Pressure, Pleasure & Pain: The Scale of Intimacy

This week's episode has been sponsored by Oh My Bod, shifting the evolution of pleasure. Hi, this is Suzanne Noble, and you're listening to Sex Advice for Seniors. This week we've had a tube strike in London, which has been very disappointing for me, particularly because I was hoping that I was going to give a talk with a doctor who works in sexual function to a bunch of junior GPs about talking about aging and intimacy issues as a healthcare professional. But unfortunately, the tube strike put an end to all of that. But that's okay, because today, actually, I'm talking to somebody who's really informed when it comes to that. And that's actually one of her specialty topics. So I'm going to have even more to bring to the table when that talk does get rearranged. We've spoken before, but I'm really pleased to welcome back to Sex Advice for Seniors Michelle Jeremey. She's all the way in Norfolk, and she runs a business called the Yoni Therapist, but she's also a psychotherapist, and she works a lot in healthcare settings talking to women about sex and pleasure and pain and all of that fun stuff. So welcome, Michelle, back to Sex Advice for Seniors.

I am so pleased to have you having me back. I can't wait to talk about what's been happening.

I want to know what's been happening.

Uh, well, so obviously when we first spoke, my little, my little idea on how do we get clinicians, other health professionals talking about sex, in particular for me, that passion project is women's pleasure. Um, and I finally, I've got a couple of conferences lined up And there's research in the bag. We are looking at a piece of research that I'm hoping to roll out and be working with you and your client base.

Oh, I am so excited about that. And I think, you know, when I know that one of your topics that you're particularly keen on talking about is low libido, which of course is a massive topic. We hear about it all the time. I hear a lot from men of, you know, oh, my wife or my partner really isn't up for sex anymore. And so what are you doing around that particular topic?

Yeah, so I would say that's a big percentage of my work, particularly when I'm looking at sort of peri to postmenopausal, um, if I'm looking at surgery, if I'm looking at trauma. So it can be sort of low libido, um, pain on penetration, uh, that they're the big factors that come through. And one of the talks I'm doing next month actually here in Norfolk, um, is called pressure, pleasure, and pain. Um, and it's partly because what we tend to find in a clinical setting is they do measure the sort of the biomedical parts of low desire. So it's like a tick chart, it's called the Female Sexual Function Index Questionnaire, and it's about like, in the last 4 weeks, have you felt aroused? And, you know, you score, etc. Lubricated? Have you reached an orgasm? But there's so much that relational aspect's missing.

Yeah, yeah.

And that's what I want to work on. That's, that's the bit I want to really, like, lean into. And so I'm in the process of devising a new tool that we'll be able to roll out for all clinicians, um, and, and that's going to be those questions that I wrote a few down as examples that I just don't think these are the questions that are being missed in a clinic setting. And it's, um, sometimes I have sex because I fear my partner would be unfaithful if I didn't.

Great question.

Um, I've got here, doesn't work about a safety aspect, but there will be repercussions in my relationship if I say no to sex. Um, I have a clear sense of what I enjoy sexually because so many of my clients don't know.

No, no, that's right. Yeah.

And then an interesting one here is, I engage in sex more for my partner's satisfaction than my own.

Yeah, another great question. Yeah, and I know when I had a really great conversation with Lauren Streicher, who's an American doctor, and she was— we were talking about the, the aspect of libido and how complex it is. And, you know, she was saying that the hormonal aspect of it is, is one part, but it's multifaceted. And often what we don't hear is the relational aspect, how you're getting on with your partner. Like, do you have a— do you feel you have a good relationship with your partner? Do you feel you could call yourself happy in your relationship? Right? Which then leads to all sorts of other questions about, you know, your sexual life with your partner. And the other aspect that she brought up that I thought was also really relevant was just like, how generally tired do you feel? Like, do you feel fatigued more often than not? Are you getting good quality sleep? Because she was just saying, you know, so much of libido is around just good sleep. Like, if you're exhausted, you're not going to be up for it because you're just going to want to go to sleep. So when women go, I just want to go to sleep, it's not generally because they're trying to avoid sex. It's because they literally just want to go to sleep, right? They don't— like, my sleep was massively interrupted during the May, you know, during most of my 50s, and sex was the furthest thing from my mind. It's like, I just need to get some rest. So I think all of that is, is other aspects of libido that's ignored. You know, I mean, obviously, there are some women respond better. I've just started taking testosterone about 4 months ago. And I have to say that I wouldn't say like, it's made like the most massive difference. But it has made some difference.

