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Questions about love and sexual attraction, libido, pleasure, and performance

Have a question for Dr. Pezzi?  He will be happy to answer it in this forum for free.
And now for the requisite fine print . . . .  All submissions become the irrevocable property of Kevin Pezzi, MD and may be published on this site in its Q & A forums or in other venues.  By submitting a question, you specify that you are over the age of 18, or have obtained the approval of your parents or legal guardians and they agree to the foregoing terms.

No liability is assumed with respect to the use of the information herein or otherwise provided.  Medicine is an ever-changing science.  The information presented is based upon my assessment of the current body of knowledge, but this base of information will change in the future.  Hence, before instituting any of the measures presented you should consult with, and obtain the approval of, your physician for the most current recommendations.  No material intended for the general population can attempt to treat specific individuals, and no material in this site or otherwise transmitted to you should be construed as offering individual medical advice.  Given the innate variability of people, it is critical that your physician approves the adoption of any information as being safe and effective for you.  A physician's circumspection is his—and your—greatest asset.

Note:  I have all this material on a separate web site ( www.sexualtips.net ) that is more extensive and more visually appealing — and the pages load much faster!  :-)

Exercise + breast discharge = ?

Q:  I'm a 29-year-old healthy woman who began jogging five months ago.  Since I began jogging, I've noticed that my libido has diminished and occasionally my breasts have a slight milky discharge.  Does this make any sense to you?  I thought exercise was supposed to increase libido, if anything.  My doctor is stumped.  I'd be very grateful if you can help me.  Thanks, Melissa.

A:  It sounds as if you're suffering from a condition called benign galactorrhea.  I will explain this so that it is easy to understand, so don't be fazed by the big medical words.  Galactorrhea just refers to a condition in which breasts make and discharge milk at a time not associated with either childbirth or the nursing of an infant.  Benign, of course, simply means that it isn't dangerous.  However, it is a good idea for anyone with this problem to see a doctor for testing because certain medical conditions can predispose people to galactorrhea, and these conditions should be excluded before one assumes the condition is benign.

Your galactorrhea is probably induced by the nipple stimulation that results from the to and fro motion of your breasts rubbing against your bra.  As I mentioned in The Science of Sex, nipple stimulation in both women and men increases the production of prolactin, a hormone that stimulates lactation (milk production).  One of the side effects of prolactin is its ability to impair libido even if its concentration is not high enough to induce lactation.  Therefore, even people without lactation may be suffering from the libido-suppressing effects of prolactin.  Obviously, for some people nipple stimulation increases libido instead of decreasing it.  The reason for this is because breast stimulation also increases the release of oxytocin, a hormone that improves sex in many ways.  I'll discuss oxytocin in more detail at the end of this topic.

It is interesting to look at the connection between nipple stimulation and libido suppression from a teleological perspective.  In other words, did Mother Nature or God have some logical reason for suppressing libido after childbirth?  Of course!  Pregnancy can be very hard on women, and that was probably more true eons ago before the advent of modern medicine and an assured food supply.  If a woman with marginal deficiencies of some nutrients became pregnant, the fetus would further sap her.  After pregnancy came lactation (no formula in the Stone Age, obviously), which really drains energy and nutrients from women.  After that, another pregnancy following shortly thereafter could have been fatal, for the mother, her fetus, and her infant.  Since there weren't any doctors around in those days to warn women of this serious risk, Mother Nature stepped in and shut down libido.  In case an amorous caveman was able to seduce a woman who was still breastfeeding, the chance of conception was rather low because the hormonal changes associated with breastfeeding reduce the risk of pregnancy.

There are numerous causes of hyperprolactinemia (increased blood prolactin) besides jogging and breastfeeding, including eating, stress, strenuous exercise of any sort, alcohol consumption, exposure to xenoestrogens (man-made chemicals that mimic natural estrogens), certain drugs (oral contraceptives, estrogen, Aldomet^®, opiates, tricyclic antidepressants, phenothiazines, Reglan^®, Compazine^®, Phenergan^®, Tagamet^®, Prozac^®, and Haldol^®), hypoglycemia, primary hypothyroidism, and sexual intercourse (in women). Apparently bizarre causes of hyperprolactinemia are certain chest wall lesions, including neoplasms of the chest wall, herpes zoster (shingles), and surgical scars or trauma affecting the chest wall. Since prolactin serves to switch off sexual excitement after orgasm, anyone who wishes to maximize their potential for multiple orgasms should keep these factors in mind.

Prolactin output is normally held in check by dopamine, a neurotransmitter that often declines with aging. Hence, prolactin secretion tends to increase with age. Lindsey Berkson, an expert on endocrine-disrupting chemicals, stated in her book Hormone Deception that certain chemicals may either mimic or indirectly affect prolactin.  Incidentally, prolactin can contribute to obesity since it can stimulate appetite and promote fat storage.

OK, what can you do about this problem?

• Switch to a different form of exercise (e.g., swimming).
• Use a sports bra that minimizes breast motion.  It may also be a good idea to place a large Band-Aid^® over each of your nipples before donning the bra.
• Consider taking an herb, vitamin, or medicine.  Here are some things that help:

Bromocriptine (Parlodel^®):  Bromocriptine is a drug that can reduce prolactin secretion.  Bromocriptine can improve libido, especially in people with high prolactin levels, and it may increase sexual pleasure, too. One of the unique properties of bromocriptine is its ability to increase sexual desire while postponing ejaculation.  Interestingly, since bromocriptine can reduce prolactin secretion, it can therefore promote fat loss.  However, that should be viewed as an ancillary benefit and not a primary indication for use of bromocriptine.

Ginseng: Ginseng's reputed aphrodisiac effect has a scientific basis because ginseng can depress blood prolactin levels. This effect is more pronounced with repeated use.

Vitamin B₆: High doses of vitamin B₆ can improve libido by reducing prolactin secretion in both sexes. B₆ can also improve the quality and intensity of sexual pleasure in some people who have poor genital sensation. Vitamin B₆ is excreted within 8 hours after absorption, and thus should be supplied at least every 8 hours. An average dose for these conditions would be 50 mg three times daily. Taking too much B₆ can result in too vivid dream recall. Doses over 200 mg daily can result in neurological disorders if taken for several months.

Those are some of the specific therapies for combating the libido-suppressing effects of prolactin.  There are many other general ways of heightening libido, as I discuss in The Science of Sex.

More on oxytocin

Oxytocin is a hormone that promotes contractions of the uterus during childbirth, but it is produced at other times as well. Its secretion increases during sex and breast stimulation, and it is triggered by certain emotional stimuli. It has been termed the "cuddle chemical" because it promotes snuggling, pair-bonding, and the desire to please others. This may explain why women are more likely to want to cuddle after sex. Thus, there is some truth in the phrase "making love." Oxytocin stimulates erection, enhances vaginal and uterine contractions during intercourse, and increases sexual sensation before and during orgasm.

Oxytocin was available by prescription as a nasal spray (Syntocinon^®), intended to assist initial postpartum milk ejection from a woman's breasts after childbirth, but at the time of this writing it is not available; perhaps a generic version will be offered in the future. Oxytocin has been used cosmetically, too. Apparently unaware of the fact that application of a vacuum could achieve the same effect, some Las Vegas showgirls used to sniff Syntocinon to make their nipples more prominent.

Estrogen enhances sensitivity to oxytocin, and thus women with more estrogen are more likely to experience the positive effects of oxytocin—and perhaps its negative effects, too. According to Theresa Crenshaw, MD, author of The Alchemy of Love and Lust, oxytocin diminishes the capacity to think, reason, and remember.

Breast stimulation increases oxytocin in both women and men, and this is therefore a more readily available means of sexual enhancement than the administration of Syntocinon. The amount of oxytocin produced by breast stimulation in men and nonpregnant women is less than that which can be administered by a Syntocinon nasal spray, but you will not find many doctors willing to prescribe Syntocinon simply to enhance your sexual pleasure. However, since breast stimulation can also increase prolactin (which suppresses libido), relying upon breast stimulation to enhance sex is problematic. Since the ratio of oxytocin to prolactin produced as a result of breast stimulation is individually variable, breast stimulation is not a surefire catalyst for sexual pleasure.

Premenopausal women sometimes become attached to a man with whom they have had sex, even if the man isn't good for them, because the sexually induced secretion of oxytocin encourages this binding. After menopause, intercourse does not result in an oxytocin surge, thus permitting women to make a more rationale, and less instinctive, choice. Premenopausal women who wish to avoid being hormonally blinded should know that alcohol suppresses, and heat increases, oxytocin release. To put this into proper perspective, let's look at some real-world examples.

In women, alcohol temporarily increases testosterone and, hence, libido. However, since alcohol also suppresses oxytocin, women who consume it are more likely to engage in sex, but less likely to feel good about it afterwards. They're also less apt to feel attached to the man, and less likely to feel as if they're falling in love.  Physiologically-hip, conniving men can to some degree circumvent this stumbling block by remembering the effect of heat. Lounging in a hot tub, and then cuddling in a warm bed—or, better yet, vacationing on a warm, exotic island . . . they don't have anything to do with romance and love, do they? Yes, they do, and I think that most people have an intuitive understanding of this.

Women often assume that men desire sex just for the physical pleasure it provides. No doubt, that's sometimes all the man is after. However, I think that many men realize that intercourse can make the woman feel attached to the man. Longing for love, men may desire sex as a means of fostering a romantic bond.

Situational beauty phenomenon

Q:  I'm not having much luck attracting men.  I keep myself in good shape, but I wasn't born with good looks.  I'm not a dog, either, but I'm evidently not what men are looking for.  Short of plastic surgery or new clothes (I've tried the latter, with no success), what can I do?  Thanks for any help you can give me!  Terri.

A:  In The Science of Sex , I devoted one chapter to the enhancement of intersexual attraction.  I put a couple of my tips elsewhere on my web site, so I won't repeat that info here but I'll provide a link to that page.  One thing that I didn't mention in my book or on that other web page is that you can enhance your desirability by taking advantage of the situational beauty phenomenon.  I'll illustrate that by the following story.

A few years ago my brother Ray and I were snowmobiling in Michigan's Upper Peninsula, and we stopped into a restaurant to get a hot chocolate.  A few minutes later a woman who'd been snowmobiling entered the restaurant, and we both opined that she was quite attractive.  Musing about this over the next few days, I questioned why we thought that woman was so attractive.  She was slim, but otherwise possessed no extraordinary physical traits.  Moreover, had I passed by her in a mall or in a restaurant in a non-snowmobiling area, I wouldn't have given her a second look.  So what was it about her that elevated my perception of her attractiveness?  The fact that she was a female snowmobiler.  While women who snowmobile aren't quite as rare as a dodo bird, they're rare enough to stand out in a crowd.  I suppose it is also human nature to reflexively like people who share your interests.

Besides snowmobiling, another activity you might want to try is target shooting at a shooting range.  (Before you non-shooters start guffawing, I should mention that I took a woman friend of mine to a shooting range and in the course of a few hours her opinion changed from "I hate guns" to enjoying that activity so much she didn't want to leave the shooting range.)  A single woman who shows up at a shooting range is bound to attract a lot of attention from men, and if you try that on a Saturday afternoon and don't have a date for that evening . . . well, then you do need plastic surgery!

If shooting doesn't rate high enough on your PC scale for you to give it a try, consider golfing, fishing, boating, camping, or any other activity that draws men.  Yes, some women engage in those activities, but they're usually tagging along with a man.  Try doing it stag and you're bound to attract attention.

Does size matter?

Q:  I've heard a number of opinions on the topic of whether or not penis size makes a difference.  Does it?  Thanks, Tom.

A:  Yes, it does matter.  However, before you jump to any conclusions, bigger is not necessarily better.  "Big" or even "average" may be too large, while "small" may be just right for some women.   In my experience as a doctor I've noticed that vaginal size varies greatly — far more than penile size.  Considering only adult non-virginal women, some vaginas were so small that they'd provide a snug fit for a pencil, while others were so loose that the thick end of a baseball bat would easily fit inside.  Yes, penile size varies, but not to that degree.  Therefore, for any given couple, the size of the man's penis is less important than the size of the woman's vagina.  This fact is typically given short shrift in our culture.  Whenever the topic of "size" is broached, it is tacitly assumed that the only size which matters is penile size, while vaginal size is ignored.  If it is politically correct to discuss penile size, it should be acceptable to consider vaginal size, too.  However, while I frequently hear many direct and indirect discussions of penile size from sex experts, comedians, ad copy writers, and even on a daytime court TV program, there doesn't seem to be any commensurate mention of vaginal size.  Again, since size does matter and vaginal size is the greatest variable, it only makes sense to consider the woman's contribution, too.

Here is another reason to focus more upon vaginal size than penile size:  women have more control over the tightness of their vaginas than men do over the size of their penises.  While penis size can be increased (especially on a short-term basis, as I explain in my book), vaginal tightness can be dramatically altered on a long-term basis by doing Kegel's exercises.  In women, one of the greatest benefits of Kegel's exercises — and one that is rarely mentioned — is that the depth of the outer "tight zone" of the vagina can be increased. I've never met a man whose eyes didn't glaze over at the thought of a tight vagina, but such an improvement can benefit women, too. When this zone of the outer vagina is not just tight, but tight and deep, the penis is better able to stimulate the sensitive outer third of the vagina and the G-spot.

Kegel's exercises are able to increase the depth of the tight zone by causing hypertrophy (thickening) of the pubococcygeal muscles, as depicted in the following diagrams:



The diagram on the left is from a woman with a poorly developed pubococcygeal muscle, and the diagram on the right is from a woman with a well-developed pubococcygeal muscle.

What's the average size of an adult penis?  And why is it less than what it once was?

Q:  Dr. Pezzi, it's Tom again.  Thanks for answering my other question.  I showed your answer to my girlfriend, and she now realizes that "my" problem is "our" problem, and probably even more "her" problem.  But, she's working on it.  My question today is, what is the average size of a penis?

A:  The length of an average erect penis in adults is 5.72 inches* (or, if you believe the latest study, 5.1 inches).  Years ago, the average length of an erect penis (measured on the dorsal, or top, surface) was 6½ inches. Later on, it was 6¼ inches, then 6 inches . . . now 5.72 or—gulp—5.1? What's going on here? I hate to tell you this, men, but you are not quite the man your grandfather was; the average penile length is shrinking. Why? There are a number of estrogens (phytoestrogens, xenoestrogens, and exogenous estrogens**) to which men are now exposed. Furthermore, the estrogen level in men can be increased by a number of factors (which I discuss in my book in the section on the testosterone to estrogen ratio). Too much estrogen, and the penis either shrinks or fails to grow as much as it should. Not good.  If you're interested, in my book I discuss dozens of environmental factors under your control that affect penile size.

* As the automobile companies equivocate, your mileage may vary. By random chance, some women have had nothing but large partners, so they may think that a guy with an average-sized penis is small; other women, having only been with men with small penises, may think that an average man is well-endowed. It's all relative. The average erect penis is 1.62 inches wide, and 4.5 inches in circumference. Most men have a penis measuring 4.6  to 6.25 inches long, but 12% of men have larger penises and 12% have smaller penises. Incidentally, the length of a fully stretched flaccid penis is virtually the same as that of a fully erect penis.

