Bringing Back Sexual Intimacy for Couples after Treatment

[00:00] Moderator: Welcome to the workshop, Bringing Back Sexual Intimacy for Couples After Treatment.

My name is Marsha and I will be your moderator for the workshop.

It is my pleasure to introduce this evening's speaker, Dr. Theresa Callard-Moore.

Dr. Callard-Moore is a sexual health specialist in the obstetrics and gynecology department at Cleveland Clinic with a secondary appointment in the Neurological Institute. She is a licensed clinical social worker, certified sex therapist, and certified sex addiction therapist with a PhD in clinical sexology.

Dr. Callard-Moore's passion is educating patients and care partners that sexual health is an important part of overall health and wellness. She has been in the mental health field for over 30 years and takes a holistic approach to helping patients.

Please join me in welcoming Dr. Callard-Moore.

[00:54] Dr. Callard-Moore: Hello, everyone. I'm so glad you could join us this afternoon. I am so excited to be here to talk about sexual health with all of you.

Let's start with the basics. What is sexual health?

I think if all of us were asked that question, I don't know that we would be able to come up with a good answer.

It really is a state of emotional, physical, mental, social well-being in relation to our sexuality. And it's not just the absence of disease or infections and things like this. It really is the possibility of pleasure and having safe experiences, but also having a safe place to talk about that with your caregivers. And that is what I am here to talk about today.

How to talk about that with your partners, how to talk about that with your caregivers and how to weave this into your treatment as you go through your process.

[01:55] The number one problem for everyone is that we did not get enough sex education ever, anywhere, ever. It really is a problem because we didn't learn the basic skills to communicate about pleasure and how to negotiate our pleasure and our partner's pleasure and also consent, how to revoke consent.

We just have no information whatsoever, and that leaves us in a state of longing. It leaves us in a state of confusion. It leaves us in a state of feeling like we're not normal. And if we're trying to figure out, am I normal? I don't know. 

We're comparing ourselves to what we see in TV, what we hear in music, what we see in movies, Top Gun kind of movies. Every movie is really the same. Everybody always wants sex. They meet, they kiss, they throw each other on the bed. They have intercourse. They have orgasms together. It's a blissful moment for everyone involved.

[03:03] When people watch those scenes, they think, oh, that's not how it's working for me. I don't look like that. I don't feel like that. I couldn't do that. I couldn't perform that way or that quickly. And I'm not orgasmic that way. My body doesn't look like that anymore. We come away from seeing these scenes and think, I'm not normal. Am I broken?

[03:28] This is before treatment even. Honestly, everyone I say that to, they nod their heads and go, yeah, I've thought that. Sure. This is just how we're all feeling and then we start to compare. We compare to how we felt when we were younger, maybe before diagnosis, how you felt. When you first got together, how it was, right? Usually you're higher, the higher sex drive, higher sexual functioning is happening.

We compare ourselves to our partners because our partner may still have a sex drive and yet we don't. We could compare it to our friends and family, but we usually don't even talk about it with our friends and family because it's too weird. It's too private. It's too embarrassing.

[04:08] It leaves us in this state of confusion, and I need to talk about this piece before I can even talk about what it's like after treatment.

The other piece that's very important here is how sexuality has been experienced. I wish and hope that everyone's experience was pleasurable, playful, comforting, connecting. That's my wish for everyone.

That's not the reality of how sexuality is experienced. Some people figure out it's a fantasy of how they think it should be or how it's supposed to be. 

Some people avoid it. They try to be abstinent on purpose, maybe for religious reasons, cultural reasons. 

Some are asexual. 1% of our population isn't interested in sex at all. They don't want to see it on TV. They don't want to experience it.

Some are focused for only reproduction. It's only to get a pregnancy, achieve a pregnancy or another pregnancy.

Then some people use it as a way to get some love and acceptance and connection. But it's not true connection. And they tend to be manipulated or exploited sometimes by other people.

Some are obsessed with it, desperate longing, right? This is where I get into sex addiction, which I'm not going to touch on today, but there is an experience like that for people.

Then that whole bottom row, I would say would be negative experiences about sex, that it's been used to achieve power or coercion in the place of workplace sexual harassment, be traded for goods or services because someone might need food, clothing, shelter, or some other need, and they're going to do sexual things to get that. And exploitation, abuse, rape, all those things would be obviously the negative, violent forms of sexuality.

[06:08] When we think about talking to a sex therapist, and if that has been your experience, let's say a very negative experience of being abused, then the idea of talking to a sex therapist and having more sex sounds terrible, right? It's not my job to tell people to have more sex. My job is to find your sexual health and help you explore that with yourself and or your partner.

[06:32] The number one problem I see and hear about is low libido. Number one. I think that's true across the board and probably very common for a lot of people here today. Because we have this sense that we're supposed to have this feeling that says, oh, yes, I want pleasure. Let's have pleasure. Can we have pleasure now?

We're supposed to have this feeling, this urge, this drive that tells us we want sex, and the reality is that's not true for everyone.

[07:01] Males have that drive kicking about 75% of the time. We do hear it more from men that they think about sex, they're able to be sexual or interested to be sexual very quickly.

