Sexual Dysfunction

Note: Not all cisgender heterosexual relationships are reflected in this story, and not all individuals with uteri are women. “What is endometriosis? I’ve never heard of it.” I stood in awe as I heard these words come out of the mouth of a person I know fairly well. This gentleman is in his 30s, well-educated, married, and has two children. The conversation began with my disclosing that I write for The Mighty and that lately, I’ve written a lot about endometriosis. Maybe I’m naive and obviously, I’m well aware of the lack of research and knowledge surrounding endometriosis, but I just assumed that most people have at least heard of the term even if all they know about it is that it is a condition affecting individuals with a uterus. Clearly, I was mistaken. This got me wondering, “How many men don’t know about the reproductive health issues those born and identifying as female deal with, and what are the ramifications of this?” After a quick Google search and cross-referencing numerous articles, what became clear to me is that this is a globally recognized issue that influences everything from female mortality due to childbirth to intimate partner violence. While religious and cultural views do exert powerful influences upon views regarding the importance of women’s reproductive health, there is a general consensus that lack of education, media bias, and social stigma are among the leading factors as to why men appear to have such restrictive knowledge about the way women’s bodies work. So what does all of this mean when it comes to the partnership between two individuals? I’d argue that it is a fundamental issue that could not only revolutionize the power dynamics between two people in a committed relationship, but it might also be one of the greatest keys to establishing deeper levels of communication and intimacy between partners, the lack which often lands people on the couch of a couples therapist’s office. Furthermore, in a society where women’s reproductive healthcare is often treated with suspicion or neglected, having an ally who is both knowledgeable and engaged in their partner’s reproductive health could bridge the gap so those identifying as female can obtain a prompt and attentive diagnosis and treatment of conditions like endometriosis from medical practitioners. What should men be asking about their female-identifying partner’s reproductive health? Here’s a list of six key questions to consider. 1. Basic anatomy. Let’s start with the fundamentals. Do you know the structural anatomy of a woman’s reproductive organs? Do you understand how they work and why? Do you have a rudimentary idea of how a woman experiences orgasm or sexual pleasure? Let’s be honest, sex is an important part of a relationship and is one of the most frequent sources of strife between couples. A man who is armed with the foundational principles is a man who is a step ahead of the game where cultivating a satisfying sex life is concerned. 2. Are you familiar with your partner’s menstrual cycle and how they experience it? Do they have severe PMS? Do they undergo an increase in their libido? A decrease? Are their periods heavy? Do they typically last three days, four days, or five days? What other symptoms do they experience? Are their periods irregular? All of this information is invaluable in not only family planning, but any concerns or irregularities may indicate an issue that might require medical attention. I get it, periods are uncomfortable to talk about. But your partner spends a significant percentage of their life experiencing their menstrual cycle. Pretending that it doesn’t exist or ignoring it is rejecting an integral pervasive part of their life. 3. Does your partner experience any pain or discomfort during sex? This one strikes a particularly sensitive chord because if the answer is “yes,” something needs to be done about it. I want to state one thing loud and clear — if there is a medical or emotional reason a person is avoiding sex, this is in no way a rejection of you. I say this from personal experience. While my sexual dysfunction was both structural (brought on by endometriosis) and psychological (a by-product of my sexual abuse), neither of these had anything to do with my husband’s prowess as a lover, attractiveness, or my love for him. But it most certainly affected him. We avoided this conversation because it was so uncomfortable. But once we finally engaged in an open and honest dialogue about it, we could begin to figure out what the causes of my sexual discomfort were and what we could both do as a team to address it. It’s not a magical cure and it can involve some tears and possible medical interventions like pelvic floor therapy, but it’s absolutely essential to the health of a couple’s relationship. 4. Does your partner have a family history of any kind of reproductive health condition? If they do, what are those diseases, and what are symptoms that both of you might be keeping an eye on? Examples include endometriosis, fibroids, cancer, interstitial cystitis, and polycystic ovary syndrome. Thankfully with the internet, this information is readily at our fingertips. There are even websites and blogs uniquely designed to educate men on their partner’s reproductive health and chronic illnesses like Worryhead, which has printables, infographics, and even an endometriosis e-book. 5. Do you want to have children? This might be a question that you should have asked way before committing to a long-term relationship, but if the answer is yes, any underlying reproductive health issues might make conceiving a challenge. If you do experience trouble conceiving is your partner interested in pursuing fertility treatments? Surrogacy? Adoption? Laying these concerns out prior to having to make these decisions won’t eliminate the grief that inevitably comes with having to come to terms with it, but it does help to have a game plan ahead of time that both of you have agreed upon. 6. Ask your partner if there are any questions they have about your reproductive health. I know, your brain just did a double take. You thought this was all about men learning about their partner’s reproductive health. Yes. That’s true. But the conversation must go both ways. If you are withholding information about things that might be affecting you, or if your partner fails to acknowledge them, that impacts both of you. You deserve to have your health and wellness taken into consideration as part of the system that exists between the two of you. Your lives are intertwined in a dynamic interconnection and that includes your bodies and minds. Don’t allow fear or shame to stop you from telling your loved one about something that might be concerning you. You owe it to your partnership and more importantly to yourSELF. What I’m suggesting above involves a radical act of self and other discovery. It represents the rejection of the status quo where matters of discussion regarding anything having to do with reproductive health are concerned. And ultimately it requires the kind of intimate emotional engagement that might feel terrifying and completely foreign. We are not socialized to be this vulnerable in our relationships, and it is my personal belief, and one that my therapist would agree has validity, that all of us would benefit from cultivating the ability to communicate on this kind of level.

