it’s a penis or whether it is a vibrator. But if you are having penis in vagina sex without a condom, coconut oil is a fantastic option because I love it because it’s a natural antimicrobial. It smells amazing.
It’s really fun to use for foreplay in both partners and it really moisturizes both the vulva and the vagina. So, the outside and the inside. And it can really just help prevent a lot of those fissures and those tears. And I get lots of feedback from my patients who have used it and loved it. And the partners love it too. It’s like you can’t go wrong with coconut oil.
LEAH: Yeah. In the sex positive community I’m in, coconut oil is a big thing.
MAYA: Yeah, it is. That’s funny.
LEAH: Yeah. And people will do body on body slip and slide kind of stuff. You just coat yourself with coconut oil.
MAYA: Yeah. It’s really good stuff. The only downside that I’ve come up with with coconut oil is that it’s an oil, so it stains towels and sheets.
MAYA: That’s it. And so, I tell people that. Put a towel down under you if you’re concerned about that. But that is really the only downside. Otherwise, the feedback is so positive. I use it myself as well. And I think it’s just a really great natural option.
LEAH: You had mentioned that to me, to not just use it during sex, but to use it as a daily moisturizer.
MAYA: Yes. So, you can use it, absolutely. So, for my patients who are having vulva vaginal atrophy, and some people have such severe atrophy that walking is uncomfortable, sitting is uncomfortable.
And especially, there are also a lot of people who have vaginas who desire wanting to have penis in vagina intercourse or some kind of vaginal intercourse, but they haven’t had partners in a number of years. And they’re in the perimenopausal or menopausal stage.
And often, in those cases, what happens is there’s this old adage that if you don’t lose it, you lose it. And I know that’s not a very nice way of saying it, but it actually is accurate for the vagina. And so, if somebody hasn’t had penis in vagina sex for a number of years, and then they’re interested in restarting that process, and they’ve gone through menopause or they’re in perimenopause, it can be very painful. They can have very severe vulva vaginal atrophy.
And that is a process that you work with somebody on in terms of regaining the ability to start receiving into the vagina. And it’s very possible to do because the vagina is miraculous and it’s elastic and it’s an amazing organ. But that is more of a process.
And so, that’s when sometimes, you would use the coconut oil just like you said as a daily moisturizer, but you can also use it as a massage on the perineum. So, it’s like wanting to prepare for intercourse and they’ve had pain or haven’t had intercourse for a number of years and they’re in that stage, they can use coconut oil in the perineum to do a daily massage along with dilators to start assisting them.
LEAH: I was going to ask you if dilators are something that you recommend.
MAYA: Definitely. Dilators are really fantastic especially in that circumstance. And even people who are having penis in vagina sex who are with a long-term partner, whatever it might be, but are having painful sex, I do also recommend using dilators just by themselves.
LEAH: I want to invite you to imagine for a moment what your ideal sex life looks like and feels like. Who are you with? What type of sex do you have together? How do you feel while touching them? And how does your body feel when they touch you? Or maybe you’d like to be having less sex than you’re currently having. If you don’t know or if that vision of your ideal doesn’t look at all like what’s currently going on in your bedroom, I can help.
With personalized sex and intimacy coaching, we’ll explore where you are, how you got here, where you want to be, and the steps to help you get there. There are no right or wrong answers, just the answers that work for you.
I understand that exploring your sexuality and all that goes with it, your body image, your belief in your lovability and more can be terrifying. Believe me. I sat in the middle of that fire for decades. I know how painful it is. But I also stepped out the other side stronger, more confident, and more certain of my lovability and desirability and I want the same for you.
I work with couples and one-on-one, whether you’ve never explored your sexual desire before or you want to explore things you’ve never done before like maybe BDSM or non-monogamy or if you and your partner need some help figuring out how to communicate together so you can have better sex. I’m queer, kinky, and poly-friendly and I want you to have a deeply fulfilling intimate life. Together, we can help you get together.
For more information and to schedule your free discovery call, visit www.leahcarey.com/coaching. A new client recently said that before her discovery call, she was extremely nervous, but that I made the experience feel easy and comfortable. So, book your free discovery call today at www.leahcarey.com/coaching.