Females, it's not true. The average is about 15%. So, and again, this is average. This is before treatment, anything.

15%. You could be in the middle of your day and think, oh man, it'd be really nice to watch that show and make out on the couch. That sounds great. Right, and then the very next thought could be, oh, did I send that email for Tuesday's meeting? Let me make sure I put down, we need ketchup for our hamburgers on Thursday. We literally are jumping right over into our other subjects that we think about because that's what our brains do. Especially as women, we're constantly thinking about what's best for the village at all times. If we don't have that first drive, kind of driving that, it tends to go to the lower scale of our priorities.

[07:55] There is a whole other version of that. It's called responsive desire. And I'm going to teach you all about that.

But first, I want you to know it's normal to have low libido. Okay, what we want to look at is can we warm it up? And stay tuned, I'm going to show you what that means.

[08:12] So here's those statistics I just mentioned, 75% of the time men have that 15% for women. Here's a graph of responsive desire, but here's my simple explanation.

It's four types of categories coming together. 

The first category is, am I feeling close and good with my partner, right? If that's a no, chances are you're not going to be sexual in any form. But if we're getting along, yes, this is my best friend.

The next category is everything in your environment outside and everything in your environment inside. Those variables could be it's too hot. It's too late. I'm tired. I just woke up. I need to brush my teeth. Could I take a shower and shave? I don't feel really comfortable. I want to take care. Maybe I'm fatigued. Maybe I'm nauseous from that treatment we just did. You know what, partner? Could you make sure the dog is not scratching at the door and the cat's not in the room? Because that's going to throw me off too. 

We really need to know everything is okay in our environment. No one's going to hear us. No one's going to see us. No kids are going to jiggle the doorknob and try to come in. I need to feel everything is good in order to relax and choose to be close with you. Okay, so that's the second one.

[09:33] The third one is thinking about this as a psychological desire, not a “hot for you baby” feeling, right? We're looking for this feeling usually and I'm saying let that go. Let's go up here in our heads and go, am I choosing pleasure? Am I receptive to pleasure?, and I'm, it basically, I'm saying, yes, I'm going to be close with you and I'm going to try and let's see what happens.

The fourth element is time. We really need a minimum of 20 minutes for our bodies to kind of wake up and warm up, and really we look at three outcomes. This is true for men and women. I hear this more on the female side, especially when I see women who have gone through medical issues and menopause, perimenopause.

That is A, I feel this warm up. Like, okay, yeah, I'm feeling close to you. This is nice. I'm not super turned on. I'm probably not going to be orgasmic, but I'm happy we're doing this. Okay, that's A.

[10:35] B is excited and hot. This is what we were looking for. Oh my gosh, it worked.

[10:42] And C, I call the dead battery, and that is, I'm choosing to be close to you. I'm saying yes. But my body is saying, no, I can't get into this.

It doesn't feel right. It doesn't feel good. I'm not sure. I just can't warm up to this, and it's been 20 minutes. Can we stop rubbing and touching in this way because it's not working for me? That dead battery is still a normal outcome, again, for anyone, okay?

[11:09] But we think something's wrong with us if we have A only or C, that dead battery. Where we think we're supposed to be on and ready to go with that “hot for your baby” feeling.

So, this is my way of saying, know sometimes these things need to come together, and it feels like a combination lock. Sometimes the combination hits and sometimes it doesn't, even if you're doing the exact correct thing that worked last week..

Partners sometimes get thrown off by that. because they're like, I think I know what to do. This is what's worked for you every time. Why isn't it working today? What is wrong? And there's nothing wrong. It's just these variables are thrown off.

[11:50] Okay, I'm saying all that because I want to normalize your experience.

This is another model that I really like, and it ties in with what I just said. Really asking yourself, am I capable of pleasure? Am I receptive to pleasure? Which is our key question.

[12:07] Then the next question is, does my body have the capacity to respond? Am I able to get aroused? Do I have enough lubrication for penetration? Am I getting an erection, keeping an erection if we're wanting to try for penetration or need an erection, right? Is the body working? Because that's a whole other level and we can add sex therapy things to those if there's an issue there.

[12:26] Then the other piece is it's not about the orgasm. Right now, the model on the TV, the screen is kiss, touch, intercourse, and the focus is intercourse and orgasm. And I say, you know what, that's not our best model. Let's focus on pleasure, connection, right? And orgasm can be a side effect to that, but it's not our main event, nor is intercourse.

I usually tell people, let's not make that our main event either. Let's focus on pleasure and I'll talk more about that later.

[13:01] If we're able to move into arousal. So here we have desire, maybe a warm-up, maybe we've moved into arousal. This is what happens, there's changes in our body. We're perceiving it to be pleasurable, we're consenting, but the body is now responding accordingly to that.

In female bodies, the genitals would get swollen with blood, so the whole vulva gets puffy. The clitoris gets more sensitive and more erect as well; it gets firmer, and we would produce lubrication. We may still need extra lubrication, especially if there's been a perimenopause, menopause, or medical menopause as a part of your treatment.