Dear Gynecologist, My name is Monika and I am a child sexual abuse survivor with endometriosis. I’m writing to you today to voice my concerns with those in your profession about your proficiency in interacting with patients like me within your practice. I understand that there isn’t much emphasis on what is called “trauma-informed care” in your training and frankly, it shows. I have been to numerous gynecologists throughout my life and each experience was worse than the previous one. Pelvic exams are uncomfortable at best for all women, but for women with a trauma history and a chronic illness requiring more frequent visits to a gynecologist, the experience can be downright traumatizing. My sincere wish in writing to you is not to demonize you or your profession, but rather to offer some words of advice on how you could make your patients more comfortable and less triggered when they come to see you. First, your intake paperwork should inquire about any history of trauma. A patient may not divulge this information verbally because they may feel ashamed, but if there was a box to check on a new patient form, they might be more likely to at least indicate that there is something to look out for. Additionally, all staff from reception to nurses should be on the lookout for any indication of trauma including, but not limited to extreme anxiety, reluctance to enter the exam room, or any physical or verbal cues that a patient is experiencing dissociation or otherwise checking out and not able to consent to treatment. Next, I understand that insurance companies require you to get patients in and out quickly, but it behooves you to spend at least some time talking to a patient. Ask them if they are scared or concerned about what to expect. Offer detailed explanations of what you will be doing and why. And ask for consent at each stage of the exam. The patient needs to feel as though they are in control of their own body while they are laying there in such a vulnerable position. Have the nurse offer to hold the patient’s hand for comfort and please verbally announce every step of the exam so that the patient knows what is happening. And if at any point a patient requests that you cease, don’t pressure them by saying “We’re almost done.” Just stop. All of these steps can create an environment where a patient feels as though they have bodily autonomy and that they will not be violated. Third, make it a point to incorporate questions about a patient’s overall health and wellness, including asking about relationships, whether or not they are sexually active, if sex is painful, and if sex is satisfactory. Sexual dysfunction can be a huge red flag when it comes to many reproductive illnesses like endometriosis, but it’s not something we are socialized to talk about openly, so most of us won’t bring it up unless prompted. You should also ask about urinary tract health, bowel movements, and digestion. Concerns surrounding any of these might also be a clue as to the presence of a condition you should be investigating. Basically, I’m saying that reproductive health involves more than just a patient’s vagina, uterus, and ovaries. It is a holistic thing that can extend to many other parts of a patient’s body and your awareness of this is critical to your patients receiving the comprehensive care that they deserve. And finally, if a patient tells you that something feels off… believe them. We are pretty perceptive about our bodies and what we know to be our own “normal.” If we say our periods are disproportionately painful, don’t insist that all periods are painful. If we say our menstrual flow is excessive or that there are weird clots, don’t dismiss this. And above all, never insinuate that our concerns are purely psychological in nature. Women generally have a very high pain tolerance and a very low level of comfort with expressing their needs to others. We’ve been socialized to not be a bother and to put on a happy face. The container of a doctor’s office should be the one place where we don’t have to don a mask of perfection and we can be fully ourselves without judgment. All of these things are just good practice in general, but they are particularly necessary for those with vulnerabilities like mine. It is well documented that survivors of sexual violence are less likely to seek routine gynecological care because of their trauma, so when they do finally muster the courage to come see you, give them every opportunity to express their concerns. Otherwise, they will likely become one of the many who will suffer in silence unnecessarily with conditions like endometriosis. One final note. As a woman who has chosen not to procreate, don’t ever interject your opinion about my choice during an exam. Comments about my changing my mind or it being a shame or how being a parent is the greatest thing in life are completely out of line. The only questions regarding pregnancy that belong in an exam room involve contraception options. Your expertise about the pros and cons of each is welcome. Your personal biases or religious views on my sexual activity are not. Thank you for taking the time to read my concerns. I do hope that you will take them to heart and implement them in your practice. Doing so will ensure a much more tolerable experience for your patients and will arm you with better tools and knowledge to treat them effectively and respectfully.