** Phytoestrogens are chemicals with estrogen activity that occur naturally in a variety of plants such as soybeans.
     Xenoestrogens are man-made chemicals that mimic natural estrogens.
     Exogenous estrogens are estrogens unintentionally introduced into people from ingestion of food or water containing estrogens from animals, humans, or pharmaceuticals.

Why did my penis shrink?  What can I do about it?
How to trigger a "second puberty" of penile growth

Q:  I am writing to you because my doctor is an idiot.  I'll explain why in a minute.  I am 47 years old, healthy, have usually one beer each evening, never use drugs, don't smoke, and I haven't gained any weight.  I see my doctor once yearly for an annual checkup.  So far, so good, except for one thing.  My penis is shrinking.  It doesn't look as big, or feel as large when I grasp it with my hand, even when it is fully erect.  I mentioned this to my doc, and he told me that penises don't shrink.  Well, mine did.  It's about ¾ inch shorter, and ½ inch less in circumference.  My doctor thought I measured wrong.  No way.  I work as a machinist, and routinely measure things to an accuracy of less than one-thousandth of an inch.  There is no way that my measurements are wrong.  I must have measured my penis at least a dozen times when I was a teenager, and I've checked it several times in the past few months.  There has been a definite size decrease, so I know my doctor is just plain wrong about his statement that penises don't shrink.

My questions are:  1) Why did my penis shrink?  2) What can I do about it?  3) Why do doctors say that penises don't shrink, when they clearly do?  I assume I am not the only man who has experienced this problem.

A:  You are not alone.  I'll tell you about a 62-year-old patient I saw in the ER years ago.  As I prepared to insert a catheter into his penis, I asked his daughter to step out of the room.  He said, "That's all right, doc.  She can stay in here.  There isn't much left to see.  It used to be large, and now it's just a shriveled up noodle.  But I'm proud of what it did.  It gave me two beautiful children."  This revelation about the shrinkage piqued my curiosity, and I would sometimes ask other patients if they had the same problem.  Amongst older men, this was surprisingly common.  This caused me to wonder why so many doctors cling to the belief that penis size is fixed at the end of puberty.  I know of a few cases in which there has been a documented size increase (I discuss why in my book), and many more cases of shrinkage.  Tissue shrinkage is actually a very common accompaniment of aging.  Breasts shrink, the vagina shrinks (unless estrogen is given after menopause), the brain shrinks, skin and bones thin, muscles atrophy, lips shrink, testicles shrink, we become shorter, and so on.  In spite of this, physicians routinely maintain that penis size does not change.  The penis of an average 88-year-old man is just as large as it was on his 18th birthday?  Hogwash.  Doctors are wrong.  Don't be too surprised, though.  This isn't the first medical myth to crumble under the weight of objective scrutiny.  For example, there is the myth that the average body temperature is 98.6° F.  That is not true, but many docs are seemingly ignorant of circadian temperature variation and research which indicates that the average body temperature is not 98.6° F.  If doctors can be deceived by the body temperature myth, it is not surprising that they can be duped in regard to age-related changes in penile size — a far more esoteric subject.

Doctors routinely see men in their flaccid state, rarely inquire into their erect size, and almost never discuss if there's been any change in size.  With this in mind, I have a difficult time understanding why physicians feel qualified to make a sweeping generalization that penis size is immutable.  They believe that to be true because they heard it from another doctor, who just passed on what he heard from another doctor who also didn't know the truth because he was just relaying a myth that he'd heard or read from someone similarly uninformed.  Is this any way for learned professionals to behave?

Why did your penis shrink?  That could result from decreased testosterone and especially dihydrotestosterone (DHT), which is derived from testosterone.  DHT is known to be the primary catalyst for penile growth.  Physicians are taught in medical school that this is important only before the end of puberty; once the penis develops, it'll maintain that size forever.  I know that is wrong, and it frankly doesn't make any physiological sense to me.  As I discuss in my book, the body continuously rebuilds itself.  If your house could do the same thing, it could tear off an old shingle and replace it with a new one.  In time, your house would replace all of its shingles, and you'd have a new roof.  Your body does a fairly good job of renewing itself until you hit middle age, at which time tissue regeneration begins to sputter.  After a few more decades, this process slows even more.  Wounds heal more slowly, and muscles take longer to regenerate after exercise.

If the cells and molecules in your body were not broken down, you could live off sugar water.  You wouldn't need protein.  But you do require dietary protein and other nutrients because tissue destruction and regeneration constantly occur.  This process is more rapid than you might imagine, because your body recycles some of its building blocks.  Only a fraction of the recycled material is lost in the urine or feces.

The bottom line is that the vast majority of the molecules in your body weren't there a year ago.  The old ones are gone, and new ones have taken their place.  Even bone, which may seem as active as a fossil, is torn down and rebuilt.  The penis is no exception.  Let's think about this logically.  If DHT is critical for stimulating penile growth (and it is), why would this matter only before the end of puberty?  Isn't there still a receptor for DHT after puberty?  Yes, of course.  Once DHT binds to the receptor, doesn't it affect DNA transcription, as it does before puberty ends?  Yes, of course.  However, physicians who contend that penis size is fixed after puberty would have you believe that it doesn't matter if your DHT level is zero, or if you have DHT bubbling out your ears.  Can you think of any other example in which the level of a hormone is totally immaterial to its target tissue?  I can't.  I graduated in the top 1% of my class in medical school, so I am not ignorant about how the body works.  Hormones exist for one reason:  to influence their target tissues.

In reality, the penis becomes less sensitive to DHT after puberty, but the sensitivity is not zero.  Thus, the DHT level can influence penile size, but to a much smaller degree than it could before the end of puberty, when the penis was still very sensitive to DHT.  As I mentioned before, I don't think the DHT level matters after puberty in regard to penis size, I know it.  (If any physician or scientist doubts this, put your money where your mouth is.  Let's wager a million dollars.  You'll lose.)

After reading all this, you might think that increasing the DHT level is the way to go.  It may help a wee bit, but there is a much better secret that I accidentally discovered.  I discuss this topic in The Science of Sex.  Using this method, your penis won't just be larger, it will be exquisitely sensitive, and sex will feel much better.  Your libido will increase to the point that you would be called a nymphomaniac, if you were a woman.

Besides DHT, other factors influence penile size.  Genetics obviously matters, but it is pointless to discuss them because this is not under your control.  In terms of what you can influence, DHT is the most important factor, but there are others.  I won't reiterate everything I said in my book, but I will briefly mention other things that make a difference:  other hormones, hormone transport proteins such as sex hormone binding globulin (SHBG) and albumin, cadmium, zinc, antiandrogens, phytoestrogens, exogenous estrogens, endogenous estrogens, xenoestrogens, obesity, numerous drugs and chemicals, collagen, elastin, and a dozen other factors.

Why does sexual pleasure vary so much from one woman to the next?

Q:  I'd like your medical opinion on something.  I've had sex with over 60 women and I've noticed that there is a huge difference in the pleasure I feel during sex with different women.  With most of the women it's very pleasurable, with a few it's so little pleasure it's barely worth doing, and with some others it is so pleasurable it's off-the-scale, out-of-this-world, mind-blowing pleasure.  Why is that?  I used to think that tightness was the only thing that made any difference, but there's more to it than that.  I don't think that this variation is attributable to how horny I am because some women are consistently duds and others are consistently extraordinary.  Plus, on a few occasions I've had sex with two women, changing partners every few minutes, and I know there can be a significant difference.  Why?  Another thing I wonder about is why sex feels so different even amongst women who are extraordinary.  I don't know how to explain this other than to compare it to eating pizza and eating steak.  I love both equally well, but they taste entirely different.  So can you see what I'm trying to say?  When I think about the two women who've given me the most sexual pleasure, the sensations I got from each women was noticeably different.  This really has me stumped.  I know there must be some factors that make one vagina better than another, but how can two vaginas feel equally fantastic but yet very different?  Thanks, Phil

A:  You're correct, there is a significant difference.  I've noticed it, and other men have reported to me that they've noticed it, too.  There are many factors that underlie this difference, and I discussed them in a chapter in The Science of Sex.  One of the reasons why I explained this so extensively is because men sometimes dump women who are "duds," as you termed them.  What's important for women to realize is that many of the factors that influence this variation in pleasure are things they can influence.

I don't intend to minimize the importance of love in a relationship, but the fact is that an average couple in the United States begins having sex after three dates.  I think it is safe to assume that most men are not truly in love after three dates, so if they don't obtain the pleasure they're seeking they don't feel compelled to stick with that woman.  I've heard many women wondering aloud, "Why did he dump me right after we slept together?"  Well, it's not because your bedroom was messy, trust me.  Maybe the guy suddenly realized he needed to spend more time mowing his lawn . . . or maybe he's been spoiled by sleeping with women who gave him substantially more pleasure.  Such pleasure is addicting, and once a man has experienced it, he will often turn up his nose at women who have less to offer in the bedroom.  My message to women is this:  you can't change the expectations of men, but you don't have to be snubbed.  If what you have isn't good enough for the men in your life, you can make it better.  I'd like for all women to be superstars in that department, because that would force men to choose partners for more substantial reasons.  As a doctor, I've witnessed the pain experienced by women who are repeatedly rejected after The Night.  Again, women are dumped for other reasons, but this is one, so why ignore it?

To answer your question about why sexual pleasure can be quantitatively the same but qualitatively different (i.e., both are equally pleasurable but in different ways), the primary reason for this is because there are so many factors that account for the differences in sensation amongst women.  As an analogy, consider the three basic colors (red, blue, and green) that are combined to produce the spectrum of colors on your computer monitor or television set.  Those three colors can combine to produce equally beautiful but substantially different colors.  Or imagine the different flavors produced by cooks who combine flour, sugar, butter, and eggs in different ways to produce entirely different foods.  The ingredients may be the same, but when the proportions are varied the end result can be quite different.

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Q: While browsing at the bookstore, I came across a book which proclaimed that the cul-de sac is the "ultimate pleasure spot." First, what is the cul-de-sac? Second, is it really the ultimate pleasure spot?

A: The cul-de-sac (also known as the rectouterine pouch or the pouch of Douglas) is a space above the vaginal apex, above the posterior uterus, and in front of the rectum (see diagram).




















In reality, there is no direct way to stimulate the cul-de-sac during sexual activity. It can be indirectly stimulated by stimulation of the cervix or posterior fornix. The cervix projects down into the vagina near its apex, leaving a circular recess around it called the vaginal fornix.

So why did that author say that the cul-de-sac is the ultimate pleasure spot? Probably because cul-de-sac is a sexier and more euphonious term than posterior fornix. Aside from that minor point, is that area some sort of magical hot button? Yes and no. I hate to equivocate, but there's no simple answer. Here are the facts:

• Some women do obtain extra pleasure from cervical stimulation during coitus. If the penis thrusts deep enough to contact the area around the posterior fornix and cul-de-sac, it will inevitably contact the cervix, too. Since these structures are in a small area and they're attached to each other, stimulating one will stimulate the others. Hence, it's a moot point whether one area is the "pleasure spot."

• Calling it the ultimate pleasure spot is a bit of an overstatement. Most women think that the ultimate pleasure spot is the clitoris, especially when the clitoris is stimulated along with the outer vagina and G-spot. Think of that as the South Pole of Pleasure, and the cervix, posterior fornix, and cul-de-sac as the North Pole of Pleasure. Which is the ultimate pleasure spot? 99% of women would choose the South Pole any day — or night.

• For some women, the North Pole isn't the ultimate pleasure spot, it is the ultimate pain spot. If a woman has endometriosis* or an infection of her cervix or tubes, deep thrusting can be uncomfortable or even exquisitely painful.

* A condition in which functional endometrial tissue is present outside the uterus (the endometrium is the lining of the uterus).

Do I have a fornix?

Q:  Hi Dr. Pezzi.  I've just discovered your question & answer page and have found the reading very interesting.  I was doing a search trying to find a diagram of the cul-de-sac after reading about it in a book entitled Super Sexual Orgasm.  I found your diagram and description, however now I'm concerned that I may not even have a posterior fornix after a total hysterectomy.  Am I correct in assuming this?  Thanks for your information, Alexandra.

A:  By definition, the vaginal fornix is the recess or arch (fornix is a Latin word that means "arch") formed between the vaginal wall and the part of the cervix that projects into the vagina.  If you've had a total hysterectomy that removed your cervix, you do not have a posterior fornix (or an anterior fornix, for that matter).  I wouldn't fret over this for a couple of reasons.  First, some of the tissue that once formed your fornices (plural of fornix) is likely still present, but instead of reflecting or looping into an arch-like structure, it is just sewn together into what is sometimes termed a "blind pouch" that forms the end of your vagina.  Secondly, I don't know of any evidence which suggests that the fornix tissue possesses any special sexual properties.  Some of the magic attributed to it is instead due to the cervix.  However, as I've pointed out before, not all women think that cervical stimulation is pleasurable.  Some love it, some think it feels "weird," while others think it is downright painful (although these latter women usually have some sort of pelvic pathology).

Doctors are now — thank God — less cavalier about hysterectomies than they once were, so if your doctor removed your uterus and its cervix, he likely had a good reason for doing that and you are probably better off without them.

"I don't get horny any more"
Doctors think that "OK is good enough," but patients don't

Q:  I'm a 36-year-old married man with a problem.  I'm healthy and I don't smoke or use drugs, and I rarely drink.  I'm happy, except for one thing.  I don't get horny any more.  I still have sex, but that's primarily because I want to please my wife.  I never have that burning desire for sex that I once had.  When I do have sex, it feels OK, but it's not as intensely pleasurable as it once was.  I saw my doctor about this, and since I can still get an erection, have sex and an orgasm, he didn't see what the problem is.  He just doesn't get it.  Is there hope for me, or should I just give up?  Steve

A:  Yes, there is hope for you.  First, let me tell you a little secret about doctors and their modus operandi when confronted with a problem for which they're clueless.  Doctors don't like to concede a lack of knowledge, so rather than admit that they cannot solve a problem, they'll trivialize it.  If the problem is sufficiently minimized, there's no problem to be solved (at least in their minds), so this mitigates their anxiety about not knowing the answer to the problem.  This psychological defense mechanism doesn't just afflict quacks who work in seedy offices; I know physicians who are members of the faculty at the most prestigious medical schools in the world, and they do it, too.  When they don't have an answer, they pull this dismissive stunt.  Furthermore, in subsequent private conversations with their colleagues, they'll often denigrate both the problem and the patient.