Yeah, yeah. I definitely— all my female clients that come through with low libido, the wellness is the first thing. So I get them to do that Wheel of Life, and part of that looks at sleep, it looks at their mental health, physical health. I include feeling loved, physical touch, and sexual satisfaction. So I start to get a little bit of an inkling on what's going on But for me, I always say the first thing to go is desire. Yeah. And it's the last thing to come back.

Yeah.

So you've got to feel good in yourself before you can even think about who you are as a sexual being.

Yeah. And as you said, one of the key aspects as well is if you don't know your own body and if you don't know how to pleasure yourself, then it's often very difficult because we haven't been taught how to communicate our sexual desire and our sexual wants and needs to other people. So, you know, that question of, I often feel stressed, you know, pressured to do this because of my partner's desire. I suspect that's a huge aspect of what goes on.

Yeah, we perform, we perform because it's either expected, it feels like a duty, obligation to society, you know, we still play into a lot of what I think is ingrained into many women in a sort of heterosexual sort of format. And I think that's the thing that we really need to be looking upon, is I, I believe particularly with a lot of women sort of peri to post-menopause is, is that time where they no longer can get away with performing.

Yeah, yeah, yeah. And also there's the pain that often is associated with it. I mean, this questionnaire, when is it typically brought out? Because I certainly, when I went, I've never had it. I've never had a questionnaire like that in all the, in all of the times that I've been prescribed various things.

So it's so weird. I was literally, I've been inviting some of my current clients and past clients to sort of just basically be case studies for me moving forward for when I'm going in for these talks with clinicians. And I literally was on the phone to a client today and I said, the Female Sexual Function Index, have you sort of completed that in the last— hang on a minute, it was 2014 when she was diagnosed and started obviously asking that she was having sexual dysfunction and the impact it was having on her relationship. She came to me a couple of years ago, so she'd gone obviously nearly 10 years having said this is an issue.

Oh God, yeah.

And she's been referred to every other department, but no one has spoken about this sexual dysfunction and the negative impact. And she said she'd never seen that questionnaire.

No, I've never heard of it. Never heard of it. So is this— is this questionnaire— I mean, do you think it's not being— why is it not being used? Is it because it sounds like it's a thing? I mean, you're telling me that you're revising something which is a thing I've never heard of before.

A thing that's in the cupboard.

A thing in the cupboard, that's right.

Yeah, so I think this brings on to what is missing. I mean, I know when we spoke before, and there's a massive question mark, like within the NHS here in the UK, we don't have psychosexual relationship therapy on the NHS in massive parts across the UK.

Yeah, that's right, we spoke about that.

Yeah, so I do wonder if within the NHS. I mean, and there's a couple of things that have come through when I've spoke to, to friends that are obviously doctors, consultants within the NHS, and I'm saying to them, you know, why is this not being spoken about? What, what are we all afraid of? And I think it is probably because we don't know where we would send these patients to. Um, there's also an element I do wonder about within the NHS, you know, it's research and evidence-based. Do they think it's a bit too woolly, or it's not concrete clinical evidence that they can gather, even though we know the evidence is there.

Yeah, I mean, I— two thoughts kind of went through my head as you were saying that. First thought is when a guy goes in to see his GP and he reports that he might have some unreliable erections, as I like to call them, the, you know, they will go through a series of questions with them. And a lot of that may be on his cardiovascular health, right? Because, because we know the— how important cardiovascular health is to erectile function. So they'll send them off to a cardiologist, and they'll do all the tests. And if there's nothing wrong with their heart, then they'll send them off to a psychosexual, you know, doctor to go and figure out whether it's something else that's going on, right? But there's, there's clear pathways. I, when men have that sort of issue, right? And I suspect when women have issues around sexual function, it's not deemed as important because most doctors are men still. And older women and sexual function, I know because I hear from lots of other women, it's like, well, you're this age and you're menopausal and blah, blah, blah, blah, blah. So that's what happens. Yeah, that's what happens. So I suspect there's a— there's not as much interest in solving that particular problem for women as there are— as there is for men. And the pathway doesn't seem as clear as well. And I think like the NHS is all about— since I've been on my NHS program for 12 weeks, I learned since I've spoken to you, I went to figure out the procurement process of the NHS and went through a 12-week program. And I was like, holy shit, like no wonder nothing gets done here. Like I just was completely, I was horrified by the whole thing. But what I understood from it was that A, a lot of it's just down to money, right? Like how much is this gonna cost us and how much is this gonna save us? And, and so it's, it's kind of quite easy to quantify some numbers. If you give a guy a blue pill and he gets a hard-on, then like, you know, you can move on, right? Whereas with women's desire, libido, it's a bit more complex than that. And you might have to take— it took me 6 months to get an appointment to get testosterone, right?