Not long ago, I noticed C-SPAN was going to be featuring testimony before Congress on mental health issues and legislation. I thought I’d see what was up. What I heard was a lot of questions about the opioid crisis and what the nation’s response to that ought to be. I tuned out and turned it off. I had been hoping to hear about issues such as insurance parity, access to treatment, assisted outpatient treatment, and more. Instead, what I got was a focus on substance use. I also recently saw a map that indicated which states had reimbursement programs for substance use disorders (SUD) and mental health initiatives. By far, most of the programs were for SUD. States that covered mental health conditions were in the minority, and most of them provided coverage for both SUD and mental illnesses. I’m not denying substance use is a problem in the U.S. or that legislative attention needs to be paid to it. I know the opioid crisis is tragically affecting individuals and communities across the country. Nonetheless, I wish as much attention was paid to other mental health issues as well. They affect individuals and communities, too. I was a little short-sighted as well as impatient, however. The two topics are not mutually exclusive. Mental illness and drug use are often comorbidities (also called co-occurring disorders or dual diagnoses). Still, there are in many places rehab facilities for people who abuse drugs and alcohol, and separate facilities for people with mental illness. The two conditions share many characteristics. Both can be attributed to brain chemistry. Verywell Mind notes, “[t]he activation of the brain’s reward system is central to problems arising from drug use. The rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug.” The effects of brain chemistry on mental illnesses such as depression, bipolar disorder, and schizophrenia are not well understood and are even debated. But though the mechanisms of action on the brain may be different, there is little doubt the brain is involved in both addiction and mental illness. Medline Plus notes there are other similarities in possible causation, including genetics, stress, and trauma. Various psychiatric disorders are associated with substance use, including psychotic disorder, mood disorders, obsessive-compulsive disorder (OCD), sleep disorders, sexual dysfunction, and neurocognitive disorders. Despite this, PubMed has said, “In spite of the high association between substance use and psychiatric disorders, there is a surprising paucity of studies related to treatment and outcome. A few well-designed studies have been recently published and more studies of this nature are required in order to address the challenges posed in the treatment of dual disorders.” One thorough, well-researched article with many sources listed is available from Mental Help. The latest version of the DSM recognizes the overlapping of substance abuse and mental illness, with substance-related disorders added to the DSM-5. Addiction Policy Forum reports: “The DSM-5 has eleven criteria, or symptoms, for substance use disorders based on decades of research. The DSM-5 has helped change how we think about addictions by not overly focusing on withdrawal.” The National Alliance on Mental Illness (NAMI) says, “The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance use disorder. The idea that ‘I cannot treat your depression because you are also drinking’ is outdated — current thinking requires both issues be addressed.” They add that the treatment should consist of six elements: inpatient detoxification and inpatient rehabilitation, psychotherapy, especially cognitive behavioral therapy (CBT), medications (including those that assist in detoxification), supportive housing such as group homes, self-help, and support groups — whether faith-based or not. Of course, the idea substance use and addiction are diseases has not caught on with many members of the general public. They consider them to be personal failings or the result of having no self-control or hanging around with disreputable friends. Perhaps that is one reason public officials do not listen to those who promote changes in legislation to improve both substance abuse and mental health care. The intersection of addiction and mental health challenges is even more foreign. Advocates who contact their legislators are likely to be brushed off with a, “Thank you for contacting my office” letter. Politicians are also disinclined to listen to medical advisors on the subject, especially now that their attention is focused on COVID-19 policy. Perhaps those who advocate for more enlightened responses to substance use issues, mental health treatment, and dual diagnoses should start a little lower. Educating legislators is fine, but change is not likely to result until their constituents demand it. For one thing, advocates for reform could attend local city or county meetings to counter the pervasive “Not In My Back Yard” (NIMBY) response to treatment facilities. They could also educate their family members and friends about the realities of drug use, mental illness, and the intersection between them. When more people understand these ideas, they may be more likely to support legislative approaches that encompass them. Grassroots efforts such as Mothers Against Drunk Driving (MADD) have worked in the past to contribute to societal change and legislation regarding that problem. It may take a similar effort to achieve change in how addiction and mental illness are understood and treated.