That's enough psychological dissection of doctors and how they respond to a potential threat to their egos.  Now, on to your problem.  I'm amazed that so many doctors simplistically assume that erection and orgasm are evidence that everything is A-OK in that department.  There are erections, and there are rock-hard, fully inflated erections.  In terms of preorgasmic and orgasmic sexual pleasure, there is pleasure, and there is pleasurable that is indescribably intense.  The realization that pleasure varies so much was one of the primary factors that spurred my interest in researching sex, because this topic has been given short shrift by the medical profession.  Ask a typical gynecologist or urologist why some women can give men more sexual pleasure during intercourse.  The traditional medical view is that this is explained by one variable, vaginal tightness.  If you want to be entertained, you might try this some time:  press the doc for more reasons why this variation exists.  Most likely, he will hem and haw, say "um," scratch his head, and look befuddled.  Ask him to enumerate a half-dozen reasons, and he'd be utterly stumped.  This is one of the central flaws of medicine.  Doctors assume that the absence of disease is health, and pleasure is pleasure.  Obviously, things aren't so black and white.  People don't just want to be free from disease, they want to have radiant health and feel great.  They don't want just so-so sexual pleasure, they want intense sexual pleasure.  However, physicians possess a different mindset, and they think that "OK is good enough."  This conviction pervades most specialties within medicine (with the notable exception of plastic surgery, where there is a relentless pursuit of "even better").

Hence, I am not surprised by the apathy evinced by your physician when you discussed your problem with him.  The good news for you is that there are many causes of diminished libido and sexual pleasure that are easily treatable.  I can't discuss every possible cause in this space, but here are a few that I will briefly mention.  Your testosterone level may be low, or your estrogen level may be too high, thus depressing your testosterone-to-estrogen ratio.  You may have too much SHBG (sex hormone binding globulin), a blood protein that gloms onto testosterone to transport it, but in the process makes the testosterone inactive.  You may have another hormonal imbalance, even endocrine problems that seemingly have nothing to do with sex.  You may be deficient in some nutrient, or you may be suffering from an exposure to some chemical in the environment.  Surprisingly, common chemicals that people are exposed to every day have the potential to rob them of sexual gratification.  As strange as this may sound, the problem may not be you, but your wife.  Apart from the obvious (e.g., is your wife still attractive and loving?), there are several physiological reasons why your libido hinges not just on you, but also what goes on in your wife's body.  I explain all these things, and many more, in my book.

Accutane causing vaginal pain and fragility

Q:  When I took my second course of Accutane I developed severe vaginal pain during intercourse.  For two days following intercourse, my vaginal lining would slough and during this period of time it was extremely sore.  No tampons could be inserted and certainly no penises either!  I saw several doctors through Kaiser Permanente, but none knew why it happened.  Not one of them linked it to Accutane.  It became almost impossible for me to have sex.  I could still do it for a minute or two with a bearable amount of pain, but that too became rare.  It has gotten to where I cannot have intercourse at all as insertion of anything feels like I am being stuffed with an extra large sandpaper dildo.  Of course, this reduced my appetite for sex.  I was a beautiful, flirtatious young lady with a steady boyfriend when this happened to me and suddenly my hopes for a healthy sex life or even a marriage were more or less destroyed.

Have you read about the researcher who worked for Roche who claims that Roche ordered him to destroy research documents on Accutane?  I may have a copy of his story if you're interested.  Niki

A:  Yes, I am very interested, and I'd greatly appreciate that.

I think I will be able to help you overcome your problem, or at least minimize it.  First, some background information.  Accutane is known to cause skin fragility and dryness.  It can also cause dryness of the mouth, lips, eyes, and nose.  It can cause peeling of the palms and soles.  It can induce eyelid inflammation and conjunctivitis, which is inflammation of the conjunctiva (the mucous membrane lining of the inner surface of the eyelid and the exposed whitish surface of the eyeball).  It increases the probability of epistaxis (nosebleed).  It can trigger keratitis (inflammation of the cornea).  It can cause inflammatory bowel disease.  It can also cause bleeding and inflammation of the gums (an interesting aside that is tangentially related to Accutane:  researchers discovered that gums undergo cyclic hormonal changes during the menstrual cycle, which led them to theorize that oral tissues, like the vagina, possess hormone receptors).  Considering the foregoing, I am not surprised when I've heard women report problems similar to yours.  Accutane causes many problems other than the ones listed above, but one of its characteristic effects is to cause abnormalities with skin and mucous membranes (a.k.a., mucosa).  The vaginal mucosa is not an exception, as you know.

In the Physicians' Desk Reference, Roche admits that the "exact mechanism of action of Accutane is unknown."  Hence, it is not surprising that they do not understand the causation of Accutane's side effects.  I think some of Accutane's effects result from it interfering with the action of certain hormones.  This plausibly explains why Accutane can decimate libido and sexual pleasure, and why it can lead to vaginal problems such as yours (fragility and pain) that are typically seen only in hormonally deficient postmenopausal women.  Hence, one logical therapeutic option is to use supplementary hormones.  The mechanisms by which hormones act are very complex.  Many doctors oversimplify this subject and think, or act, as if hormone levels were the only important key.  In reality, they are just one link in the chain that begins with the body trying to do something and ends with the body accomplishing that task.  Hormonal effects can be blocked by competitive inhibition (which I explain in The Science of Sex), various nutritional deficiencies, genetic problems, and exposure to certain chemicals — including Accutane, in my opinion.

I will give you an analogy to help illustrate why measuring hormone levels will not necessarily ensure that your hormonal effects are OK.  To clarify this, I'll put the analogy equivalents in parentheses.  Let's say that someone (a patient) has difficulty hearing sound (achieving a hormonal effect) from his AM radio (body).  He consults an engineer (doctor), who uses a signal strength meter (a lab test) to determine the strength of the radio waves (the hormone level) in that area (in that patient).  If you're knowledgeable about electronics, you know that the engineer could not possibly declare that everything was OK just because the signal strength was fine.  Perhaps the radio receiver (the hormone receptor) was defective or blocked.  Do you see what I'm getting at?  Hormones do nothing by themselves.  They're just messengers the body uses to signal desired effects.  Just because the signal is OK does not mean the effect is OK.  Inexplicably and perversely, many physicians ignore this fact.  Whenever they wish to gauge action of a hormone, they do a lab test to measure its level.  If engineers were that illogical, they would measure AM radio sound levels by testing radio wave signal strength.  If you found an engineer that daffy, you'd fire him and find someone else.

I am not opposed to measuring hormone levels, but it is important to remember that hormone levels are just one link in the chain, so to speak.  It is also important to assess the hormonal effects.  If I were your doctor, I would evaluate the adequacy of your hormonal effects by looking at the hormonally responsive tissues of the body.  Some of this investigation would involve visual clinical judgments, while other facets of the evaluation would involve biometric assessments and microscopic evaluations of hormone-responsive tissues (such as vaginal cells).  I'd also use various clues (e.g., old photos and your self-assessments, pre- and post-Accutane) to help determine if Accutane is indeed blocking some of your hormonal effects.  I'd then consider the totality of the evidence from your history, physical, and lab tests to assess whether or not your body's hormonal messages are "getting through," so to speak.  I would not tell you that everything was hunky-dory just because your hormone levels were OK.  If your hormonal effect deficits were confined to your vagina, you and I would consider using a topical vaginal cream to supplement the local hormonal effects.  If your problems were more widespread, we might opt for oral or transdermal hormonal supplements.

But what if hormonal effects were not the root cause of your problem?  Some of Accutane's adverse effects have no clear-cut connection with hormones.  If that were true in your case, I'd offer you an invention I conceived while reading your question.  This would enable you to experience pleasure with intercourse, instead of pain, and it would also be pleasurable for your partner.  I assume that simple measures, such as sexual lubricants, were not adequately helpful.

If you want to read my book The Science of Sex, let me know and I will give you a free e-book copy of it.  In any event, let's keep in touch and solve your problem.

Should heterosexuals worry about AIDS?  Why did the media lie about this?
(If you haven't already read the above text in the yellow box, please do so now.)

Q:  I just heard an interview with Bernard Goldberg, a respected journalist who had a long career with CBS.  He wrote a book entitled Bias: A CBS Insider Exposes How the Media Distorts the News.  In this interview he said that the media distorted the facts about AIDS as it pertains to heterosexuals.  Basically, he said that the media made it seem like any heterosexual could get AIDS from regular (vaginal) sex, but that AIDS was really only a problem for gay men and heterosexuals who injected drugs.  Tell me, Dr. Pezzi, did the media lie to us?  Have they wrongly instilled a fear in us heterosexuals who don't use drugs?  Why did it take so long to expose this myth?  Thank you for your time, Jeff.

A:  Yes, Bernard Goldberg is correct:  the media lied about this.  Why did it take so long for the truth to come out?  I've been writing about this for years, and some doctors who are far better known than I am have said the same thing.  However, if the media disagrees with either your message, its implications, or how it is presented, they will quash your message.  The media love things that are politically correct whether or not they ARE correct.  Regarding the notion that heterosexuals should be shaking in their boots about AIDS, some people speculated that the media spread this myth to curry favor with homosexuals, or perhaps because the media seem to have taken it upon themselves to sanctify and champion the causes of anything dealing with homosexuality, homelessness, minorities, and women's rights.  Homosexual men, of course, have good reason to fear AIDS.  They also have good reason to make us believe that we're all at risk for this disease.  Why?  Because it makes it so much easier for them to get funding to support AIDS research.

I know we like to think we live in a time in which such a propagandized distortion of the truth doesn't occur, but unfortunately we often can't get our facts straight even when they're not laden with deep sociological implications.  Take something as simple as body temperature.  Ask doctors what is normal, and 99% will answer, "98.6° F."  You've probably heard that a million times, too.  There's just one problem:  this number is based on research done in the early 1800's, and was passed from generation to generation with few people questioning its validity. The actual average body temperature is about 97.6°.  In the morning, it's about a degree lower, and later in the day it's usually a degree (or more) higher, depending upon activity level and other factors.  I don't intend to turn this into a treatise on body temperature; I just want to point out how we're so susceptible to believing things if we hear them often enough.

In the case of the myth about how heterosexuals should fear AIDS even if they don't abuse injectable drugs or engage in anal intercourse, there is more to how this myth gained credence than mere repetition.  During my years of training, I'll never forget the subtle but unmistakable brainwashing I and my colleagues were subjected to regarding this matter.  I could spend hours writing about that experience, but the bottom line is that we were pressurized into adopting certain attitudes toward homosexuals and their — oops, OUR — disease:  AIDS.  I don't favor ignoring AIDS research just because it will likely be of tangible benefit only to gay men and drug-abusing heterosexuals, because I think every taxpayer is justified in wanting more federal dollars to fight "his" disease.  Michael J. Fox wants money for research on Parkinson's disease, Mary Tyler Moore wants more diabetes research, and on and on.  We all have our pet projects and interests, and just because someone has a vested interest in funneling more dollars to something that threatens him doesn't make that cause any less worthy.  Hence, I don't object to the fact that gay men want more money to research AIDS.  Instead, what galls me is the ease with which the truth of this matter has been trampled.  Unfortunately, this deliberate distortion of the truth has left in its wake a lot of collateral damage.  I've seen heterosexual patients in the ER sobbing uncontrollably, worried that they may have contracted an HIV infection just because they had vaginal intercourse.  What used to be one of life's greatest pleasures is now something that we often fear more than Russian roulette.  The needless hand-wringing engendered by this pervasive myth about how HIV is spread has damaged many lives, causing people to fret about an unfounded fear.  We all have enough real fears to conquer without losing sleep over things that aren't worth worrying about.  How much time do you spend worrying about whether you will die in a car accident?  Do you stop driving and huddle under your bed just because many people die in car crashes?  No, because automobile transportation is too vital to life.  Well, sexual pleasure is one of the foremost things that makes life worth living.  It is prudent to be cautious, but don’t let fear rule your life.

I discussed this subject in more detail elsewhere on my web site.  You may also wish to read The Myth of Heterosexual AIDS by Michael Fumento.  Yes, heterosexuals can contract an HIV infection, but if heterosexuals don't use contaminated needles or engage in homosexuality, their risk of acquiring AIDS is vanishingly small.  In fact, one state that once required HIV testing before issuing a marriage license ended that requirement when so few positives appeared — remember, those people may not have acquired HIV via heterosexual means, but rather by drug abuse or sporadic homosexuality.

Let's put this risk into perspective.  I've seen several people killed during traffic accidents while on dates.  I've seen people who died while engaging in sporting activities.  I've seen men who died at work.  I've seen people who died from a faulty furnace.  As a former ER doc, I've seen people die in just about every way possible, yet I've never seen a non-drug-using heterosexual die of AIDS.  But do people worry about dying in traffic accidents on dates?  Or do they worry about dropping dead while playing sports?  Or at work?  Or sleeping at home?  No.  Virtually no one worries about such things, although those and dozens of other seemingly innocuous events are far more likely to kill than vaginal intercourse.  Do you see how the media have twisted the facts?  Heterosexuals now think of sex as a potentially lethal event that is one of their gravest threats.  Does this make any sense to you?  Virtually every heterosexual who isn't an IV drug user dies of something besides AIDS, but the media do not harp about this — they rant about HIV as if we had good reason to make this our supreme fear.

The HIV virus has been so politicized that it will be years, if ever, before people put this into proper perspective.  As a doctor, I'm flummoxed by the fact that people are usually oblivious to infectious agents and diseases that are far more of a threat to them than is the HIV virus.  I am not encouraging people to take unnecessary risks with their health, but only to spend more time worrying about their greatest threats and less time fretting over less likely dangers (see the following question).  Let's face it — no one has enough time to worry about every risk we face, because everything we do carries some risk.  I could be killed while snowmobiling, because there are plenty of kooks in that sport who drive at grossly excessive speeds on the trails.  Or I could be killed while mowing my lawn.  It's hilly, and riding lawn mowers occasionally tip over and crush their riders.  Or I could drown, be hit by lightning, or be crushed by a falling tree while logging.  After three close calls, I invented a way to cut down trees from a safe distance.  This is the correct way to deal with risk:  identify what is most likely to kill you, then think of a way to reduce that danger.  Incidentally, I also invented various ways to reduce the risk of STD transmission, and I'll announce these in future editions of my book.

Relevant article: Celebrity promotion of charities 'is largely ineffective' says research

Dismantling a common myth about the transmission of STDs
(If you haven't already read the text in the yellow box that preceded the above topic, please do so now.)

Q:  You've answered somewhat similar questions on your excellent web site, so I thought I'd write to you for advice.  My college prof assigned us to write a paper on a sexual misconception.  Anything come to mind?

A:  Yes.  I've received so many requests from college students asking for help with their papers that I've begun to wonder if I should offer a service writing term papers for a fee.  :-)

There are countless sexual misconceptions, but since you're in college, I presume your teacher is not interested in shattering myths that prevail only amongst teenagers and the proletariat.  To impress your professor, you need a myth that even an intellectual might fall for.  OK, here goes.