LEAH: There will be some people listening who don’t know what dilators are. So, can you give a brief explanation of what that is?
MAYA: Yes. So, you can buy sets of dilators and they really just look like dildos like phallic or penis-shaped objects that are typically I would say probably six to eight inches long and they come in sets of very, very narrow. So, you can choose the diameter, but they can come in the size of a pen to then larger in terms of girth or diameter. And then, you use those to help your vagina become more elastic. It’s physical therapy essentially or the core pelvic floor therapy.
LEAH: Yeah. And there’s something similar people may have heard me talk about anal dilators, similar if you’re wanting to work up to having full penetrative anal sex. You can use a similar thing.
And the one other coconut thing that I wanted to mention is you said earlier if you’re having sex without condoms, coconut oil will break condoms down. So, if you’re using them for pregnancy prevention or STI prevention, that is not a good road to go.
MAYA: Correct. You only want to use coconut oil when you have a partner who you know their status.
LEAH: The other thing that I remember from our conversation that blew my mind is you talking about there being an actual hormonal reason that as we get older, we start giving less of a fuck.
MAYA: Yes. Excuse the pun.
LEAH: Yeah, right.
LEAH: Yeah. So, can you talk some about that?
MAYA: Definitely. That’s really fascinating to me and I actually remember talking to you about this. I think that our society really focuses on the reproductive age woman and when you’re not reproductive age anymore, there’s this real cultural notion of you’re not really worth anything anymore. You become invisible. You don’t have anything else to give. And women are so much more than that and we are so much more than our reproductive status.
Estrogen itself drives our desire to want to have sex. And so, as a reproductive age person who has estrogen, they are driven, and so is their partner specially to want to have sex whenever they’re ovulating. It’s this pheromone thing. It’s this primal need. It’s a human instinct.
And then, when we start to ovulate less or our estrogen starts to decrease, it really can affect our libido and our desire to want to have sex and also our partner’s interest in wanting to have sex with us because we are not driven in that primal way by ovulation and estrogen anymore.
And so, often what happens in that perimenopausal and menopausal stage is that we have to reframe or change our framework or look at things through a new lens of how do I want to connect to my partner or partners now and what does connection look like now? What feels good to me? What is pleasure? What feels good to my partner or partners? What’s important to me around sexuality and intimacy? And that really changes as estrogen declines. It’s a hormonal function.
LEAH: There’s an entire group of people like me who didn’t have our sexual coming of age or sexual awakening until our early 40s when presumably our estrogen is beginning to decline. I assume there has to be some reason why so many of us, it happens at that time period.
MAYA: Yes. I have a theory. I don’t have any evidence. You want my theory?
MAYA: I don’t have a lot of evidence, but I have a lot of anecdotal theories. My theory is we just start caring less about what other people think about us. We start coming into who we are as people, as individuals. We start realizing that we have been mute, quiet, submissive for most of our lives and we’re not willing to do that anymore.
And I do think that there is an estrogen component to that. I think I may have shared this with you. I have a colleague of mine, a good friend, who used to be my medical director that said to me, I don’t remember if I shared this, she’s post-menopausal now and she called estrogen the inhibitory hormone, when she wanted to people-please and take care of others and not take care of her own needs and not speak up for what she wanted and needed.
But then, when she went into menopause and estrogen declined and decreased, she was like, “I don’t care what anybody else thinks of me anymore. This is what I want. This is what I need. And I’m going to ask for it and speak up for it.”
And my theory is that is what happens in terms of what you’re talking about, the sexual awakening that happens later in life because that is a thing for sure. A lot of people will report that their sexuality and their pleasure increases during that time and I think it’s because inhibition decreases. And they’re just like, “This is what I want you to do to my body. This is what feels good. This is what does not feel good,” to just be able to find your voice.
LEAH: So, the estrogen is the people-pleasing hormone. And as that decreases, it’s more okay to just be like, “Fuck that noise, doing what I want to do.”
MAYA: Yes. And that is the reason why I think that perimenopausal and menopausal women are one of our biggest untapped resources because we have so much potential and so much to offer and we are overlooked. And I think that if we could shift that, I really do think the world would change. We would have a completely different structure than what we live in right now. We are really an untapped resource.