I have written before about the ways in which my experience with sexual abuse and endometriosis have both impacted the ways in which I inhabit my body. Shame and a feeling of disembodiment accompany both and with that comes sexual dysfunction. Whether it’s emotional or medical, discomfort with intimacy and with pleasure become a pervasive aspect of one’s identity and a source of angst. That’s why I was intrigued by the new series “The Principles of Pleasure” on Netflix. And for as awkward and often uncomfortable as I felt watching it, it certainly taught me a lot about why pleasure is a human right and how exactly it works. Here are some key takeaways: Sex Education As a society, we have been taught that sex is something inherently dirty and that women’s bodies are inherently shameful, a source of disease, and problematic. This has created a culture in which sex education, including the basic knowledge of what makes up the female anatomy, has been virtually nonexistent at best or downright misleading at worst. Myths like a broken hymen equaling a loss of virginity, which was something my own mother told me was a thing, are not only false, they give the illusion that a woman’s sexuality doesn’t belong to herself but rather to the person to whom she “gives herself to.” And most of these myths are reinforced by systems of oppression rooted in white male heteronormative religious structures aimed at shaming those who don’t fit within those structures. Masturbation and Interoception One of the solutions to helping women figure out not only what their body parts are and how they make them feel is masturbation — something which has been a fraught subject for me personally because of my sexual abuse history. Masturbation, particularly for those who present as female, can help with the development of what is called “interoception” or the ability to know what’s happening within one’s own body. Because our sexual organs are not as visible or easily accessible, it takes some trial and error to figure out what feels good and what feels bad. Additionally, there has been some research indicating that sexual stimulation has the potential to treat various disorders, including chronic illnesses like endometriosis, sleep disorders, and even depression. The hormones released during sexual stimulation can help alleviate pain by reducing cortisol, which has profound implications for the future of pharmaceutical use. Bonus: if you’d like an in-depth education on sex toys, there’s an extensive segment called “Tool Time with Dirty Lola” that might pique your interest. Mind-Body Connection As important as it is to have an understanding of human anatomy and what feels good or bad, an even more important component of pleasure is actually the mind-body connection. Pleasure is the brain’s way of rewarding us for adaptive behavior and is therefore evolutionarily useful. Billions of neurons in our brain are stimulated by sensation signals in our nervous systems, which are then sent into the emotion parts of our brain for processing. That’s where pleasure itself is determined. The interpretation of pleasure relies upon a host of different inputs coming into the body which can become disrupted by either trauma or a medical issue, rendering them inactive. The good news is, these neural networks can get rewired so that we can re-learn what is and is not pleasurable. Hormones If our brains are like the operating system of a computer, then hormones are the software running that system. They determine everything within our bodies, including our experience of pleasure. Interestingly enough, hormones have often been given a bad rap, being associated with moodiness and behavioral changes in women specifically. But they aren’t as black and white as that. Testosterone in men tends to fluctuate wildly throughout the day, adjusting to things like sexual imagery, the presence of children and even watching a favorite sports team win a game. For women, hormones are far more predictable and line up with menstrual cycles. During the first phase of this cycle, the Follicular phase, the body is flooded with estrogen, which has been associated with increased energy, clarity, heightened senses, better memory, better capacity to learn, and even the ability to dull pain. During the second phase, the Luteal phase, progesterone takes over, which is associated with increased fatigue, being more hungry, having a lowered libido, and generally just feeling blah. This knowledge becomes invaluable in terms of how women choose to manage their reproductive health. The birth control pill has had profound implications on women’s ability to contribute to society and elevate themselves socially and culturally by enabling them to choose if and when to have children. However, birth control pills can negatively impact the ways one experiences the world. Senses, feelings, and even libido can become more muted, which may cause someone to revisit whether or not the pill is right for them. From my personal perspective as someone who was prescribed the pill as a teenager to treat my endometriosis, I wonder how much this actually influenced my ability to experience pleasure throughout my 20s and 30s. Politics of Bodies and Medical Misogyny Society has a very black and white view of gender identity that insists on putting individuals in boxes reinforced by certain stereotypes that define not only who deserves to get pleasure but what is safe in terms of being vulnerable. These coded stories afford free license on pleasure to white heterosexual males first