Nowadays, people usually interrogate prospective sexual partners before sleeping together.  The tacit message I've seen in innumerable sources is this:  your risk is decreased if your partner has had few sexual partners.  This seems so intuitively obvious that you may wonder why I am discussing it.  Why?  Because it is misleading.  Let's analyze this.  This simplistic assumption would be true if disease transmission were 100% per sexual experience, but it is not.  For example, from one act of intercourse, the risk of female-to-male transmission of herpes is 0.05%; male-to-female spread occurs 0.2% of the time (you might hear somewhat different statistics from various sources). While the odds are worse for gonorrhea (female-to-male, 20%; male-to-female, 70%), gonorrhea is easily cured.  The risk of HIV transmission varies with type of intercourse (vaginal versus anal) and presence of lesions, like herpes, that break down the vaginal lining or penile skin.  If those lesions are not present, some docs think that vaginal intercourse is very unlikely to spread HIV.  Some physicians and scientists say the risk is zero, or close to it.  I doubt the risk is zero, because virtually everything carries some risk — even drinking water.

For the record, I've had more patients die from using a blow dryer than from AIDS if they were heterosexuals who never used drugs or engaged in anal intercourse.  I've also had more patients succumb from welding, chainsaw or mower injuries, snowmobiling, hunting, jogging, alcohol abuse, drug abuse, overeating, smoking, driving to school or church, drowning, climbing in trees, or stupidity (like touching live electrical wires while standing in a pool of water).  A few years ago, Americans were treated to a spate of brief public service commercials in which somber Hollywood celebrities gave us condescending short speeches about AIDS.  Ask yourself this question:  if prevention of death is the goal, why have I seen a thousand commercials about AIDS and none about chainsaws, obesity, or the hazards of electricity?  Hmmm?  I suppose those celebrities get their information from biased sources that give them a skewed perspective.  I obtained my information firsthand.  When a man was cooked by electricity, flattened in a car accident, or died in any one of numerous other obvious ways, I did not need a pathologist or medical examiner to tell me why he died.  Nor did I need some politically motivated statistician or spokesperson to tell me what is killing 99.9% of Americans.  I've seen tens of thousands of patients, so my sample is large enough to be statistically valid.  From this, I know that heterosexuals spend their time worrying about the wrong things.  Instead of worrying about AIDS, it would be far more logical to worry about dying from food that your spouse cooks for you.  Remember Poppin' Fresh^TM, the adorable little Pillsbury Doughboy^TM?  Or Betty Crocker^®, Mrs. Butterworth’s^®, and similar icons?  The processed foods they represent have contributed to the death of more heterosexuals in the United States than has the HIV virus.  This is probably true even when heterosexuals are not excluded because of shooting drugs or engaging in anal intercourse, and it is undoubtedly true when these risky subgroups are omitted.  Obesity, heart attacks, diabetes, strokes, cancer — those are the big killers that people should worry about.  Dr. Dean Edell recently reported a study that suggested the high rate of heterosexual transmission of AIDS in Africa is not due to sexual intercourse (as had long been presumed) spreading a different subtype of HIV than is prevalent in the US, but is instead due to unsafe medical practices such as using dirty needles.  Interesting.

The bottom line from the preceding discussion is that the risk of acquiring some sexually transmitted disease from one episode of intercourse is less than 100%, and very low for the incurable diseases that concern most people.  Thus, what matters more is not how many people you've slept with, but how many times you've slept with them.  I've been exceptionally careful about who I sleep with, and my precoital interrogatory/investigation is probably more thorough than that of just about anyone else.  However, most people are not so careful, and they gloss over subtle hints that would be red flags for me.  If they're horny, they jump into bed.  Thus, the risk these people assume is unknown to them.  What difference does it make to switch from Partner #1 with an unknown risk to Partner #2 with an unknown risk?

I will illustrate this by looking at a hypothetical example.  For the sake of simplicity, assume the risk of spreading a disease is 1% per sexual encounter.  Assume that Person A had sex with eight partners, and Person B had sex with four partners.  Who has a higher risk of acquiring the disease?  That's right, you cannot determine risk based on number of partners, so I will give you more data.  Person A slept with each partner twice, and Person B slept with each partner 20 times.  We should also know the prevalence of the disease.  Let's say that is 1%.  Now who is more likely to acquire the disease?  Let's do the math:

Person A
8 partners x 1% prevalence = 8% chance of encountering a partner with the disease
8 partners x 2 sexual encounters per partner = 16 episodes of sex
16 episodes of sex x 1% chance of transmitting the disease per encounter if the disease is present x 8% chance of encountering a partner with the disease = .0128 = 1.28% chance of acquiring the disease

Person B
4 partners x 1% prevalence = 4% chance of encountering a partner with the disease
4 partners x 20 sexual encounters per partner = 80 episodes of sex
80 episodes of sex x 1% chance of transmitting the disease per encounter if the disease is present x 4% chance of encountering a partner with the disease = .032 = 3.2% chance of acquiring the disease

Therefore, although Person B slept with half as many partners as Person A, Person B is over twice as likely to have acquired the disease.  Thus, the most important factor isn't number of partners, it is the total number of sexual encounters.  If Hollywood folks are smart enough to lecture us about staying safe, why don't they give us the real story?  Don't they teach math at Hollywood High?

A very pretty virgin is falling for a man who had 350 partners

Q:  Dear Dr. Pezzi:  I am a 30-year-old woman and will be having sex for the first time in a couple of weeks.  The reasons why I waited so long vary.  I wanted to be in love with my "first" and I haven't been in love since college (he was actually sleeping with one of my friends while we were dating; I found out right before the big event and broke up with him).  I have also been very focused on my career and let my personal life slide.  The person that I am dating now is someone that I have known for years.  We have always had "feelings" for each other, we have great intellectual chemistry, and our physical chemistry (thus far) has been very good.  We didn't date before this because he was also very focused on his career and wanted to sleep around as much as possible before we tried dating.  He (and I) always felt that once we took that step, that would be it, for both of us.  He has slept around a lot (in the hundreds), and although we have maintained a very close friendship over the past couple of years I have not told him of my virginal status, nor does he suspect that I am still a virgin.  At the risk of sounding conceited, I am very pretty, in great physical shape, and very well "put together."  Men constantly approach me (even a couple of his friends, who I frequently run into at restaurants and at the gym).  So he has no reason to suspect, nor am I going to tell.  This is the problem:  as I mentioned he has had many partners and I know he likes it "wild" (hair pulling, etc.) . . . and I suspect I would as well.  However, my conception of wild may be very different from his, although I am not sure how.  We recently saw a movie together (before we started dating) that involved quite a bit of spanking.  He asked me what I thought about that and I told him that it looked like a lot of fun.  Honestly, I was thoroughly excited.

I want this to be great for him.  I know it will be great for me no matter what, because I am wildly attracted to him and very close to being in love with him.  I also know him well enough to know he feels the same way.  I have a couple of weeks to "prepare" (I am going out of town on business for three weeks in a couple of days and we decided to wait until I came back).  Do you have any suggestions?  Thank you, Clarissa

A:  Yes I do, but before I delve into that, I want to address another issue, namely "He has slept around a lot (in the hundreds) . . ."  I assume you mean that he has had hundreds of partners, correct? (Not one or two partners hundreds of times.)

Q:  Dear Kevin:  Thank you for responding to my e-mail.  Regarding "I assume you mean that he has had hundreds of partners, correct?  (Not one or two partners hundreds of times.)":  Both.  He has had hundreds of partners — probably around 350 over the past nine years, twelve of whom he slept with hundreds of times ("friends"), maybe 150 "one nighters."  The remaining:  sexual interaction occurred between 8 and 25 times with each partner.  For example, until recently he was sleeping with a woman who lives in his apartment building.  They weren't dating, they would just get together twice a week and have sex (for the past three years), but he was also dating and sleeping with other women (most of his dating relationships would fizzle out around the 6th date).

Regarding the possibility of contracting an STD:  he uses condoms, and always has, except several times about 9 years ago (he was dating someone for about two years, they were monogamous, and they didn't use them a couple of times.  He has always told me that he is very careful, always examines the "area," and he never touches himself with the hand that has touched her.  He is also a surgeon and has a blood test every couple of months.  However, he has not been careful in respect to oral sex.  He is quite comfortable with performing cunnilingus, even on a complete stranger — which obviously possesses (albeit a small) theoretical and demonstrated risk of STD transmission.

At this point, I am more concerned with his inability/unwillingness to have established or maintained an emotional relationship with any of these women.  He always said I was the standard by which he measured all women and they always fell short.  The more realistic explanation is, aside from enjoying/appreciating the same things, we have incredible intellectual chemistry.  Most of his female companions are not intelligent.  The intelligent professional women that he dated are either un-cultured or unattractive (by his standards).  But still, 9 years of meaningless, emotionless sex . . . is it possible he is addicted?

A:  The short answer:  yes.  The long answer:  You're obviously an intelligent woman, so why can't you see that you're about to make a major mistake?  He has "DANGER" written all over him.  Let's analyze this in detail.

First, it is helpful to enumerate why people have sex.  This may seem overly simplistic, but I think this is the best way to make one of my points.  People have sex for procreation, to help cement a relationship, to give and receive love, and simply for sexual gratification.  Your prospective partner (let's call him Bill) obviously is not having sex for the first three reasons.  You might think that his sexual appetite is fueled by the latter urge, but I disagree.  If sexual release was Bill's motivating factor, why is he evidently perpetually on the prowl for someone new?  Why isn't the woman he had sex with last night good enough?  Or the woman he slept with last week?  Or if finding a quality partner is so difficult for him, why doesn't he just masturbate like the rest of us do?  Why is he on a crusade to boink enough women to fill a small town?  Do women mean anything to him other than giving him an opportunity to carve another notch in his bedpost?

Oh, I get it . . . Bill's quest for new flesh will end the day you sleep with him.  A switch will flip in his mind, and he will become monogamous.  A cozy home in the suburbs, a white picket fence, just you and him forever.  Does that strike you as plausible?  It strikes me as wishful thinking and a fanciful dismissal of the evidence.  Ask a man to walk on the moon?  No problem.  Ask him to change?  Don't hold your breath.

You're probably thinking that things will be different with you and Bill because you're hot enough to make him put down roots.  Do you honestly believe that Bill is so skilled at finding duds that he found hundreds of them who were such losers that they deserved to be dumped once he had his jollies?  Do you think that Bill found 350 women who just wanted a fling?  In my experience, it is a rare woman who wants sex but not a relationship.  Do you think that Bill possesses some phenomenal ability to ferret out likeminded people?  I don't.  I think that many, if not most, of his conquests believed that they were special, too, and that they had a future with him.  Marrying a surgeon?  Gee whiz, that is almost as desirable as bagging a rock star.  Bill is obviously attractive, charming, and successful . . . and you think that he found countless women who just wanted an affair and nothing more?  It is a safe bet that this isn't true, and he knew it.  Nevertheless, he was slick enough to make them believe otherwise.  He's undoubtedly suave and skilled at making women presume that sleeping with him is a worthwhile investment.  You think so, too, don't you?

Some of the most charming and irresistible people in history were psychopaths.  Contrary to popular opinion, psychopaths are not twisted in every way at all times.  They don't reek of being aberrant 24/7/365.  They can have facets of utter normalcy, which gives them the ability to coexist with less extreme people and not stick out like a sore thumb . . . except when they choose to unfurl their tantalizing spells.  After my training in psychiatry and exposure to many thousands of patients in a variety of clinical situations, and after I've pondered why people are spellbound by political leaders who are clearly nuts, it is obvious to me that people are often magnetically drawn to individuals who know how to exploit their unorthodox tendencies.  They know that many folks are just sheep who are eager to follow "the man with something extra."  The man who does everything by the book and abides by the rules the rest of us follow — well, that man has "plain vanilla" stamped all over him.  We crave leaders who believe, and act, as if they are genuinely endowed with singular powers.

I am not necessarily saying that Bill has psychopathic tendencies, but to bed 350 or so women requires a special "gift" that is worthy of an honorable mention in The Guinness Book of Records.  An average man has to work overtime to sleep with ten partners, which is fairly typical.  Yet your Bill, in spite of the arduous years of medical school and residency, managed to have sex with 35 times as many partners?  Aren't you alarmed by such off-the-scale behavior?  Had he not been sidetracked by the nuisance of his medical education, do you think that he would have stopped at a mere 350?  He is indisputably an avid believer in the notion that "more is better."  In fact, that seems to be his guiding light.  Without that bothersome diversion of med school and residency, he'd likely had given free rein to his impulses and slept with enough women to erase your hope that his sexual appetite is not incorrigible.  Don't comfort yourself thinking that this is water under the bridge.  In the years to come after residency, he will have much more time to pursue his personal interests.  Don't believe me?  Just wait.

On to the next major obstacle standing between you and Bill and happiness forever.  If you read the topic about Why does sexual pleasure vary so much from one woman to the next? (presented earlier on this page), you know that the sexual pleasure men receive from sleeping with women varies greatly — probably much more than the pleasure variation women receive from different men, thus making it difficult for women to comprehend this.  After sleeping with hundreds of women, Bill is sure to have found a few sexual superstars.  If you aren't one, keeping Bill on his leash is just a pipe dream.

Perhaps you think that sexual compatibility (e.g., the spanking you mentioned) will suffice to keep Bill content.  One might logically wonder how unusual his sexual tastes are if he has yet to find a good match after 350 candidates have not passed muster.  Trust me, he's already slept with sexually compatible women, and dumped them.  Probably dozens of times.

On to the topic you knew I would discuss, so you preemptively attempted to dismiss my concerns about it:  disease.  I will begin by stating the obvious:  Bill has not been too careful about choosing his partners, and you don't need an MD degree to know that a quick visual check of the vulva is not sufficient to exclude transmissible diseases.  Next point:  the protection that condoms provide is far from absolute, and I've read convincing statistical analyses by Ph.D.s who asseverated that partner selection is more important than condom usage.  Again, partner selection is Bill's Achilles' heel.

By "blood test," I assume you mean testing for HIV and perhaps hepatitis.  But what about the other diseases?  And what about your real danger, which is that he's disease-free now, but may not be next Tuesday?  I am not as confident as you are that your intellectual and physical chemistry will reform his ingrained behavior.  He's had physical chemistry with others.  And surely in his storied past were at least a few women who were bright, interesting, and vivacious.  And what are they now?  History.

I am alarmed by your statement about "Most of his female companions are not intelligent."  Does he purposely choose dingbats?  Or is it so tough to find 350 bed buddies that he is willing to scrape the bottom of the barrel?  Or does he somehow prefer to sleep with intellectually vacuous women, saving you — The Prize, The Catch, The Complete Package — for long-term asexual idolization?  This is bizarre.  If I were attracted to you and we really hit it off (as you seem to have done with him), I'd want to sleep with you, not a multitude of other women.  If he were as fond about you as you are for him, he would not have embarked on his jihad to sleep with every willing woman.  Some premarital sexual exploration is normal . . . but three hundred and fifty?  Does.  Not.  Compute.

I was also alarmed when you said, "The intelligent professional women that he dated are either un-cultured or unattractive (by his standards)."  When 99.9% of men meet women they find unattractive, they don't sleep with them.  Makes sense, doesn't it?  What is it that compels Bill to buck this commonsense tenet?