LEAH: Yeah. Didn’t so many cultures have the idea of the crone as the wise woman and we’ve really lost touch with that completely?
MAYA: Yes. There’s so much validity in the lived experience, the wisdom, having been through all the things and knowing that there’s so much more to go through and to live through. There’s a lot of teaching that could happen during that time.
LEAH: I’m thinking about the women who have been through menopause and say, “I still have a great sex life.” And I’m curious if you think that those women have a higher level of estrogen in their systems or if it’s just one of those like, who knows? It’s just some people and some people don’t.
MAYA: Yeah. I think for those women, it’s probably more related to the fact that they were more pliable in terms of the drive. I think when people are less in touch with their bodies and so many women are not in touch or not connected with our bodies, largely related to trauma, and so I think when we’re not connected to our bodies and our sex drive is very driven hormonally because we don’t pay attention it.
We just do it because we rely on that. And then, it goes away and we’re like, I don’t want to do it anymore, but we’re not really connected to our bodies. I wonder, and again this is a theory, if the women or the people who have very rich sex lives post-menopausal are people that were already previously very connected and in tune with their bodies prior to menopause and that they were able to easily shift their framework from, okay, I’m not just being blindly driven by estrogen, but I’m being driven by these other things like wanting to be intimate and connect with my partner by these other factors. So, I wonder about that.
LEAH: Yeah, that’s interesting. Even those of who didn’t want to have children, there is still have biological imperative to reproduce. And so, maybe it switches from the need to reproduce to the desire for pleasure. However, that pleasure might show up because it’s not penis in vagina insertion for everyone or even dildo in vagina insertion for everyone.
MAYA: Exactly. And the one thing that I thought about just as you were talking is the use of birth control pills. So, birth control pills are a combination of estrogen and progesterone. And one of the things that birth control pills do that estrogen does is that it puts your ovaries in hibernation. So, you’re not ovulating.
And so, what we find is even people who are 25 or 30, young and reproductive age who are taking birth control pills have a very decreased sex drive because the ovaries are in hibernation. So, that ovulatory process is not happening so that biological process is not happening that drives that desire to want to have sex.
LEAH: And so, I know you’re saying this is a theory, so we don’t know what that means, but would you postulate that because their ovaries have been in hibernation for all those years that it then becomes harder for them to have that switch in framework that you were talking about?
MAYA: I don’t know. I feel like that’s more individual. I feel like a lot of this is so individual and having to do like I said before with somebody who may have had an experience, how connected are you with your body, have you had a traumatic experience in the past? Have you been somebody who’s been sexually assaulted or molested or had negative sexual experiences that make you want to protect your body? So, I think there’s a lot more to it than just that.
LEAH: Yeah. I know that you have a real focus or interest in trauma. Do you have any idea if trauma affects estrogen and how it’s produced and the levels at which it’s produced?
MAYA: So, I don’t think it affects estrogen and that’s an education guess. But what trauma does do and what there are really good studies to support are that it increases cortisol levels, chronic increase of cortisol levels. And when we have chronic increases of cortisol levels, that can lead to increased risk for certain chronic diseases, and then we have increased risk for chronic diseases, that can contribute to decreased desire for sex and more physical barriers to sex.
LEAH: When you say physical barriers, what do you mean?
MAYA: Pain mostly. So, we do find that a history of trauma can result in something called vulvodynia. Have you heard of vulvodynia?
LEAH: I have and I really want to know more about it.
MAYA: Yeah. So, it’s called the vestibulodynia. Dynia is just pain and the vulva is the outside of the vagina. And there’s also a vestibule and the vestibule, and I’m putting my hand up like you can see this recording.
MAYA: The vestibule is if you looked at a diagram of the vulva, it’s this area that’s right before the opening of the vagina. And people can develop severe pain in that vestibule and in the vulva who are reproductive age, so non-hormonal related stuff. And there are much higher rates of vulvodynia and vestibulodynia in people who have a history of trauma. Much higher, yeah.
So, again, trauma, in conventional medicine, we have always associated trauma with mental health stuff and mental health diagnoses, but trauma, there’s the whole neurobiology of trauma that it impacts our physical being, our biology, the way that our brain functions, the way that our system function. So, it’s really a whole system impact that we don’t think about often.
