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.
"Sometimes it's not actually weakness of the muscles, but tension in them that limits their effectiveness and prevents them from doing their job—keeping you dry," says Leonard. In other words, don't do your kegels like you're training for the Olympics; more is not always better, especially if you aren't doing them correctly. Instead, follow the advice of a trained PT on the type and amount of kegels that are optimal for you to prevail over the bathroom blues.
What can vaginal odor tell me about my health?
"A normal vaginal odor will have a musty, earthy smell. It shouldn't be strong," says Liz Pickett, a midwife and women's healthcare professional based in Kingston. The presence of a sharper, more pervasive odor can be a sign that something is wrong—and when that happens it's best to come in for an examination. En route to a diagnosis, Pickett will ask questions about additional symptoms such as vaginal discharge, itching, or pain. "From there, you can get clues or rule things out: Is this bacterial vaginosis (BV), a yeast infection, or pelvic inflammatory disease?"
Vaginal ecology is about pH balance; a healthy vagina will be slightly acidic, with a pH between 3.5 and 4.5, and will secrete small amounts of discharge to keep itself clean (much like saliva keeps the mouth clean). Yet a number of disruptors can throw the pH off balance: menstruation, tampons, soap, douching, sex, or sitting in a wet bathing suit or sauna for too long. If the pH of the vagina gets too acidic and wipes out too much good bacteria, the result can be a yeast infection. If it gets too basic, an overgrowth of bad bacteria can create bacterial vaginosis (BV), which is characterized by a telltale fishy odor. Pelvic inflammatory disease (PID) can cause a strong odor as well, along with pain and fever. "I always tell people the vagina is a self-cleaning organ," says Pickett. "Don't use soap in it—just water. Soap can wash out the good bacteria, and there's a reason why it's there. Women are so self-conscious about their odor. It's a cultural stigma. People think of their vaginas as these dirty things."
Pharmaceutical treatments can help with BV—but if the odor is persistent, Pickett recommends inserting a probiotic capsule vaginally every night until it's resolved. In clinical trials, the probiotics Lactobacillus fermentum and Lactobacillus plantarum were proven effective. Probiotics can also be used preventively. "If you've been tested and you have normal flora but still feel like you have an odor, you can use the probiotics vaginally," says Pickett. Most important, she adds, "Don't try to diagnose or treat yourself. You should always see your doc."
Can acupuncture help me last longer in bed?
Male patients sometimes come to Ben Fleisher, acupuncturist and owner of Woodstock Healing Arts, because they've heard that the ancient Chinese healing practice can help them regain their youth in the bedroom. There is some truth to the claim, says Fleisher. "Acupuncture can definitely help with erectile dysfunction. A number of older gentlemen have verified with me that things have improved for them in that department. There's a certain glimmer in their eye when they report this to me."
For men who would rather not take a pharmaceutical like Viagra, an alternative treatment like acupuncture can hold appeal. While there are no clinical studies verifying acupuncture's efficacy with erectile dysfunction, Fleisher points to anecdotal evidence from his own practice as well as a few documented case studies. The holistic approach of traditional Chinese medicine might have something to do with its purported success. "The question is, why are you not lasting longer, and what are your expectations? Are you thinking too much of 'performance' in the bedroom? Is there another underlying issue such as chronic pain? Usually by addressing those questions I can help with someone's overall health—psychological, physical, and sexual health. If someone is not comfortable in their body, or they have some kind of chronic distraction from being intimate, you can address a lot of those things with acupuncture."
Patients often ask if there is one acupuncture needle in particular that can work bedroom magic. "There are a few," he says. "If we are using those needles, someone with erectile dysfunction would notice a difference." But again Fleisher emphasizes the holistic piece. "Acupuncture helps with overall metabolism. We do a lot of lifestyle and dietary changes to improve how your body is functioning, and that often results in having a better time in bed."
Can Lyme disease be sexually transmitted?
When you live in a region where Lyme disease is on everyone's lips, and spring brings fresh worries about tick-borne infections, it's inevitable that questions about sexual transmission will come up. The notion is not far-fetched, says Hyde Park-based Lyme specialist Richard Horowitz, MD, author of How Can I Get Better? An Action Plan for Treating Resistant Lyme & Chronic Disease (St. Martins Griffin, 2017). "Lyme is a genetically related cousin of syphilis, which we know is sexually transmitted." Like Borrelia burgdorferi, the bacteria that causes Lyme disease, syphilis's Treponema pallidum is a spirochetal organism. The relationship between them inspired two published articles by Drs. Ray Stricker and Maureen Middelveen on the potential sexual transmission of Lyme. "What they found is that there were a small number of spirochetes that were present in sperm and vaginal secretions," says Horowitz. "So in the study it was suggested that Lyme could be sexually transmitted, like syphilis. But the difference is that when we look at epidemiological data on the transmission rates of Lyme, we see that there are spikes during the spring, summer, and fall, but not in the wintertime. We also know that with the transmitted disease you generally need very high levels of the organism, a large amount of the bacteria. So although it is theoretically possible, especially if someone has lesions and the spirochetes could get in, it is probably unlikely with the vast majority of the population. We definitely need more proof."
Yet tick bites are not the only way to contract Lyme disease. "There is a large body of scientific evidence, which has essentially been ignored by the OBGYN population, that Lyme can be transmitted from mother to fetus, and not just Lyme but other borrelia species like relapsing fever and bartonella," says Horowitz. "These are important questions for women wanting to get pregnant, or who have had multiple miscarriages, as we see sometimes with Lyme disease."
Another interesting connection between Lyme disease and STDs? Lyme is the number two most common infectious disease in the United States. The number one position goes to...chlamydia.