and foremost, and then to white heterosexual women who give men pleasure and conform to aspirational culturally constructed beauty ideals. The farther away one is from that privilege, the harder it is to earn the right to experience pleasure. As this pertains to the medical community, doctors are not attuned to individual history, nor are they educated thoroughly in mental health, women’s health in general, and trans/non-binary health in particular. Furthermore, they are not trained in considering women’s sexual health when suggesting treatment options, which can create a whole host of problems with obtaining pleasure. This creates a system in which women, trans, non-binary, and genderqueer individuals are less likely to seek out medical attention and more likely to go undiagnosed with all types of conditions, particularly those affecting reproductive organs, like endometriosis. Desire The most important aspect of desire is to understand that there is no such thing as “normal.” Everyone is unique and as long as two individuals consent with the knowledge that they can stop at any time, the sky’s the limit. Going deeper into the discussion of desire involves understanding some key terms. First is responsive desire vs. spontaneous desire. Put very simply, some individuals can get aroused instantly. Others, including a high percentage of women, require some nurturing attention within the right context and right frame of mind to get in the mood. Understanding this can help set the stage for pleasure. Next is the concept of the dual control mechanism, which involves the fact that individuals have sexual brakes and sexual accelerators. Figuring out what causes someone to put on the brakes or push the accelerator is key. A third key point is that of sexual discordance — meaning that desire, genital response, and pleasure do not necessarily coincide. This is why so often when someone’s body responds to a sexual assault, there’s so much confusion. Your body reacting doesn’t mean you consented or enjoyed what happened. And if you dissociate during sex, this is called spectatoring, and it literally means a person is watching themselves and scrutinizing every aspect of their engagement in sex without being present within their body and feeling pleasure. Trauma This leads to the discussion of trauma, which this series took on beautifully and expansively. As is acknowledged by sex educator Dr. Emily Nagoski, somewhere between one in three and one in five women will experience sexual trauma during their lifetime — and that doesn’t take into account the number of individuals who agree to unwanted sexual encounters because they feel as though it’s their societal obligation. Very few women escape without experiencing some form of sexual shaming, body image criticism, or the misogynist notion that they need to earn their right to pleasure. This means that communication about consent and what an individual likes and dislikes become that much more important. Understanding that consent is fluid and that a partner should clearly ask for consent and not just assume it is critical. The second part of rediscovering pleasure as a survivor of trauma is mindfulness, which in this case involves body scanning to be able to identify physical sensations and the protocol of sensate focus therapy which involves physical touch without the expectation of sex at the end. The bottom line about pleasure is this — autonomy is necessary for pleasure and it is the foundation for reproductive justice. Pleasure and justice go hand in hand, and this series very deliberately includes a diverse cross-section of interviewees of different races, ethnicities, religions, sexual orientations, gender identities, and abilities. Dr. Nagoski states it powerfully by calling pleasure a radical act that can “dismantle the entire white supremacist cis-hetero-patriarchal rabidly exploitative latent capitalistic system through (having an orgasm).” If that’s not aspirational, I don’t know what is.

The future — the unknown. We spend our lives pursuing it, planning for it, dreaming about and wishing for what it will look like. Often the disappointments of life come about because what we had dreamed, hoped and planned for did not come about. In some ways, we are always chasing a dream — a dream and hope of what our future will be. For some of us though, that dream became a nightmare on the day of our diagnosis, as our hopes and dreams for the future came crashing down around us. Instead of something to be feared, our future death became something that we viewed as relief and peace. For me, I now no longer feared death, because I was more terrified of living. What a cheery thought to begin an article with, right? A topic I am sure we are all ready and waiting to dive into. After my diagnosis, this is honestly how I felt. I had read so much information about Parkinson’s, and the future with this disease terrified me: TremorsSlow speechStiffnessInvoluntary movementsDepressionAnxiety All of these were no fun, but this is just the tip of the iceberg: Bladder issuesCognitive issuesConstipationInsomniaFatigueLoss of smellSexual dysfunctionDementia This list could continue even beyond this — all of which added together to create a very bleak and terrifying view of what my future could look like. As all these thoughts ran through my mind, I could not help but think of the worst-case scenario, and as discouragement overtook me, I saw nothing bright about my future, and for the first time, I saw and understood the hopelessness that some feel. When