Back to the discourse on disease.  The fact that he ends up twixt the sheets with women who usually aren't brainy is something that heightens his STD risk.  Some things are too politically incorrect to be mentioned in the mainstream press, so you may not be aware of the fact that the prevalence of STD's in dumb people is much greater than it is in intelligent people.  By definition, dumb people do dumb things — one of which is to fail to exercise proper precaution in the selection of sexual partners.  Oh, the stories I could tell you about this subject!  I'll save those tantalizing true tales for another book and just give you one of the lessons that I, as an experienced doctor, learned in dealing with patients who saw me because they were concerned after having sex with a new partner.  The intelligent people, whose circumspection made them wary, rarely acquired diseases.  The dumbbells?  They'd be whimpering "Why did this happen to me?" as I explained the results of their examination and tests and thought, "Because you slept with the wrong guy."  It's not that I am not sympathetic.  I am.  It's just that there is no substitute for prudent avoidance.

All of which brings me back to you.  You might not contract anything from him initially, and he might remain forever faithful, although the chance of that is slim.  The one thing you cannot avoid is that having 350 partners is a very bad sign.  Please tell me that you are intelligent enough for this to dissuade you from making a mistake that you may forever lament.

I've met docs like Bill before.  One of them lost his medical license after he had sex with a patient in the hospital chapel and videotaped it.  Ripley was right:  truth is stranger than fiction.  I am afraid that years of "way beyond the norm" behavior have imbued Bill with the idea that he can do just about anything.  He might cool his jets for a while, but when the 7-year itch hits (or for him, 7 months, if you're lucky), he'll revert to his old habits.  You might very well regret passing up better, more stable opportunities by devoting yourself to him.

I'm sure you've heard that saying about, "Those who do not learn from history are doomed to repeat it."  Many of Bill's partners probably felt used by him, and now regret sleeping with him.  One of the advantages of reading history and reading about others is that we can learn from their mistakes.  Wouldn't life be unbearably tough if we had to personally learn everything the hard way?  You have the luxury of having 350 women attest that Bill uses women and discards them.  And you want to be #351?

Sea-going husband suggests that his wife fornicate while he is gone; she fell in love

Q:  I am married to a wonderful man who happens to be out at sea.  While he was out he said I could have a partner.  I decided a threesome would be fun.  So my co-worker and her fiancé of five years decided to get together with me.  It has been three months now and things have been great until my friend's fiancé told me that he thought he was in love with both she and I.  And I felt the same, but remember my husband who I also love is still out to sea.  Now, my husband knows about the threesome and when he gets home we are planning to include him in the fun.  I guess my question to you is this, can a person be truly in love with two people at the same time?  Or is there another explanation for both his and my feelings towards each other and our spouses?  Thanks, Erica

A:  Is there another explanation?  Yes.  You're lonely.  And him?  Well, he is obviously not lonely.

Is he genuinely in love with you?  I can't give you a definite answer based on the limited information I have about your relationship, but there is a good chance that he is confusing lust with love.  Or perhaps you've both succumbed to the pair-bonding effect of oxytocin (discussed earlier).

Is it possible to love two people simultaneously?  Absolutely.  We're generally conditioned in our culture to confine ourselves to one romantic partner at a time for pragmatic reasons, but consider this:  is love rational and based on definable reasons, or it is irrational and based on nebulous and ethereal whims?  People usually fall in love for identifiable reasons:  physical attraction, shared interests and beliefs, commonality of intellect and sense of humor, complementary goals and personalities, mutual admiration and respect, and yes, great sex.  So if you love your husband because he possesses certain attributes, why wouldn't you be very fond of someone who was endowed with the same or substantially similar attributes?  The notion that "there is just one perfect mate for me" is sappy hogwash.  If love were predicated on this "one perfect match" nonsense, humans would have gone extinct eons ago.  Prior to the advent of motorized transportation, people usually fell in love with others who were within walking distance.

Although we all have countless potential  partners who would be good love matches for us, we typically suppress those feelings — sometimes unconsciously and sometimes with a great deal of conscious struggle.  Loving more than one person at a time is easy, but it is difficult for most people to accept that they are not the sole love interest of their partners.  To keep this from being a source of friction, we usually nix the love for others . . . or try to act as if that love never existed or was erased.  Things are obviously different in your little enclave.  If your husband is so devoid of the usual male jealousy that compels most men to throw a conniption fit when confronted with infidelity, then he may also accept the fact that you love someone besides him.  Given that he is the one who suggested that some man pinch-hit for him in his absence, he would be on shaky ground by proposing your extramarital affair but bristling at the feelings of love that might foreseeably result from it.  That would be like suggesting that you strike a match, but complaining that a flame resulted.

What does sex feel like for the opposite sex?

Q:  I'm curious as to what sex feels like for women.  As a man, I know just what sex feels like for me, but I doubt that it feels the same for women because of differences in anatomy.  I've asked my girlfriend to explain what it's like for her, but she isn't telling me much by saying it feels really good.  As a doctor, I'm sure you have a much better understanding of the differences in sensation between the sexes, and you can probably offer a much better explanation.  Thanks for solving this mystery, doc.  Ben

A:  Here is an excerpt from The Science of Sex:

Sooner or later, most people wonder what people of the opposite sex experience during sexual stimulation. To understand this, you need to have at least a rudimentary comprehension of the development of genitalia before birth. Early in development, the sexes are anatomically indistinguishable. From this identical base, hormonal and other factors mold the genitalia into either the male or female form. The important point to grasp from this is that male structures have an analogous female counterpart in terms of origin, and vice versa. That is, the same tissue is sculpted into structurally different forms. While it may appear different, the innervation — the way the nerves "hook up" — is essentially identical. From a purely mechanistic point of view in terms of sensation, the genitalia are nothing more than devices that stimulate the sexual nerves. Given that the nerves are identical, it is not surprising that the sensations experienced by the sexes are similar. Anatomical differences account for some minor disparity in sensation, but the overall experience is much the same. For example, when a man touches his scrotum, he feels what a woman experiences when she touches her labia majora (the hair-covered outer lips). Penile sensation is analogous to that of the clitoris, vagina, and labia minora (inner lips) combined. Just as a woman experiences different sensations when stimulation is alternated between the clitoris, vagina, and labia minora, a man will also experience different sensations when different areas of his penis are touched.

Having said this, it is important to note that there are differences in the sensations experienced by the sexes during intercourse. This disparity in sensation is attributable to two factors:  anatomic and tactile variation. The first results from the indirect stimulation of the glans clitoris during intercourse, as contrasted with the direct stimulation of the penis. The second factor, which is just as important, results from a variation in perceived sensation due to tactile (touch) dissimilarities between the penis and the vagina. Obviously, a penis does not feel the same as a vagina. Ergo, they cannot impart the same sensations during intercourse, even if the nerves supplying them are identical. For example, when a penis is touched by hand, and then by a vagina, the sensation is greatly different. Because the texture of a vagina differs from that of ordinary skin, the nerves are stimulated in a different manner. This difference in nerve stimulation results in a different nerve impulse, or signal, being conducted to the brain. The brain then interprets the variation in signals as variations in texture.

While the sensations during intercourse may differ, a very close appreciation of the sensations experienced by the opposite sex can be approximated when provision is made for the tactile variation of the penis and the vagina. Given the similarity in feel between the tongue and the lips (especially their inner lining, or mucosa) and that of the vagina, the sensations experienced by a woman when she is orally stimulated (cunnilingus) is quite similar to what a man experiences during intercourse, assuming that her labia minora and clitoral glans are stimulated. The sensations experienced by a woman during intercourse can be approximated in a man when he is orally stimulated by the moistened outer lips of the mouth on the dorsal (bottom) aspect of his penis, but there is no direct stimulation of the penile glans.

Weight gain after marriage and pregnancy:  is it inevitable?

Q:  I hate to admit this, but after my wife gave birth I am no longer attracted to her.  She had a good figure before pregnancy, but now she's overweight.  I've tried to get her to exercise or diet, but she won't even try.  Her doctor says her thyroid is fine, so that's not the problem.  I've noticed that many other women seem to permanently gain weight after pregnancy.  Is this something that is inevitable and men just need to accept?  Eric

A:  It's not inevitable.  The incidence of obesity in this country has skyrocketed in the past few decades.  Obesity is itself a disease as well as being one of the primary contributing factors to heart disease, diabetes, cancer, stroke, and arthritis.  Therefore, obesity is not just a cosmetic problem.  Yet in spite of the fact that it is a serious and alarmingly prevalent disease, it has become somewhat politically incorrect to think of this as a problem.  Instead, we're pressurized to accept obesity as being almost inescapable.  Men are made to feel guilty for desiring a svelte wife, and we're told that we're putting unreasonable pressures on women by expecting them to look like an actress, model, or Barbie doll.  OK, it IS unreasonable to expect every woman to be as thin as a stick, but is it really too much to ask for today's women to have the same amount of body fat as women did a few generations ago?  In view of the fact that it used to be considered unladylike for women to sweat, whereas exercise is now culturally acceptable, you might think that today's women should be in even better shape.  And with the countless numbers of diet pills, diet supplements, fat-free foods, weight loss books and clinics and whatnot, you might think that women should be as thin as Barbie.  Instead, we now have more women than ever who weigh more than their husbands.  The question is:  why?

Before I answer that question, I should point out that I'm not gratuitously slamming women.  I used to be fat myself and I know how easy it is to gain weight.  However, I also know that anyone who wants to lose weight can succeed.  When I got out of my residency program I was so fat I couldn't see my feet when I stood up.  Now, even though I'm 14 years older, I have a better body than most teenagers.  I'm not mentioning this to brag; I'm mentioning this to demonstrate that obesity is not some sort of inevitable plague.

I will not address all of the explanations for obesity since many of them are well-known and there are enough of them to fill a book.  Instead, I'll focus upon why women, more than men, are gaining weight.

First, let's discuss the "ripcord phenomenon."  I don't know if women discuss this amongst themselves, but every man I've known seems to know about it — and fear it.  In case you're not familiar with the term, the ripcord phenomenon refers to the sudden ballooning of women after they feel they've hooked a man . . . say, by getting a wedding ring or, for the ultimate hook, by giving birth.  Go ahead and scream about how politically incorrect I am for discussing this, but remember that men were derisively discussing this before I hit puberty and cared about what women looked like.  I'm the messenger, not the source of the message.  The message is that men like attractive women — surprise! — and that we're a bit miffed when the women in our lives think so little of us that they give up trying to be attractive.  This stings all the more when men think that woman don't try to lose weight because, thanks to the wedding ring or children, they no longer need to even try.  The hooks are sunk, so why lift a finger?

Instead of pouting year after year about why men are so commitment-phobic, magazines like Cosmopolitan could do their readers a favor by forthrightly addressing some of the reasons why men are reluctant to tie the knot — and one of these reasons is the fear of the ripcord phenomenon.  Or the editors of Cosmo might want to buy my $10 book (free if you buy my sex book) in which I explain how it is possible to lose weight without dieting, drugs, herbs, exercise, or surgery.  That might seem as plausible as a perpetual motion machine or time travel, but it works and the science behind it is basic physiology and physics.  Not voodoo.  Not diets that only work for Hollywood celebrities.  The problem is that hucksters have promised us weight loss miracles for decades, and 99.99% of those claims are either overhyped nonsense or a rehash of an old idea.  Consequently, it is natural that people are skeptical of weight loss claims — especially ones that seem too good to be true.  Alarmingly, the Federal Trade Commission is trying to pressure the media into not accepting weight loss ads that make "too good to be true" claims.  The problem with stifling free speech in this manner is that it presupposes that no miraculous breakthroughs will ever occur — some of which may at first seem too good to be true.  So should physicians and scientists stop thinking and innovating, fearing that a government bureaucrat with a room-temperature IQ could quash their ideas even if they're legitimate breakthroughs?  Haven't we been down this road before?  People who once suggested that the earth is round were lambasted by the folks who "knew" the obvious, what they could see with their own eyes:  the earth was flat.  And then there was the obviously premature idea circulating around 1900 in which people suggested stopping research in physics, since everything about physics was known.  The atom bomb blew that supposition apart.

Why do today's women seem to care less about their figures than women once did?  The answer is simple:  because more women than ever work, they don't need men.  Collectively, enough women gained weight so that the overall "mark" against which women are judged was lowered a notch or two.  After all, women use their looks (and other attributes, of course) to compete for the best possible man.  If enough women gain weight — and this is just what happened — then what passes for an average woman is quite a bit chubbier than before.  If a man wants to get married, he often must settle for a woman who is fatter than he'd prefer.

Interestingly, this ripcord phenomenon has not yet pervaded every part of the United States, and certainly not every part of the world.  Two summers ago my friend Tracey and her husband, who live in southern Florida, came up to Michigan, my home state.  Tracey was flabbergasted and commented, "What the hell is wrong with these women in Michigan?  Almost all of them are fat!"

One of the most common explanations for why there are so many obese women in northern Michigan is that it's cold up here, so women bundle up.  Since layers of clothes can camouflage fat, the main theory is that this reduces the incentive to diet and exercise.  That isn't the sole explanation.  It's even colder in Minnesota, but the prevalence of obesity in that state is much less.  Go figure.  Or consider women in Russia, many parts of which are far colder than Minnesota.  Women who place personals ads in Russia typically describe their physiques as average when they weigh 100 to 110 pounds.  In contrast, women in the United States (and especially regions like northern Michigan) evidently think that 150 to 170 pounds is average.  That's even more frightening than what it may seem at first.  Since the weight of most non-fat tissue in the body (brain, blood vessels, liver, kidneys, pancreas, bones, muscles, etc.) doesn't vary by much, a typical Russian woman might have 20 pounds of fat while her "average" counterpart in the United States may carry around 80 pounds of fat.  What really matters isn't body weight, it is body fat percentage.  With rare exceptions, men think that women with body fat percentages of 18% look yummy, while women who are 47% fat by weight . . . well, not so yummy.  Appearance aside, that extra 60 pounds of fat can cause a number of health problems.

Obesity is not inevitable.  I beat it, and I know women who, even after marriage and childbirth, have better bodies than most models.  I have other friends, too, like Karen, who are mothers yet have such stunning bodies they'd make any man drool.  Therefore, obesity after marriage or childbirth is not certain.  From reading your question, Eric, it seems clear to me that your wife pulled the ripcord and doesn't feel the slightest bit guilty about it.  Is there a reason for this?  Are you obese?  Is there a reason why your wife doesn't give a hoot?

Two years later I received this response from Eric's wife, Julie:

"Eric showed me your answer, and at first I wanted to strangle you.  You were right and I knew it, but rather than blame myself, it was so much easier to blame you.  However, deep down I knew that I had stopped trying to keep myself attractive to Eric.  Almost all of my friends are overweight, and to tell you the truth that lowered the expectations I had for myself.  However, I guess I never really thought about how this might affect Eric's feelings toward me.  Anyway, I eventually faced up to the facts.  I was overweight, and I had a husband who didn't like my body.  I began dieting and exercising, and I regained my old figure.  You're correct, it can be done.  Now our marriage is much better.  Eric treats me like he used to before we were married, and that of course just fuels my desire to please him more.  The passion had gone out of our relationship, but now it's back.  Thanks, Dr. Pezzi."