[13:33] For men, there's an increased blood flow to the genitals. The erection would come on, and we are able to keep that erection while we're being sexual, depending on what we're doing.

[13:45] The next slide goes into if we can build up that arousal, first gear, second gear, third gear, fourth gear, we can usually tip into an orgasmic state. 

Now here's the thing. Females need usually clitoral stimulation with a hand, mouth, or a toy. It's not required to have intercourse usually for orgasm. About 15% of women can have orgasms with intercourse.

[14:14] Here's the problem though. No one's really told us that, so we expect intercourse to have that achieved outcome because that's usually how males have orgasms. Women, if they can't orgasm every time, or if they can't orgasm with intercourse, they again think something's wrong, and I'm telling you, there's absolutely nothing wrong. Let's find what works for you. And usually it's clitoral stimulation if you're receptive to that pleasure.

[14:42] When we start to look at female sexual dysfunction, this slide captures it really well. All the medical issues can lead to some levels of sexual dysfunction. The most common that I hear would usually be pain or vaginal dryness. And that is pain with intercourse.

That's called dyspareunia in the medical field. That's our purple circle here. If you're having pain, it's automatic that you're going to have low desire, either spontaneous or responsive desire, because your body's going, oh, I don't know if I want to do that. It may hurt. Or it hurt last time or it hurt once. I'm not sure.

[15:18] So your desire is going to go down, and because your desire is down and you're kind of bracing for some pain, you're automatically not going to have that arousal build up. It's very difficult to feel good when you're having pain, and then you're not likely to be orgasmic either.

Because all those things are happening the inside the body, the muscles are starting to tighten up and say, I'm not sure that I want to have some penetration with the finger toy or penis because it's going to hurt. So those muscles cramp down and now we have symptoms of vaginismus.

Vaginismus is its own issue, but pelvic floor dysfunction becomes a part of the circle.

This is what female dysfunction looks like. It's very hard to separate one circle away from this whole map that we have.

[16:01] I'm going to stick with women for a second because I feel like this one describes a lot of what they go through because of menopause. and for partners who are on this call as well. I'm so glad you're here and I wanna help you understand it too.

When I'm looking at someone, the first question I ask here is how's the relationship?Are we getting along? Remember that was step one. If we're getting along and everything's really great, wonderful, that's not our issue.

But if there's stress in the relationship, then I say, okay, that's where we're gonna start because this is the most important thing that really is throwing us off.

Then we move into the medical conditions and if you're getting treatment currently, right?If you've just been diagnosed, your body's still in shock. You're coping with this serious thing that's just came into your life and now you're getting treatments, okay?

Your body is going through all of those things, all right? It's processing that. We're going to feel poked, prodded, nauseous, sick, all the things that come with this, right? So all of that now is really a traumatic effect on us, no doubt.

[17:17] Then we go down to the layer of hormonal changes. If there is perimenopause, menopause, anything like that, that's now another layer to what's going on. And it can cause us to feel like we can't respond accordingly, or we're not interested, of course.

Then that last quadrant is when I ask about any kind of other trauma. And here's where we go back to that sexual history of has there been abuse, trauma, and other ways that have affected your central nervous system that puts the brakes on for you. Okay, so understanding all of these are at play and there's layers to why you're feeling what you're feeling. My job is to help people understand why they feel what they feel.

[17:59] When we get into male sexual dysfunction, here's what we see. Low libido absolutely can happen as well.

Erectile dysfunction is probably the most common along with delayed ejaculation. If the cancer treatment was, for example, prostate cancer treatment, sometimes they're not able to ejaculate any longer. They could also have retrograde or dry ejaculation. Premature ejaculation is a common thing even before medical treatment.

[18:31] Peyronie's is a curvature of the penis that prevents penetration. Then we look at body image things for everyone, right? Scars from surgeries, sensitivity, hair loss. There's things that happen to us that change how we feel about our body and how our body is working, especially when we're being sexual or close with partners.

We get into fertility concerns, and then all of those things do end up leading to performance anxiety or worry because they're worried that their body's not going to work when they want it to or used to.

[19:05] So here we are. Those are normal sexual issues. And now we're moving into this medical condition that's happened and how to move into your new normal and into surviving and thriving.

I talk to my caregivers and they always ask, when should we bring sexual health up?

First of all, I say, yes, bring sexual health up, and then they say, should we bring up a diagnosis, treatment or in survivorship? And I say, yes, bring it up in diagnosis, treatment, and survivorship. Hopefully that has been your experience.

My fear is it hasn't been because when diagnosis happens, the focus is on the acute need. This is what's going on. This is what we need to do. Let's come up with our treatment plan. Sexual health usually isn't brought up, not very often, and we're trying to work on that.

[19:55] But then you're in treatment. Is that going to be the top of priority? Maybe not.

But what I tell my caregivers is, let's bring it up. Are you having any concerns? Let's talk about how this procedure or treatment may affect you and your body. And that can also affect sexual functioning or how you feel about your body.