looking at this, some days it was very hard to see hope. I remember on that day when I first felt this, I told my wife how terrified of the future I truly was. I was frightened of what my life, my future, would entail. I feared what my body and mind would look like five, 10 or even 20 years down the road. I was fearful and heartbroken for the path my family would now have to walk. I remember looking almost with hope to my future death as a release from this prison of my body that I now found myself enduring. Living this way, in this body, scared me so much more than the release of death, because I did not want to live in that state, with all of those struggles. The old saying goes, “What does not kill you makes you stronger,” the only problem is, not everyone gets in the second group. I honestly did not want to live through the first group, but ultimately, I did not have a choice. My faith certainly helped me on this path, and I knew God walked with me on this journey. I also knew the hope I have even in death, but what about now? How would I live now not fearing the future? Last month, my son and I went to a concert, and I heard an old song that I had never heard before “Live Until I Die” by Clay Walker in 1993, and as I sat there, I was captivated by the simple message: “I don’t want to think about tomorrow…I don’t worry ‘bout things that I can’t change…and every night I get on my knees and thank the Lord above…I just want to live until I die.” That simple message reminded me that I can worry about tomorrow, stop living today, and die long before I am dead — or — I can choose hope and thankfulness and live until the moment I die. Yes, the road would be more challenging. Yes, there would be very hard days. Yes, the worst I feared might happen, but me fretting and worrying about it would not change it, and it would only rob me of the life I could still have. Fear can be debilitating, but when I remember this principle and the hope I have in Him and can walk forward despite those fears, and when I do this, I will no longer fear to live. For I will be at peace, knowing the hope I have and the life that I can still live, even now after my diagnosis. I cannot let fear immobilize me and stop me from living now. I cannot live in the fear of my future, a future that might or might not come to pass. Just because we have a diagnosis, does not mean we cannot still approach life with hope, living until we die, walking forward in the face of fear, knowing that even though the road is long and hard, He walks with us, and He will strengthen us. Don’t squander today worrying about what you cannot change. Don’t fear the hard life you must live, because your diagnosis was not a timestamp, the end of the road or even a death sentence. It is simply a challenge some of us must overcome, and we overcome that challenge by choosing to live until we die.

Mindfulness has become the treatment du jour for mental health conditions of all kinds. It has been dubbed as a veritable panacea for curing all that ails us from addiction  to chronic illness , to post-traumatic stress disorder (PTSD). But what is mindfulness? The most basic definition according to Oxford Languages is “the quality or state of being conscious or aware of something” and “a mental state achieved by focusing one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, and bodily sensations, used as a therapeutic technique.” This practice can take numerous forms from conscious methodical deep breathing and deliberate eating to gratitude or feelings journaling and communing with nature. For the purposes of this article, I will focus on meditation, both guided and individual. Disclaimer: As with virtually every treatment modality that is utilized within the context of psychotherapy, and in particular trauma treatment, every patient is unique and no two patients will respond to any particular treatment the same way. What may work for one individual may not work for another and vice versa. I am mindful (word choice deliberate) that many individuals find meditation not only useful but life-enhancing. I don’t want to discourage anyone from trying any modality that they can to help treat their symptoms, nor do I wish to vilify an entire modality like meditation simply because it can come with some risks. With that, there has been increasing scrutiny within the medical community as to the safety of meditation for those with a trauma history, and who have been diagnosed with post-traumatic stress disorder . Even proponents of yoga and meditation as integral to mind-body work in trauma treatment like Bessel Van Der Kolk, author of the New York Times bestseller “The Body Keeps The Score,” have noted that due to the fact that those with PTSD don’t experience their trauma as something in the past but rather as something they are experiencing in the present, meditation may not just be impossible but harmful. Patients can become emotionally deregulated, experience flashbacks, dissociate, have increased nightmares , or even develop psychosis . While there are numerous articles citing these concerns, perhaps the most comprehensive analysis of meditation and its potential dangers was done by researchers from Brown University in 2017. The study carefully followed both practitioners and clients across a myriad of different types of predominantly Buddhist meditative practices, experience levels and lengths of time. The analysis suggests that while many experience positive effects from meditation, an aggregate 45% of experts and practitioners reported reexperiencing