And so, that is something that when I mentioned there’s a number of variables, it’s not just like this one thing that may cause somebody to have a decreased sex drive or to have pain with intercourse or any of those things, you always want to evaluate, have a conversation with somebody because there’s often more than just it hurts when I have sex.
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LEAH: Speaking of pain with penetration, I’ve had a few interviews recently with young women an 18-year-old, a couple of early 20s, and I’m not sure if every one of them has said this to me, but I’ve heard repeatedly, “The first time I had sex, it was painful because it’s supposed to be.”
And that is a cultural myth that I’m calling bullshit on because part of reason that we’re having pain is because we’re not properly lubricated because we’re not turned on, because nobody know what the fuck they’re doing, because we don’t have good sex education, but that’s another rant.
LEAH: But let’s assume that a young couple has gone through the process of turn-on, the young woman has lubricated, that first time of being penetrated, is there an exception that it is supposed to be painful?
MAYA: Not that I’m aware of. Yeah, I think the pain is a lot of fumbling like you said, a lot of like I have no idea what I’m doing. What do you do? You put the penis in the vagina? Is this how you do it?
LEAH: Made so much worse, if you’ll excuse me, but oh my god, by religion that says no sex before marriage, no anything before marriage. So, then the first time you get in bed, the guy’s like, “I want to do this. I’m going to bang her.” And then, there’s no understanding.
MAYA: Extremely painful and extremely bloody at that point. That’s not a good scenario. But if you have sex for the first time in the situation you’ve just described, especially when there’s connection with your own body and you’ve had the ability to explore your own body, I think it should not be painful. I think there’s no reason why it should be painful. There’s no physiological rationale to say that it should be painful.
LEAH: Thank you. I’ve believed that for quite a while, but I’m really glad to have somebody with actual knowledge confirm it.
MAYA: And I do think too that there’s this fallacy that young women don’t ever need lubrication. And really, there’s some numbers out there if you do a little bit of research that probably 80% of people who have vaginas need lubrication.
So, a lot of people might think they’re well-lubricated or they feel well-lubricated externally, but sometimes internally, they’re not. And not everybody who has a vagina is able to receive insertion at the same point in the process. Some people need more time to build up to lubricate and some people need less. And also, that may change depending on circumstances. The majority of people who have sex, 80% of people who have sex, do need to use lubrication. Even if you’re a 20-year-old woman.
LEAH: Yeah. One of my very first partners, I started late I didn’t have sex for the first time until I was 25, but that first partner was very anti us having lubrication in the bedroom because that somehow meant there was something wrong with both of us. And I didn’t know any better. And so, it was painful every time.
MAYA: And so, it was painful for you.
LEAH: Every time, yeah.
MAYA: And imagine if you had been able to use lubrication, that experience could have been very different.
LEAH: Could have been very different yeah. Are there any other things that you hear from your patients? Common misconceptions that you would like to speak to?
MAYA: I do hear a lot of conversations about what is intimacy now? What does intimacy mean to me now? What can intimacy look like? And I do also hear a lot of conversations around worry about partners. I’m worried that I’m not giving my partner what I need or I’m worried that I’m not a good partner because I’m not able to do something like that. I hear that often.
There’s a lot of other things that go along with perimenopause and menopause around just organs and gravity that can also contribute. And so, if somebody is having painful intercourse or just pelvic pain, it is important to have a good evaluation. And I think pelvic floor physical therapy can be huge also in people who are experiencing it’s called dyspareunia, so painful intercourse because it can really help.
The process of the physical therapy especially if you find a good physical therapist can really help you first of all be vulnerable with allowing somebody else to put their fingers into your vagina which is really great. And it also really helps connect your body, your mind to your vagina and your vulva because you’re having somebody putting their fingers in there, talking to you about your anatomy.
And so, when you can make connections to your anatomy, really makes that brain-body connection. We’ve been driven by this culture of disconnect, especially from our genitals. And so, often I’ll refer my patients for pelvic floor physical therapy to help connect with that idea of neuroplasticity and we can just make new grooves around that.