[20:16] And during treatment, this is how this is going. Are you having any sexual health concerns? Let me just check in with you. Because that tells you that this is an okay caregiver. We can feel safe and we can bring up any questions or concerns we have.

The majority of people bring this up in survivorship, right? We've gotten through it. We're trying to feel like we have a new normal. What does that look like? How do I do that? Okay, that's when sexual health tends to come up the most. That's when you're maybe ready to hear some of it. But I want you to know it's okay to bring it up at any time with your providers. And I'm encouraging them to bring it up with you during all of those sections as well.

Here's the biggest turn, right? When we're going through it and we're surviving it. There's layers upon layers of complex grief.

You're mourning losses. Losses could be, I can't go to work. I can't play with my kids the way I want to. I'm worried about fertility issues. I'm feeling depressed. I have survivor guilt about the people that I've seen in the lobby, and my outcome was different than their outcome. I'm having body image issues. I don't feel good about what I see, right? I don't feel good about taking my clothes off in front of my partner or myself for that matter. Who am I now? What is my identity? If I am not working, what's my identity? If I'm not being the parent I want to be or the partner I want to be, what's my identity? And of course, all the medical trauma and fear about the diagnosis, the fear of it coming back, all of that. That is clear.

[21:47] When we start to move into thriving it's like; let's move forward with your life.What does that look like? What are your long-term goals? What are your immediate goals, right?

Can we get up and maybe get out of the house and maybe try to go to work today or do something active with the family today and maybe rest for one or two days afterwards and see how we do?

We're seeking help for any mood concerns. Maybe we have residual depression about this. Maybe we had a history of anxiety before treatment and now that scansiety is happening and we're worried about what that's going to be.

[22:28] Maybe we need to get some extra help for anxiety and depression. We're going to cope with those feelings. We're going to find a purpose. We're going to work on accepting your body, what it looks like, how it feels to you now, and we're going to practice self-care and boundaries.

[22:42] The thing that I really like to talk about, and I hope we have a lot of caregivers on with us, is how it's affected your caregiver, right? They immediately were in this role of, I'm terrified of losing you, and I need to fix everything. I need to take care of everything. I feel powerless that I can't do more. I feel complex grief about the things that we're unable to do like we used to do.

They're fatigued. They're financially stressed. Maybe they have difficulty with depression, anxiety, anger, and substance use. Those things kicked up because of what's going on. So, caregivers take a big stress as well, but they're doing the best they can. Then when we move into survivorship they're saying to themselves, I would love to move back into being a lover with you again. How do we do that? What does that look like? How can i initiate things? Am I supposed to initiate things? Should I wait for you to initiate things?

[23:38] I don't want to force you. I don't want to push you. I don't want to hurt you. Right?

So, they're really struggling with being vulnerable. They're not sure what to do, how to do and they're interested, but it's such a big shift of thinking for the partners. Hopefully that makes sense to all of you here.

[24:00] Then I, as a therapist, I start to look at what are our barriers to being sexual. What are the breaks that are showing up?

Low desire, we've already covered fatigue, nausea, pain, hot flashes, weight gain, mood changes, scars. And I've mentioned loss of hair, changes like this, concerns about infection, right? Your immune system has been affected by everything you've been through. I think you need to think about that.

Is it okay to kiss? Is it okay to have unprotected sex. We've always had unprotected sex. Is that okay to do now? I don't know, right? We need to navigate all those things.

[24:38] Maybe you have other symptoms as well, depending on what you've been through. It could be leaking urine, bowel changes, scars, numbness on site and sites of surgery, things like this that can come up. So there's so many barriers.

But what I do in sex therapy is say, let's identify those barriers and let's see, can we get creative? Can we work them through? Or is that something we're just going to take off the menu?

[25:02] I'll show you what I mean in a moment about that. What we're looking for is accelerators, which are, this is my jazz hands way of saying that, like, yes, I'm interested in that.

Then there's this sort of neutral place of, I'm not sure, right? I would call this a yellow, like, I don't know. I'm not sure.

This is green. This is yellow.

Red is no, I can't do that. I won't do that. That's not working for me. It hurts. I don't like it. Anything like that. We start to map this out together and that tipping point can really move. It's like oh okay that touch feels nice, and that kiss feels nice, and then all of a sudden a different touch. It's like oh I don't like that, or that feels weird, or it's supposed to turn me on and I don't feel anything.  I'm not able to get aroused, so it almost feels like green red green red green red, and I want you to know that that's normal.

[26:02] The next slide shows us there are so many variables. This is kind of a small print. If you're looking at the screen, I just do that because there are so many things that can throw you off. 

Do you remember me talking about those variables? It could be the cat scratching at the door that throws you off. So anything like that can throw you off. I just want you to understand it's okay. And I think we can find ways to warm it back up. Let's communicate about that.

[26:26] It really is this calculated vulnerability and communication with your partner, right? I'm willing to do this. Oh, that's not working. Let's lean away from that and try something else. Okay. Yep. That feels good.

Oh, nope. That doesn't feel good. Wait, let's try that again. It looks a lot like that.

And that's what I want to model for you because that's not what we see in the movies, right?