Yeah.

And the appointment lasted all of 5 minutes. The guy did not ask me anything. He said, you're here because you want testosterone. I said, yes. He said, yeah, fine, no problem. We're going to send you off for a blood test after he'd already prescribed it to me. And then he— and then that was it. And I have a follow-up appointment by phone in 2 weeks' time. Okay. Like, what is he like? What I'm assuming the questions he's going to ask me is, how's your sex life? Right. Or whatever. And I'm going to go, yeah, it takes me less time to have an orgasm. Thank you very much.

Yeah, right.

So I think it's probably a little bit— it's like, how, how do we save the NHS money by giving them this information? And does, does taking all of this information down take too much time? I don't know. I mean, I'm just, I'm just playing devil's advocate here of why it is that always women's health issues are always difficult.

Yes, I think for me what comes up is what happens is it just shuts up shop. There is no talk, there is— there's nothing that happens. Um, even so much so that sometimes I'll have clients say that they will bring something up included into something else, and they'll talk about that topic but then just sort of skirt over the other.

Yeah.

So I feel like a bit like how you're saying about you've created a booklet. I think for me, exactly what you've said to me in the past about a toolkit, it's about some training that we are— we're about opening doors. We're telling people that there are options.

Yeah, yeah, yeah, yeah. I mean, the— with your— the other side of it is that we, we as women, just talking as women, I think we have to learn how to speak up, right? And we learn— and we have to learn how to speak up in a way that's not that, that healthcare professionals aren't listening to us and going, oh, here comes another Googler, another person who's just Googled their symptoms and they're gonna tell me how to solve their problem because they know better. We've gotta be able to talk to clinicians and other healthcare professionals in a way that they listen because that's the other thing I know is often they just don't listen. So what's your recommendation there? 'Cause I don't, that's what I'm curious to know. It's like, how do women go into a doctor? Like, what do we say if If we've got, you know, like, how do we make sure they hear what's going on?

So I think there's a couple of things come up in my mind as you were saying that. There's something for the clinicians, because I will say in, in most cases of people I've met in the NHS, all have the best intentions, all want best for their patients. And so there is a gap maybe in the training or the confidence And also, I think sometimes what comes up— this is what I tend to experience— is, I'm a sex therapist, but my sex does not come into the clinic room. I think there's something about with clinicians that as soon as we talk, say, the taboo of sex, that their own shame, beliefs, values surface. You know, they're not learned how to hold that, whereas The truth is, for me, when I'm in clinical practice, I go by two rules: is it consensual and is it legal? Then I'm ears to everything else, you know, it's like, welcome, where are you at here? Give someone the space. And I think that's what's missing. We are still in a society where, well, I don't know if we should talk about this or talk about that. That's creating the shame.

Yeah.

Yeah. So that's the clinician's part. From a patient point of view, I think this is part that we need to come up with some pro forma of template letters.

Totally. I agree. And I think, you know, on the one side you've got your sexual function toolkit for clinicians. I also think it would be really useful to have a little download that says, I'm going to go in to see my doctor and here's what I want to discuss. And here's, you know, hmm. What's going on in a way that's really clear, even if it means that you don't even have to open your mouth. You just say, here is what I'm experiencing, over to you now, let's have a conversation, because I'm maybe a bit embarrassed, a bit shy, a bit scared, I don't know what's going on here.

And so, so that's it. So for me, my mind just went— when I put my research head on, I've come up with this toolkit, which is a, you know, question, and then you score, you know, agree, disagree, strongly agree, etc. You could have an opportunity for like a dropdown box where if it does evoke a reaction, you can make the comment.