While it's politically incorrect and almost taboo to assail some of the "games people play" in regard to obesity, I will discuss it because I don't think that sweeping this problem under the rug is helping anyone. Obese people often claim they do everything they can to lose weight even when they know that's simply not true. Here's an example. I once met an overweight woman with a number of good qualities. She was very interested in dating me, but I was frank and explained that I am not attracted to obese women. She promised to lose weight, so I continued to see her, thinking that we could develop a friendship and perhaps more if she succeeded in losing weight. To make a long story short, she put on a great show of trying to lose weight. Whenever I saw her eat, she would either nibble at her food as if her stomach were the size of a thimble, or she'd eat some atrocious homemade concoction like seaweed soup, whose smell was reminiscent of feces. She told me that her workouts were exhausting, but I didn't see any progress after this went on for months. Had she ate as little, and exercised as much, as she claimed, after months of such an arduous regimen she would have lost weight unless her body knew how to suspend the laws of physics. I told her that I did not believe her, but she swore up and down that she was doing everything she said. This protestation did nothing to dispel my incredulity. No, really, she said. I'm trying, really trying, really, really, really trying. Yeah, right. Sorry, I said, I still don't believe you. Then she tried to persuade me using anger and a guilt trip. I didn't budge. Finally, she sent me an e-mail in which she admitted that once she began seeing me, she no longer felt an impetus to lose weight. Just what I'd suspected. Between her periods of rigorously dieting, she'd binge enough to make up for the earlier caloric deprivation. Finally, the truth.

Back in the days when I was fat, I could honestly say that I always starved myself between meals. I pretended to be into health food. I could conjure up all sorts of excuses as to why women should like me even though I was chubby. I would focus on my good qualities, and ignore the reflection I saw in the mirror after getting out of the shower. Self-deception and excuses became familiar. Sound familiar?

As a resident working 110 hours per week, with no time to exercise, and with food being the only pleasure in my life, I didn't even try to lose weight. I suppose I could have continued this deception throughout my life and become one of those physicians who use a doctor's smock to camouflage their dietary indiscretions, but I'd had enough. I stopped the self-deception, and ended the excuses. My metabolism didn't burn up calories as readily as it once did, but I lost the weight. All of it.

Obese people often think that our culture picks on them. In some respects, it does. However, our culture also bends over backwards to facilitate self-deception in obese people. Insurance companies revised their criteria for normal weights. Loose-fit jeans are the rage, not so much for reasons of style, but because our physiques often need to be housed in extra fabric. Obese people have their healthcare costs subsidized by thinner, healthier people who pay equal premiums. Childhood obesity is skyrocketing, and more prevalent than ever. The obesity thought-police ignores this, and instead just breathes a collective sigh of relief that more kids aren't anorexic. Doctors are increasingly afraid to address this problem, fearing that the parents will jump all over them for mentioning anything that might interfere with their children's self-esteem. A case in point. A ten-year-old girl had a potbelly due to the usual suspects:  too much food and not enough exercise. Not kwashiorkor. No other excuse I'd buy. I explained to her mother that the pre-pubertal period was one of the times that existing obesity predisposes people to a lifetime of fighting fat, so I urged the mother to help her child lose weight now. She already weighed more than some adult women, and she'd not yet reached the age when women tend to pack on the pounds. The Mom's response? Anger. Predictably.

Unfortunately for patients, doctors in the United States now often think of the people they serve as customers rather than patients. This ideological shift has effectively put a muzzle on docs, making them reluctant to address even glaringly obvious problems—such as a young girl with a potbelly—out of fear that the customer might be irate enough to take their business elsewhere. Doctors with better "patient satisfaction scores" pat themselves on the back, and are sometimes rewarded with more money. However, by abnegating their responsibility to do what is best for their patients, they're not doing them any favors.

Is it shallow for men to desire slim partners?  Absolutely not.  Here's why.

An overweight friend of mine sent an e-mail to me in which she more or less said that she's perfectly happy being overweight, and she suggested that men who desire slim mates are shallow.  My response to her presented a cogent reason why it is not shallow to desire a slim partner.  You can read our e-mail exchange, or just read my central argument in the following paragraph:

Marriage isn't just about today — it's about tomorrow, too. And a lot of tomorrows in the future. Obesity predisposes people to many diseases. Frankly, I don't want a wife who can't take a walk with me in the future because her knees or hips are arthritic. I don't want a wife who died years ago because of breast cancer. I don't want a wife who is tethered to an oxygen tank, and I don't want a wife whose body is destroyed by diabetes. I don't have a crystal ball to peer into the future and see who will be healthy, and who won't. So I judge the likelihood of poor health in the future by looking for the underlying factor (obesity) that is the most frequent common denominator in the diseases most apt to kill or debilitate in the years to come. Therefore, being slim isn't just a matter of beauty; it's a strong indicator of long-term health. I don't have a crystal ball, but I do have common sense. Many other men have common sense, too, and their bias against blubber isn't some shallow desire.

Vaginal Contraceptive Film
Should masturbation be taught?
Today's "sexperts":  they're sexy, but are they knowledgeable?

Q:  What do you think of vaginal contraceptive film?  Susan

A:  Not much.  Coincidentally, I just saw a commercial for VCF^® Vaginal Contraceptive Film in which former Surgeon General Joycelyn Elders said it's "the non-hormonal contraceptive you can't feel."  Really?  I wondered if she's ever used it.  Probably not.

There is nothing like hands-on experience, or in this case . . . well, I'm sure you get my drift.  I used it, back in the days when I had a girlfriend, and found that the film dissolved into a gooey, tenacious mess that seemed stickier than glue.  Now for the bad news:  it seemed to absorb the lubrication naturally present in the vagina.  Or perhaps it didn't truly absorb it, it may have just felt that way because it was so sticky.  I tried adding lubrication, but within seconds I was back to sticky ol' square one.  Plus, like all contraceptives containing nonoxynol-9 as the spermicide, it tends to cause a burning sensation.  So, from an aesthetic standpoint, I'm not very fond of it.  Could you tell?

Its manufacturer touts that it has "an effective rate as high as 96% when used properly."  That sounds impressive, but keep in mind that the real-world effectiveness of contraceptives is usually less than their maximum effectiveness "when used properly."  People who have sex are sometimes too drunk or in too much of a hurry or are fumbling too much in a dark room to properly use a contraceptive.  Here's one of the flaws of VCF^® Vaginal Contraceptive Film:  I think it takes too long to dissolve.  I have patience — anyone who can design and build a copying machine from scratch has patience! — but that patience was sorely tested by waiting . . . and waiting.  From their instructions, I inferred that it dissolves in 15 minutes.  Not in my experience.  Another problem is that its manufacturer states it should be inserted "not more than one hour prior to intercourse."  That led me to believe that its effectiveness will decrease over time.  So what do you do if intercourse is prolonged?  Insert one VCF^® per hour, then withdraw for at least 15 minutes before resuming intercourse?  However, this won't be a problem for you if you like VCF^® as much as I did, because you won't want intercourse to last more than an hour — trust me!

OK, I'm through bashing VCF^® Vaginal Contraceptive Film.  Now I'll take aim at the person who shilled for them, the esteemed former Surgeon General.  As you may recall, Dr. Elders was fired for advocating that masturbation be taught.  Such a radical idea offended the sensibilities of her boss, President Bill Clinton, a man renowned for his morality.  I'm certainly not a prude, as should be evident from my forthright discussion of sex, but I think that anyone who thinks masturbation needs to be taught has a few screws loose or isn't running on all 8 cylinders.  For heaven's sake, as a doctor I learned that even simpletons were quite adept at pleasuring themselves.  Come to think of it, every male dog I've had seemed to be an expert in that!  So this is something that needs to be taught to humans of normal or even superior intelligence?  Why?  I'll answer that quasi-rhetorical question by opining that many of our "leaders" in Washington are people with second-rate minds, and their dearth of brainpower sometimes leads them to latch onto a questionable crusade, as in the Elders' initiative to teach masturbation, as a way of justifying their professional existence.  That may make them feel good about themselves, but such a flimsy raison d'être would likely cause the Founding Fathers to turn over in their graves.

In my mind, there is only one justification for teaching masturbation, and that is when people are taught advanced techniques.  People don't need an introductory Masturbation 101 primer, but some could benefit from a postgraduate Masturbation 899 course that goes way beyond the basics.  Why?  If people were taught masturbation techniques that substantially replicated the pleasure of intercourse, young people would be less inclined to engage in premarital sex and thereby expose themselves to sexually transmitted diseases, unintended pregnancy, and the burdens of that pregnancy.  The compulsion for intercourse is primarily fueled by one thing:  the desire for pleasure.  People seem to have an innate realization that intercourse feels better than masturbation, so humans — being the pleasure-seeking creatures that we are — do what feels best.  Thus, I think that parents, church leaders, and teachers should not think that they've done everything possible to guide the next generation simply by giving them the "thou shall not boink before marriage" admonition.  Behavioral psychologists know that people are more likely to not engage in unwanted behavior if they're given an equally pleasurable alternative, instead of just being told "no."  Considering our abysmal track record at curbing premarital sex, you might think that the need for a fresh approach would be obvious.  However, we're usually more interested in conforming to the standards of hidebound propriety and doing what everyone else is doing, rather than doing the right thing.

I've read a lot of material about sex and masturbation in college, medical school, and the years thereafter in preparation for writing The Science of Sex, and I've yet to find an author discuss what I consider to be advanced techniques of masturbation.  Instead, sex authors are doing what they do in every other area of sexuality, and that is just rehashing what countless others have said.  What an utter waste of time!  If you read my book, you'll see that I discuss groundbreaking subjects and give a fresh approach to old ones.  Rather than giving you exciting new facts by experts who are brimming with knowledge, the latest trend is for sex authors to be gorgeous young women whose claim to fame is based on appearance, not knowledge.  This new breed of sexologist is comprised of individuals without advanced degrees (or any degree, in some cases) and without anything novel to say.  Yet we Americans, enamored as we are with appearance, put up with the drivel emanating from these babes.  So why is there a market for their echoing of ideas that were old news a few decades ago?  Because they look sexy.

Publishers know that readers often purchase books because their covers are alluring, not because the content is noteworthy.  Therefore, it isn't surprising that these "sexperts" are often provocatively pictured on their book covers.  Taking this trend to an absurd extreme, one of today's hottest sexperts is pictured throughout her book.  No matter what page you turn to, there she is, again and again.  Isn't this an egregious waste of space?  If a book is worth reading, that space should be filled with worthwhile information, not a picture that is repeated a hundred times.

Is it selfish for a man to not want to use condoms?
Why women should dislike condoms as much as men

Q:  My fiancée won't use any form of birth control other than condoms, and she wants this to be our form of birth control even after we're married.  Needless to say, I'm not very happy about that.  Is there a way for me to discuss this so that I don't come off as being selfish?  Do you think it is selfish of me to NOT want to wear a condom?  She says she cannot use the Pill.  Can you suggest other options?  Ben

A:  First of all, I do not think it is selfish of you to object to wearing condoms.  Sexual pleasure is the most intense pleasure that people can experience, and condoms substantially reduce this pleasure for men.  Therefore, by insisting that you wear condoms, she is blithely asking you (or telling you) to forgo that supreme pleasure.

I don't think that it is in her interests to cavalierly disregard your pleasure.  Sexual pleasure is the primary glue that binds men and women together.  If you think I'm overstating this, consider the likelihood of marriage or other lifelong commitment if you could not have sex with your partner.  In that case, why bother?  You could assuage your need to talk to women by maintaining close friendships with them, couldn't you?  I don't know any man who'd be willing to accept the responsibilities of a marriage without sex.  She isn't asking you to abstain from sex, but she is evidently willing to toss down the drain a lot of the pleasure that you deserve as a husband.  That isn't good for her, either, because when sexual pleasure is diminished, so is the strength of the bond between a man and a woman.  That is one reason why I think it is important to amplify sexual pleasure as much as possible, because when it is enhanced, so is the strength of the bond between the couple.  Furthermore, sexual activity fosters health in many ways.  However, it is important to realize that the quality of the sexual experience varies from disappointing to heaven on Earth, and the health benefits are commensurate with the pleasure:  so-so sex isn't as conducive to health as is fantastic sex.  Therefore, in The Science of Sex I discussed many ways to intensify sexual pleasure.

If your wife cannot truly use the Pill, then there are many other alternatives.  Perhaps the best one for long-term use is an IUD.  When women hear IUD, their knee-jerk reaction is often, "An IUD in my body?  No way!"  IUDs acquired a bad reputation because the ones used years ago often caused problems, but the modern IUDs are one of the safest and most effective birth control options available.  If I were a woman, my first choice for birth control would be an IUD.  I don't know your age and whether you plan to have children, so other birth control options such as vasectomy or tubal ligation should be considered.  If you and your fiancée can tolerate the burning induced by most spermicidal contraceptives and you aren't troubled by their lower rate of effectiveness and aesthetic drawbacks, then those might be viable alternatives.

Women often incorrectly conclude that they "cannot use the Pill" because they fear one of its potential side effects without considering some of the positive aspects of using oral contraceptives.  For example, while the Pill may increase the risk of breast cancer, it reduces the risk of ovarian and endometrial (uterine) cancer and may reduce the risk of colon cancer, too.  As a general rule, it is shortsighted to consider only the negative aspects of using a drug without also considering its benefits, too.  This one-sided viewpoint often leads some postmenopausal women to conclude that they'd be better off without supplemental estrogen.  In reality, estrogen therapy has many more benefits than risks.  Even if women ignore their quality of life and appearance (which are substantially better with estrogen), the overall risk of death is less in women who take estrogen than in women who do not.  (I discuss this subject in my book because the media have twisted the facts in regard to postmenopausal hormone replacement therapy.  "The media" largely consist of people with degrees in journalism, not medicine.  It shows.)

Hedonistic calculus and the Pill:  are women who insist on condoms selfish?

Q:  My wife refuses to use the Pill, saying that no man ever died of a blood clot caused by a condom.  I HATE using condoms, but when she presents her argument against the Pill this way, my reluctance to use condoms might seem selfish -- as if I care more about my pleasure than the health of my wife.  Your thoughts?

A:  Look at it this way.  If she insists on condoms, there is a 100% chance that such usage will decrease your pleasure.  On the other hand, if she used the Pill, there is an excellent chance she'd never develop a blood clot.  Thus, she evidently believes that the remote risk of a blood clot is more important than the certainty that using a condom will substantially diminish your pleasure.  Now who is being selfish?

I've yet to see a woman with a blood clot caused by the Pill.  Yes, I've read the studies, and I know that the risk of thromboembolic events is increased when women use the Pill.  But if this were a common occurrence, after treating many thousands of women, I would have had at least one who developed a blood clot while on the Pill.  Interestingly, I've treated several women for blood clots, none of whom were on the Pill.  This brings up an important point.  If those women were on the Pill, everyone would reflexively blame the Pill for the clot.  However, women develop clots for other reasons (smoking, bad veins, bad genes, a diathesis to clot, random chance, angry Gods, etc.).  Hence, many clots that are blamed on the Pill would have occurred even without it, but because some women on the Pill develop blood clots, the Pill is blamed for the clot — often incorrectly.