We don't understand that this is sort of a touch and go thing until we figure out how to find a nice rhythm and a nice recipe.

The biggest thing I tell people is let's focus on pleasure. If you haven't been sexual in a while, and chances are that's true, okay, for a lot of you, it feels like climbing Mount Everest to get back to this, right?

It's like, how do we even start? Let's start with you, each of you, and finding simple pleasures. A bite of a yummy food, right? Like, that's really nice. I love people to even tie a number to it. Like, oh, that's a five. That's a five out of 10 right there. That's a seven. That tastes great, right?

[27:32] Anything simple like that, going for a walk in nature, hearing your children laughing, you laughing could be good.

Relaxing with a good book, holding hands, something very simple, but still connecting, getting some tasks done, right? having an initiative and moving through some things that you really wanted to get done and you haven't been able to do possibly, exercising, feeling productive. It's like, oh, that felt good, right?I might need to rest still, but it felt good to do that.

Noticing those moments of pleasure, and we're going to extend them out. We're going to kind of focus on them, being mindful about them and broaden them as much as we can.

Then when we start to look at the sensual, sexual side of that, because those were simple things, now we're going to get into more sensual. Really giving yourself a chance to think about things differently, right?

And I love this phrase, I'm on my way to blank. I'm on my way to accepting my new body. I'm on my way to thinking about pleasure. I'm on my way to receiving compliments about my hair. I'm on my way to feeling better and feeling healthy. Anything like that.

If we're coming from that mind space, then we start to fill up that as our tank, right?That's the lens we're seeing everything through and it starts to feel more positive as opposed to the negative way we could think about things.

[28:58] Then I recommend simple things like taking a shower or bath and really spending time of touching your own body. How does this feel? Does this feel okay? What do I think about this part of my body?

Let's try to come up with affirmations about this part of your body. Like these arms have held people that I love. These arms held my children, right? I love these arms. Thanks for that, right? 

And in your face, in your hair, in your neck, in your chest, in your stomach, right? All the way down your genitals, hips, knees, toes. I want you to really work on warming up your body. We have seven to 13 erogenous zones on our skin. Chances are you've only found three and stuck with them. Because that's usually what people do.

[29:43] I want people to expand that. Let's find out what feels good, right? If we kissed and touched from head to toe or used a feather from head to toe, how does that feel? Are there places that feel good that you didn't even know about? Let's find them, all right?

Then, when you're ready, you can start self-stimulating. If masturbation is okay for you and your belief system, you can start with self-stimulating and just say, how does this feel? Am I noticing that I can kind of warm up to this? Do I get aroused? Could I be orgasmic, right? Is it working? And just kind of see what you feel.

Let's see if we can find some pleasure and see if we can let it build up and kind of ride these steps here and know that every response is still normal, but we're just going to notice it, and if we start to notice things that are neutral or good, those are the things you can start to share with your partner when you're ready, okay?

[30:38] The next way, this is my favorite handout. This is, and this is a simple thing you can do.

Get three pieces of paper. The first piece of paper says green lights on it. Second says yellow. Third says red.

Here's some examples. You could say, all right, what is always a yes for my partner and myself? If you have a partner. If this is by yourself, that's okay.

What's yes for you? It's okay to hug. It's okay to hold hands. It's okay to cuddle, watch TV, have dinner, go for a walk. Anything like that. Normal affection. You would do this with children too. This is PG stuff usually.

[31:13] We need to have that connection before we can build on that and move into sensual connection, which to me is the yellow lights, okay? But before we go to yellow, I want to go over to our reds.

As I already mentioned, there are things that could put the brakes on, right? There are things that you're just already, no way, no how, I've never liked this, okay?Don't ever do it. But we may have new things that are red that we didn't know we had.

You might get cramps. You might really run out of steam because of fatigue with your treatment. You might get nauseous, right? You may have pain with intercourse that you didn't used to have. You may lose an erection. It could be anything, right? I'm back to the cat scratching at the door.Anything could be a red.

[31:58] If you hit a red, identify that. Tell your partner, hey, this isn't working. Can we and pivot to move to something else? Can we pivot to a yellow or can we pivot back to cuddling? I’m just not able to do this right now. Let's go back to just neutralizing it and being close, so we have that connection and intimacy the whole time.

[32:21] Now, if it's good and we don't have any reds, now let's go to yellow lights. And I love to think of 30 things.

Here's your challenge, 30 things that you can come up with that says this makes us feel close and connected.

The first 10 are sensual and playful, but not necessarily orgasmic or erection not needed here. It could be, could we take a shower together, if you're okay being naked in front of your partner? Could we cuddle without clothes on or very little clothes on? Could we do massages on each other and just get used to touching and giving maybe some instruction on what feels okay, what doesn't feel okay? Just kind of open up. Could we tickle with a feather? Could we use an ice cube, right? What feels good? Let's explore.

 [33:11] Then if that is okay or you're ready, you can move on to adding the second section of the list. That would be our more obvious sexual things.

Could we get in between our ears again and think about maybe that sexy time we took that trip that was so hot and fun, right? Let's talk about that. Let's use that as our springboard to kind of warm things up.

