Sexual fantasies. Incontinence. Vaginal ecology. Erectile dysfunction. STDs. We might skirt gingerly around issues like these with our doctors, if we are the modest sort. Or we might get down and dirty with them. For this article, I chose to get down and dirty. I asked five health professionals to share their patients' most intimate questions, along with their expert answers. Here's the netherworld of knowledge we uncovered.
Are my sexual fantasies normal? And what about that other taboo: masturbation?
When people come seeking the intimate counsel of Garrison-based sex therapist Marian Dunn, PhD, some express worry about their sexual inner world. "Many women feel embarrassed if they have rape fantasies," she says. "It's not that they want to be raped. The fantasy is never violent, and the perpetrator is handsome, seductive, and giving them pleasure against their will. But it goes with the female script of being inhibited and not wanting to admit that you are very sexual, that you have sexual feelings. It's 'I couldn't control myself; he was doing this to me. I didn't have responsibility.'" Dunn reassures her female patients that fantasies like this are common and can be used constructively in the bedroom. "They can maybe use it for arousal, to be more turned on when they are with their partner."
Sexual fantasies usually start when we are young and are rehearsed during masturbation, explains Dunn. "So they become kind of fixed, and people are concerned about that." People who fantasize also often feel guilt—a sense of disloyalty to their partner because they are thinking of another person or another scenario during lovemaking. "They might feel like masturbation is safer," she says. Yet masturbation itself often comes saddled with the weight of taboo starting in childhood. "People are uncomfortable talking about it, even though it's normal. Yet studies show that the majority of people do masturbate, even if they have a sexual partner."
Dunn suggests thinking of masturbation as a way of learning about your body—"the kind of touch you like, the kind of pressure you like, the kind of pace you like. Then it's much easier to share it with a partner." Masturbation can also be a way of equalizing sex drive. "If he has a higher drive than she does, maybe they make love once a week and he masturbates a couple of times a week. Or vice versa." And of course, it can be a way to be sexual when someone doesn't have a partner. "Masters and Johnson say that with sex drive, we use it or we lose it. With aging, if there is no sexual activity in a man, he tends to have more difficulty getting an erection. And I think for women, the less sex they have, the less sex they want to have. So masturbation can be a way of priming the pump, keeping things in circulation."
I know where every bathroom is from New York City to Albany. Can you help me with...incontinence?
The shame of springing a leak can make people want to run and hide rather than seek out medical advice. With 25 million adult Americans suffering from some form of urinary incontinence (75 to 80 percent of them women), that's a lot of red faces. Yet incontinence is treatable in many cases, and not just with surgery. "There's a lot we can do," says Cathy Leonard, a physical therapist specializing in pelvic rehabilitation at Northern Dutchess Hospital in Rhinebeck. "Once we identify the type of incontinence, we establish a treatment regimen and in many cases resolve the issue."
Sometimes a cough, sneeze, or laugh can trigger a bit of leakage; these are signs of stress incontinence, which often results from underactive or weak pelvic floor muscles. The first-line treatment is kegel exercises to strengthen this region—yet "90 percent of women who come to see us perform kegels incorrectly," says Leonard. "Many perform them in a way that promotes incontinence." Doing it properly involves isolating the pelvic floor muscles and pulling them in and up ("you should feel your vagina and/or rectum lift"); the belly, legs, and buttocks should stay relaxed, and the breath should not be held. Kegels are a cornerstone treatment, yet they are not the only approach. If the problem is not leakage due to stress incontinence but urge incontinence—characterized by increased frequency and urgency of urination—therapy will involve working to change bathroom behaviors, such as avoiding using the toilet "just in case," which can lead to an overactive bladder and make the problem worse.