Given the variety of alternatives, I don't know why people sometimes think that the choice of a contraceptive is either the Pill or a condom.  In any case, if you cannot change your wife's opinion, you should consider using a subcondom, as I discuss in my book.  This can increase pleasure for both partners, for reasons I explain therein.  While using a condom with a subcondom is more pleasurable than using just a condom, it isn't as pleasurable as intercourse without a condom.  Since sexual pleasure is not something that should be cavalierly disregarded, I think women should consider this when making a contraceptive choice.

Hedonistic calculus is Bentham's strategy for balancing the pleasure or pain that a given action is likely to generate, and hence whether that act is desirable or not.  While hedonistic calculus sounds like something that'd interest only pointy-headed academics or students of philosophy, we all intuitively use such calculus in making decisions in our lives.  I enjoy riding motorcycles, but consciously choose not to do that any more because of the risk of that activity — which is why ER personnel sometimes refer to motorcycle riders as "organ donors."  Whenever I hear wives insist on condom usage, as if their health meant everything and their husband's pleasure meant nothing, I always think of how hedonistic calculus applies to other facets of marriage.  For example, in my years of working in the ER, I had ONE woman who died on her way to work and NONE who died at work.  In contrast, I had countless male patients who died either commuting to and from work, or while at work.  Generally, men assume the riskier occupations and often commute longer distances.  I think it is second nature for men to refuse to allow women to perform genuinely dangerous work.  While this can be analyzed ad infinitum by a variety of perspectives (Darwinian, pragmatic, social, etc.), the bottom line is that men are willing to assume some risk in order to benefit their partners.  No doubt, many women do this too.  However, some women — and your wife appears to be one of them — fail to appreciate that a good marriage involves broadening their perspective of hedonistic calculus to include not just what is best for them, but also what is best for their partners.

I'll now dispense with the highfaluting discussion of hedonistic calculus and present this matter in shirtsleeve English. When I hear female sexologists and other professionals clamoring for condoms, I think, "That's easy for you to say." Their enthusiasm would no doubt be tempered if condoms deadened their enjoyment. In my mind, they would be far more effective if they acknowledged the disparity of pleasure reduction between men and women, and discussed ways to reduce it (such as by using subcondoms, or forgoing condom usage and making better decisions about whether a given partner is an acceptable risk or not). The usual chatter about this is too simplistic and narrow in scope. As an ER doctor, I learned that sexually acquired diseases are far more common in certain groups — and I am not just referring to the well-known ethnic and racial disparities, either. The prevalence of sexually transmitted diseases varies with occupation, intelligence, personality type, locale, and other factors. People who know what to look out for can usually boink to their heart's content and stay safe. On the other hand, people who are clueless often acquire an STD the first time they hop into bed with someone. Very predictable.

Why vaginal laxity is a problem that most men simply cannot discuss with their wives

Q:  For the past few years my husband refuses to sleep with me.  Every night it is the same old story:  he falls asleep watching television and spends the night on the couch.  This began shortly after I gave birth.  We resumed intercourse after my vagina healed sufficiently, but that lasted only for a month or so.  I don't know what the problem is.  Otherwise, I have a great relationship with my husband.  He doesn't use drugs or alcohol, and I know he's not cheating on me because he works out of our house so I always know where he is.  He still has a sex drive because I sometimes see him masturbating when I walk into the bathroom when he's in the shower.  I don't have any big stretch marks, I lost all of the weight I gained during pregnancy, and I work out regularly to keep myself in shape so that can't explain why he's evidently repulsed by me.  One of my friends thought he may have the Madonna/Whore Syndrome, but I really don't think so.  We saw a counselor several times at my insistence, but my husband never revealed just what is going on in his head to explain why our sex life is a big zero.  I've read all the usual explanations for why men lose interest in sex after childbirth (such as wives ignoring their husbands), but none of them seem to apply to our situation.  He still says he loves me, but it obviously seems more like the love of a brother for a sister.  Do you have any insight as to why he's acting the way he is?  Pamela

A:  Let me summarize this to put it into perspective:  you have a husband with an apparently intact libido who isn't having an affair, doesn't otherwise manifest disaffection from you, and he "tried out" sex for a month before giving it up? This is not one of the Great Mysteries of the Universe. The most likely explanation is that he found sex after childbirth much less pleasurable than it once was.  This commonly results from vaginal stretching and tearing during delivery.  This affects some women far more than others.  A few lucky women seem to emerge unscathed by vaginal delivery, but most experience some permanent dilation of the vagina that reduces sexual pleasure for both partners, but men seem to be more finicky and sensitive to this change than women.  It isn't that uncommon for a woman's vagina to be so stretched by childbirth that men find it very difficult to obtain a gratifying level of pleasure from intercourse.  I've heard some men complain to me that they sometimes have difficulty telling whether or not they're still inside the vagina because it is so loose.  May I let you in on a little secret, ladies?  Judging by how often I've heard men discussing this problem, men seem to have no difficulty discussing it with other men.  However, this is something than most men find almost impossible to discuss with their wives.  Even if you can appreciate how uncomfortable a typical man is if he even thinks about bringing up his dissatisfaction with his wife's weight, you probably have no idea how utterly impossible it is for most men to discuss such a sensitive and potentially hurtful issue as dissatisfaction over vaginal tightness.  Many people are uncomfortable discussing any sexual problems with their partners, and men may be hesitant to discuss vaginal tightness because it may make them seem shallow.  However, I don't think that it is shallow for anyone to not want to be shortchanged on life's greatest pleasure.  Therefore, it is unreasonable to blame men who are dissatisfied by this problem.  Sweeping this problem under the rug won't solve it, so what will?  Men often aren't great communicators, and it is sometimes easier for a man to keep silent, stew over his disappointment, and chase after another woman instead of having the courage to discuss this problem with his current partner.  Ironically, men who truly love their partners may not want to discuss topics that they feel might emotionally wound their loved one.  Hence, the problem is swept under the rug, not solved, and the marriage slowly dissolves or remains perpetually dissatisfying.

His choice to sleep on the couch likely results from the fact that he doesn't want to take the risk that you might initiate intercourse.  For him to break off your advances would require some direct refusal that he might find uncomfortable, whereas if he sleeps on the couch that is a very passive and easy way to say no.

My advice for you is to see your gynecologist and ask him for his opinion on whether or not your vagina is too loose.  Don't assume that your doctor would have already mentioned this even if he'd noticed it, because doctors are usually trained to not point out a problem unless it may be serious.  For example, if a doctor noticed that a man had skin cancer and did not mention it to the patient, that would be a serious mistake.  In contrast, if a doctor noticed that a man had an unusually small penis, the doctor certainly would not comment upon this unless the patient first broached the subject.  Similarly, a doctor would be remiss for telling a woman that she had a loose vagina unless she specifically inquired about that.  I've performed pelvic exams on many women who had loose vaginas (some of whom had never given birth), but I never told them how tight they were unless they first asked me.  A woman with a loose vagina may have a husband with a large penis, so her vagina may be just the right size for him.

If you want an immediate improvement in subjective tightness during intercourse, you can use a vaginal wedge, as I discuss in my book.

Some people think that Kegel's exercises can completely correct childbirth-induced vaginal loosening.  In some cases, that is true.  However, in most cases — Kegel's or no Kegel's — there is a noticeable laxity of the vagina after delivery.  Surgery may be the only way to undo the damage.  I understand that some women feel an emotional compulsion to give birth vaginally, but vaginal childbirth can cause problems other than vaginal loosening.  The following excerpt from Fascinating Health Secrets discusses some of these problems:

Want to maximize the intelligence of your child? Deliver by C-section rather than vaginally. For a variety of reasons, some children born through vaginal delivery have compromised oxygen delivery for variable periods of time. This can be enough to cause some degree of mental deterioration. Only rarely is this pronounced enough to warrant a label or diagnosis such as "cerebral palsy" or "mental retardation."  If the child was otherwise destined to have a superior I.Q. and sustained some degree of hypoxia (low oxygen) during delivery, this might only reduce his I.Q. from 140 to 100. Since 100 is by definition normal or average, it is difficult to retrospectively appreciate the tragedy which occurred during the birth of this child.

Since many C-sections are done only after some problem has already developed, a simple statistical analysis of the intelligence of children born via C-section versus vaginal delivery does not serve to adequately illuminate the cerebral risk of vaginal birth.

Unquestionably, if I were a woman, I would choose to deliver all of my children via C-section. Vaginal childbirth can be excruciating, and C-sections can be done almost painlessly. Furthermore, vaginal childbirth often permanently stretches the vagina and surrounding structures. This can reduce pleasure during intercourse for both the woman and the man. The stretching can also predispose a woman to prolapse of her uterus and other problems, such as stress incontinence. Stress incontinence, in case you are curious, has nothing to do with psychological stress. Rather, it refers to a momentary loss of urinary continence that results when the pressure within the abdomen increases as a result of coughing, sneezing, laughing, heavy lifting, or even something as seemingly innocuous as standing up. It may also cause a woman to discharge spurts of urine during sexual orgasm, which is often erroneously interpreted as representing a female ejaculation. While I certainly sympathize with women who are afflicted with this condition, who no doubt derive some degree of comfort by viewing their emission as an ejaculate, I am compelled to report that scientific studies on this matter have shown that such ejaculations are, in fact, nothing more than spurts of urine that are discharged from the urethra. While this problem can be minimized by the use of Kegel's exercises, the best treatment is obviously prevention.

The preceding topic prompted a woman to write to me.  The gist of her e-mail was this:  "Well, I've already had kids by vaginal delivery.  My vagina is loose, I have stretch marks, I've gained weight, my husband seems distant, and the sky is falling.  So, your advice may help women if they haven't yet had kids, so they can choose to have a C-section, but what about us other women?"

My response?  Generally, I eschew writing about topics unless I can offer a solution.  After all, what is the point of broaching a topic unless I can suggest a remedy?  I don't think it does much good to commiserate, so you'll rarely find me wailing about an insolvable problem.  Hence, when I write about a problem, it's because I have the answer.  And in this case, I do.  In my book, I discuss several ways to either tighten or effectively tighten the vagina, such as by using a vaginal wedge.  In regard to her other laments, I presented solutions to them elsewhere in my books and web site.

A too-tight vagina?

Q:  I've been with my husband for two years and we have had a sporadic sexual history. The frequency of intercourse declined from every day to once every two to three months.  I asked him why the change occurred and he gave me several reasons, such as a poor adjustment to us living together, change in his work schedule, and decrease in energy due to allergies. This year we got married and began trying to have a baby.  Our sex life improved slightly and we began having sex once every month around my ovulation time. Recently I told my husband that I would like for us to have sex more than once a month and he finally told me that the REAL reason we don't have sex more often is because my vagina is too tight and it causes him pain.  It is worth noting that my husband is the first uncircumcised man that I have ever been with and it usually takes a second for my body to adjust to the width of his penis.  But after that period of adjustment is over, I truly enjoy having sex with him.  Moreover, I always have an orgasm.  Can you suggest something that I can do to loosen up?  Oh, we already tried K-Y jelly and he says that it's still too tight.  (Name withheld by request)

A:  I'm not going to beat around the bush:  I don't believe your husband.  First, he offered some lame excuses, then he fessed up to the "REAL" reason, your tight vagina.  I don't doubt that your vagina is tight, but tight enough to cause pain for him?  Unless he has some penile abnormality or has taken Accutane*, it is safe to say that he still isn't telling you the truth.  Why can I say this with confidence?  Because sex is pleasurable for you.  Even though it usually takes a second for your body "to adjust to the width of his penis" (which is common), you experience pleasure, not pain.  In my experience as a doctor, I've seen women with vaginas so small that they'd tightly grip a pencil, and men who are hung like horses and make male porno stars look like boys with pre-pubescent penises.  Even when the fit is tight enough so the woman is literally ripped open and wincing with enough pain to cause her to go to an emergency room, I've yet to hear a man complain about a painfully tight vagina.  Instead, they're dreamily marveling at how great a tight vagina feels.

* Some men who've used Accutane reported to me that it made intercourse unpleasant and even painful, even after discontinuing that drug.  One man was so distraught over this that he was suicidal.  Incidentally, I've heard from several women who reported that Accutane made intercourse painful, too.  For more information on the adverse sexual effects of Accutane, visit this web page.

When I was in medical school, my girlfriend had a vagina so tight that it took me months of trying before I penetrated her — and that success was only due to hours of patiently using a series of progressively larger dilators.  By the way, when I finally got in, it was pure pleasure, not pain.  It sounds as if your vagina isn't quite that tight in relation to the penile size, so it doesn't make any sense that tightness is what is dissuading your husband.  Furthermore, even if tightness were the problem, your husband could gratify you and himself by stroking his penis on your labia minora, clitoris, and vestibule (the area around the vaginal opening).  Or you could perform oral sex on one another, or do other satisfying things.

I think it is apropos to briefly mention two scientific facts before I proceed.  First, there is a tidbit from physics, Newton's third law, which states that for every action, there is an equal and opposite reaction.  This law is applicable everywhere, including the vagina.  Translating this principle of physics into everyday sexual language boils down to one simple fact:  the pressure or "tightness" is the same for the penis and the vagina.

Next tidbit, this one from anatomy and physiology.  When a woman experiences pain from an overly thick (relative to her vaginal diameter) penis, that pain is due to stimulation of stretch receptors.  During intercourse, a man's penis is compressed, not stretched.  The threshold for pain in stretching the vagina is far less than the threshold of pain for compressing the penis.  If the penis were stretched, it'd be just as sensitive as the vagina, or even more so.  Any man who doubts this can prove it to himself by placing his penis in a vacuum/pressure chamber.  Noting the sensation when the absolute value (such as 5 psi, or pounds per square inch) of the vacuum is the same as the absolute value of an applied pressure, it is obvious than men will flinch with pain at vacuum levels that are not unpleasant if that same number of psi is applied as a pressure.  However, because the penis is compressed, not stretched, during intercourse, the penis is impervious to coital stretch pain.  Practically speaking, the threshold for penile pain in compression is so great that it virtually never occurs during vaginal intercourse, except if the penis is very forcefully bent during rapid thrusting when there is a mismatch between the axes of the penis and vagina; that can stimulate stretch receptors.  In general, any body part — vagina, penis, arm, etc. — is more sensitive to pain from stretching than compression.

Let's consider the foregoing two principles together.  Because of Newton's third law, I know that the pressure stretching your vagina during intercourse is the same as the pressure compressing his penis.  Because people are more sensitive to pain from stretching tissue than compressing it, you would experience pain from stretch long before he'd experience pain from compression.  The fact that you don't have pain indicates that tightness isn't the problem.