You could make up erotica. You could watch erotica. You could act out erotica. There's no limit to erotica if you're open to that.

Then we could do things like oral sex, manual sex, outercourse. If pain with intercourse is one of those things that can happen, maybe rub the genitals on the outside of the body with some lubricants.

Could we do tie-ups, blindfolds, right? Lick chocolate syrup off of each other and then take a shower. Mutual masturbation with toys.

[34:00] But there's so many things that we could think to do that maybe we didn't used to do or maybe we did long ago, but we didn't think to do that. Let's open up the recipe because now we have lots of choices. And the goal, remember, is pleasure and connection, not necessarily intercourse and orgasm.

Okay, so we're just having pleasure and it may not achieve an orgasm for anyone, but it was nice and it was fun and we did something, right? Now it becomes a habit. Okay, this helps us with that.

[34:29] Then I get into more specific suggestions in sex therapy. I mentioned this earlier. If there's something that's a red, I would suggest something that might help you overcome that red.

For example, if there's vaginal dryness with any menopausal symptoms or medical menopause from a hysterectomy, I'll say, well, let's talk about lubricants, how to use them, and moisturizers.

This is like lotion for the vagina. Here's how to get them. They're over the counter. Let's try that.

It could be if you're worried about maybe having your partner see a scar or something you don't really feel comfortable yet with your body, is there some lingerie that we can cover that up or leave a shirt on so you feel comfortable about that, right?

It may be vaginal dilators if we need to do something to help with removing pain with intercourse or something like that. I go into very specific things depending on what's going on.

[35:29] Then I mentioned this earlier, and I want to at least touch on this again. There might need to be a conversation and a practice about barrier methods, depending on where you are in your treatment, what kind of treatment you're doing.

If your body fluids could transmit to your partner or if your partner could expose you to an infection, even a cold, for sure something like COVID or the flu, right, would be a serious thing if your immune system is low, obviously pregnancy, right?

There's another layer. We want to prevent that as well.

Using things like condoms might be something to bring back in or start in your relationship, even if you didn't do it before. Dental dams are barriers that you put over female genitalia in order to do oral sex on them, and they're kind of hard to come by. You could probably order it from Amazon.

But I usually tell people take a section of saran wrap, put lubrication on the vulva so it's comfortable for the female, and then put that the saran wrap over, right? Hold that saran wrap over and you could do oral sex on the vulva without transmitting fluid back and forth.

[36:34] You can use obviously oral sex on men with a condom. If it's the right kind of condom, you don't want to have a spermicide on the condom or a taste that's unpleasant, but it's possible to do oral sex with barriers.

Having gloves handy, I think, is a great idea. For sure, washing hands before and after, absolutely. Every time, for everyone, I would say that. But gloves are handy because it's going to help the risk of any kind of infection or dirt or anything getting into your body.

So I want you to just know that this is something to think about, something to ask about.You can always ask your doctor if you have any concerns about how body fluids could be affected and any time you're at risk or higher risk for immune issues.

[37:18] Now I want to suggest some resources that would apply for everyone. This is, again, even before treatment, I really, really like Come As You Are.

It is geared towards women and finding out what is your sexual health all about. There's no pictures, there's no positions in this book. It's not that kind of book. It's really about how do you feel? Where are your breaks? Where are your accelerators? How can we help communicate that with your partner. Very, very well done.

[37:47] Then she later wrote a book called Come Together. It's about couples who are struggling with that initial sex drive and finding ways to bring it up with each other and communicate with one another. So just general sex ed, that's my favorite.

Then I get into intimacy after cancer. Even though all of you may not have a cancer diagnosis, I love this book. As I was reading it, I'm like, oh, that's exactly what I would have said, right?

[38:11] So it's written as a sex therapist would tell it. I feel like there's lots of resources and it answers a lot of questions, so this is my favorite. Hopefully you can all check that out if you want to.

[38:28] The next piece is building your healthcare team, right? Finding the people that you can talk to about this. I know that you may have experiences where a provider is not comfortable talking about sexual health.

This is hard for everyone because they did not learn about sexual health either. But I'm hopeful it's getting better. Hopefully you have one or two providers and it might be the nurse. It might be the MA. It might be the oncologist or the radiologist. It could be the therapist. It could be sex therapy for sure is available.

Find a team of people to help you with your journey and be able to get the questions answered that you want, get the support that you need.

[39:06] Here is my information. I am available for questions if you have any. I'm happy for anyone to reach out to me here at the Cleveland Clinic. And now I'm going to turn it over to questions. I see some, so how are we doing, Marsha? Do you want to read those?

Q&A

[39:24] Moderator: Thank you so much, Dr. Callard-Moore, for your excellent presentation, and we do have some questions.

The first one is asking about antidepressants and wondering whether or not there are any that have less sexual side effects.

[39:41] Dr. Callard-Moore: Yes. Okay. This is a really important point, and I'm going to come at it from a couple of different angles.

SSRIs, but there are other medications too, like beta blockers and other things that can cause us to have a lower drive, a lower response, and a lower orgasm response, so it can affect any arena. That's true.