of traumatic memories. Other negative outcomes cited included (and I recognize that this list sounds a bit like the side effect list of a really bad pharmaceutical commercial but I digress) delusional/irrational paranormal beliefs, dissolution of perception of sight and sound, derealization, hallucinations, anxiety , panic, paranoia, suicidal ideation, mania , psychosis (sometimes requiring hospitalization), anger/irritability, dizziness, gastrointestinal distress, cardiac irregularities, fatigue, sexual dysfunction , appetite changes, nightmares , involuntary body movements, anhedonia, social impairment, and loss of sense of self… amongst others. That is by no means a comprehensive list but a snippet of the highlights. Additionally, 88% of clients reported that their negative symptoms affected them in their daily lives beyond the context of the meditation experience for anywhere from one to three years to varying degrees of impairment. Preexisting psychiatric or trauma history was noted as one of the primary causes in this analysis and the type, duration, and length of practice did factor into the development of difficulties. While this is by no means conclusive, it does highlight the potential pitfalls of engaging in meditation for trauma survivors. In my own experience, I have had both positive and negative results from varying types of meditation. I grew up doing yoga and meditation and frequented a yoga summer camp. While some of my experiences were positive, I also had some experiences that left me feeling uneasy about the situation. A small part of me felt like I was being indoctrinated into some kind of a cult. That along with some other more ambiguous spiritual trauma in my childhood have left me skeptical at best and somewhat averse at worst to meditative practices that tend to feel more religious in nature. So I generally avoid those if I can. I have also engaged in yoga for its physical benefits, particularly as an ex-dancer with a myriad of old injuries. Yoga can be a fantastic low-impact exercise regimen that can help reduce stress, increase flexibility/strength and help me connect with my body in a healthy way. Yet, even with my background as a dancer who has done yoga on and off for the majority of my life, I have gotten triggered in yoga classes by certain poses which caused me distress and subsequent flashbacks to my sexual abuse . And I often find that at the end of class when we lie down for “shavasana,” which is the meditative portion of a yoga class, I cannot quiet my mind. It races uncontrollably and the more I try to regulate my breath, the more I feel like I’m hyperventilating. It doesn’t happen every time, but it has happened where I felt lightheaded and like I was going to pass out or throw up. Anecdotally, I have discussed the challenges of doing yoga and meditation with other sexual abuse survivors who have had similar experiences with being triggered or otherwise retraumatized in session. I’d say the key is not necessarily avoiding meditation per se, but rather beginning a meditative practice with the presence of a trauma -informed practitioner who can monitor you during your practice to ensure that you are safe, remaining calm, and are not in any way dissociating or experiencing a trauma response. For me, it was helpful to have my therapist do a guided meditation in her office. We started with a shorter exercise lasting about 10 minutes the first time and then did a kind of debriefing where I was able to identify what I was thinking, feeling in my body, and noted any red flags or concerns. The next week we recorded a slightly longer one and then did the same type of debriefing. I was instructed to try it at home but to stop immediately if I began feeling dysregulated in any way. The first time I did it alone, I did feel a bit triggered so I stopped. We discussed what changes we could make to help ground me better in the practice. Once I did that, I was able to successfully complete a session on my own. With that said, even though I have the guided meditation recorded on my phone with her voice (and I find the sound of her voice calming and soothing), I don’t do them very often. I don’t find the meditative practice to be a magical cure for some of my more persistent PTSD symptoms including ongoing nightmares and hyperarousal at night, anxiety, and dissociation, so I only use the recordings when I’m having a panic attack and need to hear a familiar safe voice. For my ongoing trauma symptoms, however, we have moved on to other modalities to try to address these more effectively. But… I do continue utilizing other mindfulness techniques that do not involve meditation, particularly physical activity, journaling, and deep conscious methodical breathing, which I find especially helpful at night when I wake up from a nightmare and my heart rate is elevated. If you are a trauma survivor inclined to investigate meditation, start slowly, gently, observantly, and most importantly don’t go it alone. If it’s not working for you, know that you aren’t doing it wrong and there’s not something amiss just because you aren’t benefiting from it. It’s quite a common and well-documented phenomenon that I wish mental health and wellness practitioners were more aware of and cautious of before recommending meditation as a cure-all for everyone. By not informing trauma survivors of potential negative consequences, clinicians are not only doing their patients a disservice, but they also may be putting them directly in harm’s way which is irresponsible and unethical.