LEAH: Yeah. If somebody’s having pain and hearing you and thinking, “I should go get this checked out, but I’m not super comfortable with my provider,” what should people be looking for when they’re trying to find a provider? Are there some words that are good flags on a website? Are there certain questions they should ask?
MAYA: Yeah. So, this is a really good question. Unfortunately, there’s no key words.
MAYA: You can start with your OB-GYN or your gynecological provider if you want and see what you get from what them. But there’s no real special words. But what I tell people, this is my medical philosophy in general is you have autonomy. You are the director of your body. You get to choose who you see and who you don’t see.
And it is okay to go see somebody and feel them out and decide you don’t want to see them anymore. It’s also okay to go see somebody and you not feel good with them and not feel comfortable in that room. And when they want to do a physical exam, you say, “No, thank you. I’m not comfortable with this.”
And so, it is really important to always know that you have autonomy over your body and the choice to choose yes for the exam or no for the exam. You never need to go through with it if you don’t feel comfortable with it and you just keep going until you find somebody that you are.
One indicator and unfortunately, this is when you wait until you get in the exam with the provider to know whether they are conscious or not is they should be asking you for consent before they touch your body.
LEAH: I have to say coming to see you was a revelation because you literally asked for consent every time you were going to put your hand on my body. Even though I had been in the room with you at that point for 45 minutes, you still asked every time you were going to put your hand on my body. I had never experienced that before.
MAYA: Yes. And that needs to be the standard of care. I should never touch your body without your consent even if I’m listening to your heart, even if it seems like a benign simple thing, it is not safe. It’s not acceptable for me to touch your body without consent. And so, I always say that that’s a red flag.
For me, with providers, and I always say as well that use your voice when you’re in a room with a provider. It is that idea of do what the doctor says is so old school. We don’t have to go there anymore. It’s a collaborative conversation. And so, if somebody starts to touch you without your consent, you can say, “Can you please ask for my consent before you touch me?”
LEAH: Wow. And something else that I just learned in the last few months is that you don’t have to consent to being weighed.
MAYA: Correct. I actually also don’t weigh my patients. I say that I deemphasize weight.
MAYA: I will ask for stated weight sometimes at the initial visit when they’re first establishing with me. But I do not weigh my patients unless there’s a medical need or the patient requests being weighed. Absolutely, you can say no to whatever you want to say no to.
There’s this idea in medicine that you just have to do everything they tell you to do. And I think that’s set in this very patriarchal again dogmatic culture that we have that this person is the authority or this system is the authority and therefore, I have to do everything they tell me to do.
And frankly, I think that can be extremely triggering for the majority of women who have been traumatized in their lifetime, which is probably at least 50% of us. Yeah, so it’s one of my biggest soapboxes and I wish I could just scream it off the rooftops that you have full autonomy. You choose what you say yes to and what you say no to. And if you feel uncomfortable at any point in the process, you could walk out the door.
LEAH: I wonder in terms of, sure, there’s not a code word that people put on their website, if there’s a way that when you’re calling the office to find out if a provider might be a good match for you to ask what their practices are around consent?
MAYA: I do think it’s important to look for trauma-informed providers or trauma-aware providers. When you call, you can ask is this a trauma-aware or trauma-informed practice? And I think it’s becoming a little bit of a buzzword. And so, a lot more people are using that terminology who may not really know what that means or may not embody that type of care.
LEAH: They might have done a weekend warrior kind of class.
MAYA: I think that some people are just more naturally trauma-informed or trauma-aware than others. And I think there is some common sense to it and there’s a lot of intuition to practice that way. And also, there’s a lot of how would I want to be treated? This kind of sense of compassion like I would want to be treated this way and I’m going to treat my patients this way.
LEAH: Maya, this has been amazing. Thank you so much. Is there anything we haven’t covered that you think we should?
MAYA: I can’t think of anything. No, this is great.
LEAH: Will you come back?
MAYA: Will I come back? Sure, absolutely.
LEAH: Excellent, okay.
LEAH: That’s it for today. Before we go, I want to remind you that the things you may have heard about your sexuality aren’t true. You are worthy. You are desirable. You are not broken. As a sex and intimacy coach, I will guide in embracing the sexuality that is innately yours no matter what it looks like.
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