However, I steer things towards, why are we on these? Because usually there's a mood issue, right? I promise you, if you're feeling depressed or if you're feeling anxious, you're not going to want to be sexual anyway.

I steer it towards let's get your mood where you feel good. You feel like you, and then go back to what I talked about with that responsive desire. It's usually desire that's our problem. Can we get the warm-up? Can we get some pleasure and arousal, right?

If there's a problem where you just can't get anything and you used to be able to, or you can maybe get aroused but you can't orgasm, then we might have a medication issue. 

Sometimes they will add Wellbutrin to it. The SSRIs could be Lexapro, Prozac, Effexor, there's different ones. But if they add Wellbutrin to it, sometimes that corrects it and you still get the mood benefit.

We could try Wellbutrin straight up and see if that helps you too. That has the least sexual side effects. But I'm going to steer you towards the medication that actually works for you. And then let's see what we can do to help you with the sexual functioning. It's not always a medication problem.

[41:22] Moderator: What do you think the best treatment for vaginal canal narrowing would be?

[41:27] Dr. Callard-Moore: I mentioned that just briefly, I mentioned vaginal dilators as one of the things we would talk about. It's kind of its own talk, but I'm going to briefly go through it with you.

The idea is you'd get a set of dilators, usually on Amazon, look up vaginal dilators. You're going to pay attention to what kind of style you might like and what it's made out of.

If it's made out of silicone, you need to use a water-based lubricant with that. If it's made out of plastic, you can use any lubricant you want.

You're going to use the dilators to gently stretch that vaginal opening, okay? You might need extra support from your providers on this. Some of my OB-GYN doctors provide vaginal estrogen to help with this, sometimes numbing cream to help with this, sometimes muscle relaxers, a suppository, a vaginal suppository, it's a muscle relaxer.

We might need extra support here because even the dilator could be really painful. But if it's okay and it feels like tugging, pulling, stretching, right? You're going to use that gently on your own.

Physical therapy, just you without your partner to gently stretch that up. You might do that for months, right? Slowly build up on size until you get to the size of the penetration, if you're trying for penetration of a toy or penis, what size you need, right?

It might take six months, but that's okay. Cause while that's under construction, you've got your green lights and yellow lights you can be doing with your partner. So you're having a good time with your partner.

This is just physical therapy on the side until you get to the size where you think you could do some penetration. Then you're going to gently have your partner, you know, take that dilator out and gently have your partner go in.

Now that you have an idea, like, I think my body but if it can't, let me just say, if it can't, some of my patients, we just never can get there. It's too painful or there's permanent damage from surgeries. Then, okay, that's on the red list.

Let's find other pleasurable things we can do. It doesn't always have to include intercourse. Okay, just wanted to say that again.

[43:43] Moderator:Does chemotherapy interfere with male orgasm?

[43:48] Dr. Callard-Moore: Wow, I feel like chemotherapy can affect anything. I'm not an expert in chemotherapy. I'm a social worker.

I can't answer that medically, but I feel like all the, the toll that it puts on your body going through it can affect all kinds of things. What I usually am hearing is how it's affected the body and the ability to be sexual in other ways.

I feel like it’s because of the body image issue, the loss of hair, the fatigue alone, right? I mean, if you're fatigued, even before a diagnosis, chances are your body's not going to be that great, right? You might not get an erection anyway. So, I feel like there's all these other layers to it.

The answer is yes. I think anything's possible. Is it a direct thing that we hear a lot about? No, I don't hear it that way, but I just listen to the patients. What's happening for you? Explain it to me, right?

I you do work with a provider; I would maybe get into the specifics about that.

[44:58] Moderator: You talked about vaginal dryness in your presentation, but somebody would like to know if there is a particular product that you recommend.

[45:07] Dr. Callard-Moore: There's a number of products. They're all over the counter. The ones that are over the counter, you could, again, go to Amazon. I see a few like replens at the store, but the ones on Amazon would be Ah Yes. There's Medicine Mama, I think, is another one. There's a lot of different ones.

It's going to come down to your comfort. How do you feel? Do you like it? Does it feel irritating to you?

If you have a steady partner, you're not using a condom, you could use something like coconut oil or vitamin E oil or even olive oil. A lot of people use coconut oil because it is a moisturizing product too. You can use it for lubrication and or dryness. You can put it on your skin anywhere as long as you're not allergic, so I feel like there's different things that you could use.

It's going to come down to what do you prefer the feel of, the taste of, the smell of, and if it's effective for you.

The most common one, though, is Replens over-the-counter, and that's the one I see at Target and Walmart and all that.

[46:11] Moderator: Someone is asking a question about a drug. They said, can you have unprotected sex with Epkinly? Am I saying that drug correctly?

[46:25] Dr. Callard-Moore: That's going to be a medical question. I'm afraid I'm not going to be able to answer that, but let's ask your provider about it. Be ready to talk about that with your partner if we need to use barriers or condoms.

[46:37] Moderator: How can I tell the difference between genital GVHD and just vaginal dryness and irritation?