Yeah, yeah.

A doctor would see that and they would know, oh, this is more biomedical. I need to do hormone testing. I need to prescribe this. I need this. Versus this needs to be signposted to a psychosexual relationship therapist or to a gynecologist or pelvic floor physio.

Yeah, yeah, yeah, yeah. And that makes sense. That makes sense. And that's, and that's a way of saving time, right? So to know precisely how to signpost these people to different forms of support. Rather than just taking this assumption that we're all lumped in together. Like I said, they never asked me any questions at all about anything. They just, I just said I was presenting with low libido because frankly, I just was taking too long to have orgasms. I just wanted, you know, I was getting bored myself. I was just thinking, well, if I could speed this up a little bit, that'd be great.

And has it, has it, I mean, given you just—

Yeah, I mean, I do think that just generally, yeah, I feel, I mean, I'm still not back to my, and I'm never going to be back unless I take a substantial dosage, which is, you know, I'm not planning on doing. I'm never going to be back to my 40-something self who's thinking about sex 20 gazillion times a day, but nor do I want to. I don't really want to. But yeah, I think that the, the thing for me is the, the length of time it took to get something that was relatively simple to get. And also the other thing that I've discovered is the number of women who just have no concept at all that, that they could even, that libido could be, you know, biomedical solutions like testosterone, for instance, could help them, that vaginal estrogen could really help. Prevent the pain. And you know that all this stuff is just out there. And I think that's, that's the other side of it, is just not making women feel like when they're asking for this, oh, it's a big deal. Oh, I don't know if I'm going to be able to do this for you. You know, I mean, this is a big ask that you're, that you're making here. It's not a big ask.

Well, that's if they can even get in. That's the problem, isn't it? They build up the courage and then they're not even getting the appointment. So then they just then go off and lose, you know, motivation. But I will say from, from my clinical practice, I am finding that the hormones are really are just one part. Yeah, um, it, it's— it amazes me how many years so many women are going with that, you know, sex on Sunday or blowjob Thursday, you know. It's, it's that type of relationship that they're driving through to keep their partner happy.

Yeah, yeah, I love Sex on Sunday, frankly, but because it's a whole day of it, it's not—

yeah, I've got to say that I think your Sex on Sunday has a very different feel about it.

My Sex on Sunday is fabulous. But yeah, I think that there's a lot of— there's certainly a lot of pressure. And a lot of women I know have just told me about the pain that they experience. And I spoke to— I spoke to somebody in Australia. I was on their podcast this this week, and she was saying, look, you know, I'm having real problems. And I said, but what about this? And what about this? And what about this? And she said no. And I think that's the other thing that's very, very important is you have to find a sympathetic doctor. Like, sure, everybody should have this toolkit. Everybody should be sympathetic. Everybody should be open-minded. Everybody should be receptive to hearing what the women that they're seeing are telling them, but that's not always the case. And, and often I'm hearing that people are dismissive. They're saying, ah, you know, it's not really such a big problem. And so if that's the case, find someone else. Yeah.

Yeah. But I even guess, like you say, we're talking about the doctors, even if it was, say, the nurses that was doing these questionnaires, that if it's a biomedical signpost, they're signposting here. The other side, you know, looking at blood pressures and heart rates and wellness scores, you know, the depression, that could be a nurse. It could just— it's getting in and normalising the conversations first.

Yeah, and that's a really great point because we don't actually need to take up doctors' time with something that could be done, you know, initially by a nurse who could, you know, people might feel just more comfortable with.

Right, I think so. It definitely raises that, that there is, there's education for clinicians, but there's education for, for, for us. And, and also, like you say, is it education or actually stepping into knowing it's our right to be asking these questions?

Yeah, and one of the things that we were going to talk about in my, uh, the talk that I was meant to be doing this week but didn't, is just having a more expansive view of what sex is in general as well. We, we were, we were going to talk more about the fact that sex has been so for so long equated with penetration, and sex is so much broader than that. And how can we start to talk about sex in a much more expansive way in a clinical setting without it all boiling down to, you know, are you able to have penetrative sex, right? So what kind of sex are you having with your partner? Like, how much, you know, like, what is it? What does it encompass? Are you having the full buffet? Or are, you know, because if there's, if you're not having any oral sex, for instance, or there's no masturbation or fingering or something, which might get you all lubed up to start with, then how are you expected to just be ready for penetrative sex, especially as an older woman? You know, it has to— there has to be lots more going on.