One of the most common stories told by those who have dealt with endometriosis is the challenge of getting a diagnosis. Doctors often don’t even think of it as an explanation for the symptoms commonly associated with endometriosis. Being your own advocate and approaching your physician about the possibility can often be a quagmire. Doctors don’t like being told what to think when it comes to diagnosis. Often they will dismiss you with a “Don’t use Dr. Google” comment without giving any consideration to the fact that maybe you have done your own research and are on to something. With this in mind, it seems useful to share some of the specific symptoms I experienced due to endometriosis that baffled my doctors, and some suggestions for how to get the proper medical attention and care that you deserve. Please note: I am not a medical practitioner and I understand that everyone experiences endometriosis differently. This is simply my own lived experience and what I wish I had known sooner so I could have had a better quality of life during my late teens, 20s and 30s. Endometriosis Symptoms to Look Out For Many of these symptoms can be indicative of numerous different medical conditions. But in combination, they may be suggestive of endometriosis. Irregular periods While amenorrhea is common for athletes or those with anorexia, my periods were irregular on and off even when I was not exercising a lot or restricting my caloric intake. In an attempt at regulating my periods, I tried everything from acupuncture and supplements to seeking the help of an herbal specialist who gave me a cabinet full of disgusting concoctions designed to rectify whatever it was that was causing the irregularity. Needless to say, none of these approaches worked to correct the problem. Extremely heavy periods with debilitating cramping and frequent large blood clots It’s hard to establish what a “normal” period is since every woman is unique, but if your period lasts more than a week, and is so heavy that you are having to replace your tampon or feminine napkin every hour or risk bleeding through your clothing, you may want to bring this up to your doctor. Additionally, some cramping is fairly common but can generally be managed with over-the-counter pain medication and a heating pad. I was taking prescription pain medication and still couldn’t get out of the fetal position due to the pain for the entire duration of my cycle, which often lasted up to 10 days, leaving me exhausted, anemic and unable to do anything. And, while some clotting is common for many women, large frequent clots may be a red flag that something more serious is going on. Infertility If you are having trouble conceiving and there is no clearly identified medical reason that either you or your partner cannot conceive, endometriosis may be at play. My gynecologist who finally diagnosed me told me that most of their patients with severe endometriosis have difficulty conceiving due to the amount of scar tissue left behind by the endometrial lesions. Abdominal bloating and discomfort I had always attributed this to my irritable bowel syndrome, but, in fact, a lot of the pain and swelling I was experiencing was connected with my endometriosis, not something gastrointestinal. The endometrial lesions caused inflammation that radiated pain into my abdomen and sometimes resulted in constipation alternating with diarrhea, only exacerbating my discomfort, particularly during my menstrual cycles. Frequent bladder discomfort, urgency, pelvic floor dysfunction All of these symptoms can again be signs of other medical conditions, but the scar tissue left behind by endometrial lesions can cause pain and frequency issues with urination that mimic an actual bladder infection. What I thought were constant recurring infections requiring antibiotics were actually attributable to the scars on my bladder. In hindsight I likely took antibiotics far too frequently for something that didn’t require them, something many physicians now warn is ill-advised. While I still have some residual issues with this from left behind scar tissue, a lot of it has been resolved by my laparoscopy and subsequent hysterectomy where they removed a lot of the scar tissue from my bladder. Painful sex This is an uncomfortable topic to discuss, especially for people with a sexual abuse history like myself. While there are perhaps other contributing factors to painful sex that may be related to the emotional effects of trauma, again, endometriosis can affect the vaginal canal and therefore may cause vaginal sex to be uncomfortable at best and intolerable at worst. How to Discuss Endometriosis With Your Doctor Make sure you are comfortable with and trust your doctor This goes without saying, but particularly where gynecological issues are concerned, it is absolutely crucial to find a doctor you feel 100% comfortable talking to about all aspects of your gynecological health, including sex and sexual dysfunction. I specifically needed a female doctor to feel safe due to my sexual trauma, however, each person is different. Additionally, it may be helpful to discuss this with both your primary care physician and gynecologist. If both of them are involved, you may find it easier to get appropriate and timely treatment. Thoroughly document your symptoms This includes the length of, pain level and any other important details associated with your menstrual cycle. The more specific information and consistent pattern of symptom frequency you can present, the less likely they are to dismiss you. It may help to create a chart noting your daily symptoms and when they flare, noting your pain level on a scale of 1-10, 1 being minimal to 10 being the worst pain imaginable. Make sure your doctor isn’t affiliated with a hospital or medical organization funded by a religious institution At the risk of offending someone which is not my intention, I specifically had to deal with a doctor who refused to allow me to get a hysterectomy because it conflicted with his religious beliefs and those of the managing institution of the clinic he worked for. If I had this advice when I was going through treatment in my late 20s, I would have recognized the situation and sought a second opinion from someone else not within that institution. This may also affect coverage for treatments like birth control, which is commonly prescribed as a way of managing endometriosis. Don’t take no for an answer If your doctor ignores you or negates your suspicions that you have endometriosis, don’t give up. Persistence pays off. If one doctor won’t listen, seek counsel from another. Nobody knows your body better than you do. If you sense something is wrong, pursue it. Nothing frustrates me more than hearing stories from individuals whose doctors disregarded their symptoms or suggested they were somehow imagining them. This is particularly common with chronic illnesses like endometriosis and even more common with illnesses that typically affect women, partly because women’s voices and unique needs are often misunderstood or discounted. And one final note about getting treatment for endometriosis — don’t wait. So often women suffer in silence with this condition for decades. You don’t have to. Many new therapeutics are being developed to manage the symptoms of endometriosis and new diagnostic tools are becoming standardized that can make getting a proper diagnosis quicker and less invasive.