[46:45] Dr. Callard-Moore: Oh, that's a great question. I do want you to talk to your provider about, you know, is this a side effect of the treatment? I think it may lean towards trying some of those vaginal moisturizers we just talked about. Let's see if that helps.

But if you're still having pain or discomfort, and I mentioned that earlier too, my OBGYNs may add something to support the system or actually numbing cream or something to add comfort because of pain.

But let's check with your provider. It's almost like we have to kind of try and see what's working and then go back and try again.

I feel like this is one of those things that might be tweaked and maybe it gets better and then it could come back, right?

It's a continuous checking with your body. Does this feel green, yellow, or red to have be touched this way or whatever? Finding what things, what variables may help with it.

Medically, some of it might be prescription and or over-the-counter things that we've talked about.

[47:55] Moderator: Okay, if you are treating a couple, do you see them together and separately?

[48:01] Dr. Callard-Moore: Good question. I'm going to answer it when I was in private practice. When I was in private practice, I would do a combination of together, individual, individual, in any form. It depends on who came to the appointment first. 

That's just my style. Any therapist that you see is going to have their own style.

I feel like I personally want to see both people anytime I'm working with someone because this is affecting both people.

In the Cleveland Clinic, I don't want to go too specific into that because you may or may not be in the Cleveland Clinic system, but I do consultations and I always encourage partners to attend, but I'll see whoever is in the room.

[48:45] Moderator:Someone is saying that they are single and dating post-transplant and they're anxious about being physical or sexual again because their body is different and they're concerned about germs, which you did talk about. 

They'd like to know if there's any suggestions to talk to a new partner.

[49:05] Dr. Callard-Moore: Yes. Great question. I feel like it's harder for our single folks because how do you bring this up? When do you bring this up?

Anytime there's a disclosure, I think of a truth pizza, just to make it simple. The basic bread, right? The crust here is a basic truth.

Let's say you're online dating. Let me just pick that, and you're starting to talk to someone more frequently, text or call. And you can say, you know, I've had some health issues the last year and a half. And they may say, oh, really? What was that?

You might say, if we continue to talk, I'll fill you in. I just want to let you know there were some health things that came up, right? Then let's say you continue talking and you feel like, okay, you feel like you can be vulnerable.

Now you add a little bit of the sauce here and it's like, well, actually what I've been through is multiple myeloma and it's been a journey, right? It's been a long journey and this is kind of where it's at. Now you're kind of disclosing a bigger chunk of that.

Maybe that person is like, I've had breast cancer. I've had prostate cancer. Everybody has their story, you don't know. If their vulnerability comes out too, you're like, okay, then maybe we can keep talking about this.

Now we're going to get into specific things, like, I'm not sure I'm ready for you to see me without my shirt on or off, right? I'm not sure that I'm ready for that. 

Let's say they respond to it, well, that's all right. One, we don't have to do that at all, or two, would you feel better if we turn the lights off? Cause I, you know, I'm interested in doing that.

We could turn the lights off or maybe I could keep my shirt on and we turn the lights off. So now we're getting more specific.

Now we have our toppings, right. Our toppings are coming in and then we're going to look for pleasure and a way that we can combine that with this new, so I feel like that's the cheese, right? It's going to gel us all together. But doing that could be in one conversation because the person, it just flows, right? Or it could be over months of getting to know someone, maybe even people you've known for years, and you're just now getting into these details. You've just never talked about these things before.

[51:32] Moderator: This will have to be our last question because we're running out of time.

But there's someone who's asking about how to move forward with their partner who was their caregiver through a pretty rough transplant. They feel like he looks at them differently and they're struggling about how to reconnect.

I know you talked about a lot of that, yeah, but if you could just maybe, I guess, the caregiver and, you know, getting over how to think that they look at them differently.

[52:08] Dr. Callard-Moore: That's really tricky. I would want you to go back to that green light, yellow light, red light piece. Get those pieces of paper out.

Find, first of all, find the green that you're still feeling connected and okay. Let's start there. We need to have a good foundation there, and you might need to do it for a while.

But then ask for that first section. That's a little bit more sensual, but not sexual yet. What's a baby step that we could take, honey, would it be okay if we cuddled without shirts on and you didn't ask me about my medications or side effects for the next two hours?

I mean, kind of like outline it, structure it, have some baby steps, but maybe even boundaries about it.

Maybe do that exercise where the two of you are, you know, just sitting in the kitchen and you're having a coffee conversation and say, you know what, can we just talk about that time we took that trip? Remember that? that nice time we had, remember how hot that was, right?

Let's get back in that headspace and maybe say, if things were great now, what might that look like for us, right? Get an ultimate outcome, and then say, what are the baby steps that we could take that would help us get to that outcome. Start to have that communication.

But you might need extra support here. You might need couples therapy here. There's a lot to this, but I really like that because it's a behavioral structure way that you can get back in the habit of connection again.

[53:51] Moderator: Those are great suggestions.

On behalf of BMT InfoNet and our partners, I'd like to thank Dr. Callard-Moore for this very frank and open presentation about intimacy, and thank you, the audience, for your excellent questions.

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