Yeah. And I think even that we use a real simple sex map to identify, you know, the yeses, the nos, the curious, you know, not tried, maybe. And I think that in an instance, that would be again, just an opportunity to show that there is something out there that, as you was talking, and I was like, wow, I have so many female clients that don't like oral sex, you know, won't participate in swallowing, won't do anal sex. There's so many no, no, no taboos. And then it's about just, well, what's that about for you? What's coming up for you? Own. Is that because you've told that, you know, only sluts perform this or, you know, that that's not— that's what you do with casual relationships? It's really trying to actually go Well, who do you want to be sexually?

Yeah, yeah, completely. And I know that when I've, I've spoke to a guy who had a radical prostatectomy, went on the testosterone blockers, you know, was not able to maintain an erection, basically went into the equivalent of the male menopause, right? And suddenly had a very good understanding of what women go through and was like, wow, this unbelievable. And one of the things he said was that this whole experience that he's been going through has really taught him to see sex and pleasure in a completely different way than he had ever seen it before. And I— and there is something to be said for taking the emphasis away from erections, for example, and just, again, just talking about pleasure. And I think it's, again, I suspect it's because when you go in to see GPs nowadays, they've got 10 minutes. That's what they've been allocated to see you. So that's just bam, bam, bam, bam, bam. What are, you know, what's the problem? How are we going to solve it? What's going on here? It's all very, very quick. And in speaking to doctors who work more with menopausal women, one of the things they said is Taking time is so important, just like slowing down, just, just letting people listen and not asking too many questions, you know, leaving space for silence so that people can actually start thinking and reflecting rather than just going into this relentless delivery to try to get to the bottom of something where the person that you're speaking to may still be trying to work that stuff out for themselves.

Yeah, yeah, it's that the instant block comes on. The pain of penetration stops anything in between, you know. It's— and that's what they need to work out. What, what do I want to be? Participate? What, what is pleasurable? I always say there's pain, then there's okay, nice. Who wants freaking nice? But we put nice, then we get pleasure, then arousal, and then it's orgasmic. So it's where do you sit on the scale?

Yeah, yeah, yeah, yeah, it's a great question. And have you started handing out these, these surveys yet?

So I'm hoping to be ready the start of October, so I will, I will definitely send them over. And, you know, any— as many as I can get to fill out, see what the questions feel like, compare them to the Female Sexual Function Index one as well. That will give me a good instigator on then we roll this out to clinicians, um, and then we roll out to obviously to patients, to clients alike as well.

Yeah. And are you doing this off your own funding, or how— who's paying for this?

So this is— I put an application in for a 1-year research, but that will be self-funded. So that's why literally the pi— it will be a pilot, but the potential, it could be massive if I could get the funding for it. Yeah.

Yeah, I just wondered if maybe, well, perhaps we can work on something together. And then the other person I was thinking of is Ann Philpott from The Pleasure Project, because she works a lot with family planning around more around sexual health. And it's also around pleasure, because her whole thing is you can't take the pleasure out of talking about sexual health. I mean, you know, it's, you can't make it purely about disease because it happens while people are trying to experience pleasure. So you have to, you have to pull the whole thing together. And I think it is quite important to do that. But I think it sounds like such a great project and something that's so needed right now. And I, and I suspect that if you could get it into the hands of more clinicians, it would really transform the way patients are dealt with who are—

I hope so. That's, that's the plan. It's definitely moving in the right direction.

Yeah. Yeah. So keep your— keep us informed, keep us in touch, let us know what's happening. We will definitely distribute it. I'll definitely distribute it through my Substack network and whoever else gets to hear this, we'll put it in the summary. So everyone can answer it. But yeah, it sounds like an absolute great project. It's so great to hear that you're doing this after our last conversation. I love it when people are kind of like— when they've moved on, it's like, yes! Thank you so much for coming on again to Sex Advice for Seniors, and we will put all of your URLs and socials and all that kind stuff in the summary.

So Michelle, it's been lovely to talk to you, and thank you, been lovely to be back.