So what is the problem?  I have my own suspicions, but I am not a psychologist or psychiatrist, so I consulted several people who have expertise in understanding problems in relationships.  Incidentally, the initial reaction of every person was the same; they thought it was preposterous that your vagina was the source of the problem.  They suggested a few possibilities, such as him having a low libido, or inadequate attraction to you (or perhaps to women in general).  I may not be a relationship expert, but in this case the answer seems so obvious to me that I'm willing to go out on a limb and speculate about what I think the problem is.  I think your husband either now has the libido of an 88-year-old man, or his attraction to women is questionable.  In short, I don't think the problem is you.  There are many things that attract men to women.  Some of these factors are optical (that is, what a woman looks like), some are behavioral, and some are purely sensual.  Women feel good to men because it is pleasurable to hold you, caress you, and make love to you.  In regard to the latter point, your tight vagina would make you very desirable, not someone to be sexually shunned.

You mentioned that you're now "having sex once every month around my ovulation time."  Unless that timing is intentional (to optimize your chances of conception), this makes me wonder if the problem is your husband's libido.  Why do I think that?  Because women emit more copulins (pheromones that increases male libido) at ovulation than at other times.  If a man typically has a low libido, the boost in sex drive is more noticeable than if he's always hot to trot.

As a next step, I'd ask your husband if he masturbates.  If he does not, and his sole source of sexual release is your monthly tryst, his libido is clearly deficient.  When men have a problem with their libido, they're apt to conjure up a specious excuse, such as your husband attributing his lack of desire to a "change in his work schedule."  Stress of any sort can reduce libido, but a mere schedule change won't decimate libido to the point that he'd go from daily intercourse to once per month.  When I worked in the ER, my schedule would sometimes change five times in a week from the day shift to the afternoon shift to the night shift.  Sometimes I'd work two shifts in a day, getting off from the night shift at 7 AM, going home to sleep for a few hours, and then returning to work for the afternoon shift at 1 or 2 PM.  It's difficult to imagine a more chaotic schedule than that.  In spite of that nightmarish routine, my libido was reasonably intact and even brimming if I had a girlfriend.  Frankly, I've seen people hospitalized with serious diseases or injuries who want sex more than once per month.  Hence, I don't buy your husband's stress excuse.

Your husband needs to see a doctor to exclude a penile abnormality (unlikely but possible) or treatable causes of low libido, such as some pituitary tumors and a number of other endocrine problems (some of which I discuss in my book, The Science of Sex).

Now for the last plausible possibility:  latent homosexuality.  This isn't rare, and it is often so well camouflaged that it may never have occurred to you.  A few of my friends and relatives were engaged to people they thought were heterosexual, and when I met them, I didn't detect any clues that might suggest otherwise.  In all of these cases, they engaged in sex and truly enjoyed it — from what I heard, which was sometimes through a very thin wall.  So, when their true sexual preference was revealed, I was stunned.  I wondered, how could anyone present such a convincing acting job?  Our culture is not very accepting of homosexuality, so this undoubtedly makes some homosexuals reluctant to reveal their gender preference.  However, I wouldn't fret over this possibility.  Statistically, the most likely problem is a flagging libido.  The good news for you is that this is easily treatable.

What really turns women on?  A student doesn't want opinions, he wants proof.  He got it.

Q:  I'm writing a paper for my creative writing class in college in which I'm attempting to explain what male attributes are especially attractive to women.  Of course, women want men who are kind, attentive, and considerate.  But what about other attributes?  What attracts women more:  brains, appearance, money, fame, or power?  I have my own opinion about that, but I don't know how to prove it.  Obviously, I'll receive a better grade on my paper if I can offer conclusive evidence to substantiate my opinion.  Can you help me?  Thanks, Andy.

My answer to this question strays somewhat off the topic of this forum, so I presented it on a separate page.

Can some sexual lubricants kill HIV?

Q:  I just heard about a study which showed that some sexual lubricants can kill the HIV virus.  Is this true?  Amanda

A:  You're probably referring to a study led by Samuel Baron, M.D. at the University of Texas Medical Branch at Galveston.  He found that three sexual lubricants (Astroglide, Vagisil, and ViAmor) reduced the rate of HIV replication by more than 99.9% when those lubricants were mixed with HIV-infected semen.  However, those experiments were conducted in test tubes, not humans.  What works in vitro (in a test tube) doesn't always work in vivo (in living beings).  Furthermore, those samples were allowed to sit for 24 hours because Dr. Baron said it takes some time to deactivate HIV.  I hate to be flip, but HIV would probably be deactivated after sitting for 24 hours in a McDonald's malt, a glass of orange juice, or a zillion other fluids that have no special anti-HIV effect.

Whether or not those lubricants prove to kill the HIV virus during sex, it is nevertheless advisable to use a sexual lubricant if vaginal lubrication is insufficient because adequate lubrication minimizes the risk of transmission of various sexually transmitted diseases.  If you're looking for a sexual lubricant that kills HIV and potentially other STDs, I discuss a much better alternative in my book.

Who is the father?

Q:  I have a question that's been troubling me for a little over 2 years. I'm the mother of 2 beautiful girls and I don't know who is the father of my second daughter.

This is the situation ... I had sex on and off with my first husband for 7 months when I lived in California. My last monthly period was on Oct. 30, 1998 and ended on Nov. 5, 1998 (regular menstruation). I had sex on Nov. 11, 1998 and after that I left California and returned to New Jersey. I did not get my period in the beginning of December. I had sex again with an ex-boyfriend on Dec. 23, 1998. After that I did not have any further sexual contact with either man. On January 16, 1999 I found out I was pregnant. What confuses me is this ... On my sonogram taken on February 3, 1999, it states that my LMP (last menstrual period) agrees with my gestation period — it states I am about 8.6 weeks.

My question is if you could please help me in this matter ... and at least try to give me a clear understanding of who could be the father of my second daughter. This would take a huge load off my conscience. I would greatly appreciate your help in this matter. THANKS A MILLION!

A:  Based upon the timing of your intercourse, the most likely father is your first husband. However, when you state that your LMP "agrees with my gestation period...it states I am about 8.6 weeks," that doesn't mesh because if your first husband impregnated you, then you would have been about 13.7 weeks along. As a rule, pregnancies are dated from the first day of the last normal menstrual period. Therefore, it is possible that you skipped a period and the ex-boyfriend impregnated you. In that case, you'd likely be about 6½ weeks along on February 3.

It'd be helpful to know the duration of your cycles (e.g., are they 28 days?), their regularity, and so forth. What would be even more helpful to know is the blood type of the two possible fathers, your blood type, and your daughter's blood type. With that information, it may be possible to exclude one of the men as a possible father. That would save you the expense of testing for a DNA match — which, of course, might cause the candidates for fatherhood to raise their eyebrows.

Pro baseball player scoring on the road?

Q:  My husband is a Major League baseball player who takes Viagra (no, he's not the guy in the ads).  My husband takes Viagra with him on road trips.  I confronted him about this, thinking that he cheats on me while he is on the road.  He responded that he needs the Viagra so he can masturbate.  Does this make sense to you?

A:  Have you ever read Ball Four by Jim Bouton, the former major league pitcher?  In that exposé, he revealed the sexual escapades of ballplayers, among other topics.  I'm not suggesting that your husband is necessarily cheating on you (he may suffer from the common misconception that men need an erection to experience sexual pleasure and orgasm, or he may simply find it easier to masturbate with an erection and he is willing to incur the potential side effects of Viagra for this minor convenience), but I can certainly understand why you are suspicious, given the track record of professional athletes in regard to marital fidelity.  I suggest you educate your husband on this matter, teaching him that an erection is not a prerequisite for masturbation to orgasm, and showing him ways (if he doesn't already know them) to masturbate without a full erection.  Afterwards, if he still insists on using Viagra during road trips, he's either really stupid or he's really stupid.  Take your pick.

Disappointed by wedding night

Q:  I don't know how to put this.  I'm stunned, disappointed, in disbelief.  I had sex for the first time last night on my wedding night, and while it was pleasurable, it was not nearly as pleasurable as I assumed it would be.  Considering how much attention is paid to sex, I thought it would be fantastic.  It wasn't.  Why?

A:  Dang, where did I put my crystal ball, anyway?  You didn't say if you are a man or woman, so I can't address some of the most common reasons for a reduction in pleasure pertaining to specific sexes.  Instead, I'll discuss this topic in a general sense.  First, people are often disappointed by their initial episode of sex.  I was, too.  However, in time, intercourse became more pleasurable with that partner, and with a subsequent partner, sex was so pleasurable it was beyond my wildest dreams — I had no idea that such intense pleasure was possible.  That was quite a change from the "this is it?" shock and disappointment I felt after my first time.  I can't give you a short answer that addresses all possible reasons for this variation in pleasure; that is the subject of my 255,000-word book.

ER doc too busy to make love to the woman he's dating?

Q:  I started dating (if you can even call it that) an ER doc about a month ago. He is always really tired or really busy -- works 14 shifts a month, but what exactly is a "shift"? I know they're rotating shifts. I REALLY like this guy and can't tell if he truly works a ton of hours or if he's just blowing me off. I'm thinking "if you're too busy to f*ck me, you are TOO BUSY" but I'd like to give him the benefit of the doubt. Should I continue to wait for his call or move on?

A:  An ER shift is typically anywhere from 8 to 12 hours. However, by the time the doc completes his dictations, paperwork, and wraps up the care on his patients, each shift may be prolonged a few hours — or it may not, depending on how busy the shift was. Working 14 shifts per month may not seem like much, but ER work can really sap one's energy. I've worked many jobs in my life, and nothing — I mean NOTHING — was even a tenth as exhausting as ER work. I used to mow lawns, primarily using a push mower. Trust me, you've never seen anyone mow a lawn as fast as me. I souped up my mowers so they could still do a good job of mowing even when pushed at a breakneck speed. In the blink of an eye, I could turn the mower around and accelerate to my mowing pace (which was faster than most people run). I'd do this all day long, seven days per week. Tiring? Just a pleasant stiffness in my muscles at night. Compared to ER, it was like being on vacation.

If you think I'm getting off-topic, just bear with me for a minute:  I'm giving you this background information so you can fully grasp what I'm about to tell you. Physically, the most taxing job I had was when I worked for a guy carrying building materials up a hill (he was building a home on a hill so steep that no truck could ascend it, so he hired me to carry the boards from the base of the hill, a few hundred feet to the top. The man was really a slavedriver, insisting that I carry two thick sheets of plywood at a time up the hill. An average man couldn't even pick up two such sheets of plywood, let alone carry them hundreds of feet up a hill, and do that over and over again — building a home requires umpteen tons of lumber. Was I tired afterward? A bit, but that job was a walk in the park compared to being an ER doc.

I could regale you with tales of my other 18 jobs, but the take-home message is the same:  nothing is nearly as exhausting as being an ER doc. Obviously, ER work isn't especially demanding from a physical standpoint:  witness the paunchy physiques of most ER docs. However, ER work is mentally taxing, and that is far more onerous than physically demanding jobs. If you care to think about this from an evolutionary perspective, humans evolved to tolerate prolonged physical activity quite well, and also sporadic mental stress — like being chased by a saber-toothed tiger. Our "fight-or-flight" response is great for dealing with such periodic stresses, but it does a miserable job of coping with mental stress that goes on and on and on . . . such as what ER doctors face. It's been scientifically proven that humans and animals have a more difficult time coping with stress when the stressor(s) are not under one's control. You may think the ER doc is in control of the ER, but he isn't. He can't control how many patients flood the ER at any one time. If the patient volume is overwhelming, he can't prevent another dozen people from walking in the door, all screaming for attention NOW. He can't control what his patients are like, some of whom are so out-of-control that one such patient could sap all his time. There are hundreds of factors that are not under the control of ER doctors, and these stressors malignantly affect the docs. After all, they're human.

Most ER docs love to feel that they're tough and can handle anything. Unfortunately, they can't evade biological reality. Protracted, severe stress induces biochemical changes within the body that produces noticeable changes:  muscles atrophy a bit, and there's a bit more fat, especially on the trunk. There are a dozen other changes, but you didn't tune in for a lecture on endocrinology, so I'll cut to the chase and discuss how chronic stress impacts libido. Briefly, it reduces it, primarily mediated by a fall in the testosterone level.

Don't think that I'm writing all this to excuse the apparent sexual exhaustion of your quasi-boyfriend. I'm not. I've worked full-time in one ER and part-time in another ER while doing other jobs on the side, such as writing and inventing. Even though I'm typically a high-energy person, sometimes I'd be so drained that on my days off, all I'd want to do is sit in a chair and stare at the wall. I had so much that I wanted to do, but I was so pooped that I couldn't muster the energy . . . except when it came to sex. On those rare occasions when I had a girlfriend, I was never "too tired."

My diagnosis? There's a problem here. Either the doc you're dating has a problem with his libido, or he isn't attracted to you. Since he is dating you, I suspect that he must be attracted. Ergo, there is likely a problem with his libido. Working rotating shifts (in which the schedule changes from day to afternoon to night shifts in a cyclic fashion) is a great way to wreak havoc on the body. People who work the night shift typically live a few years less than average, and people who work rotating shifts face even greater stress, because their body never has a chance to adapt to the constantly changing schedules. Hence, it isn't surprising that an ER doc working rotating shifts would manifest some collateral damage.

Other than the stress of ER, there are countless factors that may impair sexuality. I won't try to offer a definitive diagnosis for him over the Internet, but I'd like to help. I know more about sex than Dr. Ruth.  That may seem like bragging, but it's true, I assure you. She knows the basics, but — yawn — what doctor doesn't? Compared to what I know, she is still in kindergarten. Therefore, I have a lot to offer, so I will send you a complimentary copy of my book, The Science of Sex: Enhancing Sexual Pleasure, Performance, Attraction, and Desire, if you don't mind reading an e-book. Reading that book will give you a lot to mull over, including some things you've certainly never considered. If you think I'm just hyping the book (but why I'd do that to encourage someone to accept a free copy is beyond me), I'm not. There isn't a doctor in the world who knows more about sex than I do. I read every book I can get my hands on that is even remotely similar to mine, because I believe in checking out my competitors. Consequently, I've read countless books in this genre, and most are laughably mickey-mouse and an utter waste of time. My book will have your head spinning, and if the information in it can't turn your man into a sexual dynamo, well, it's time to search for another man.

Woman upset over how beautiful women can live on Easy Street without lifting a finger

Q:  I admit it, I'm jealous of my sister.  She is beautiful — slim, fairly large breasts, a sexy belly, great legs and rear, gorgeous face, radiant smile, flowing silky blond hair — you name it, she's got it.  I'm no dog, but if she's a "10" (and she probably is), I'm a 6 . . . maybe.  I received better grades in high school and college, yet she makes more than I do.  A lot more.  That is what bugs me — men are willing to give her anything she wants, whether it's in her career, or in her personal life.  She knows this, so she isn't very responsible at work.  She often comes in late, makes excuses why she has to leave early, takes long lunch breaks, etc., but she's never been fired.  She's never done anything for her boyfriends (except you-know-what), not even given one a card, but they're always showering gifts on her.  Expensive stuff, too, like stereos, DVD machines, clothes, skis and ski gear, vacations to Europe, and even a new car . . . a BMW, nonetheless!  I've received flowers twice in my life, and she sometimes gets them twice per day.

It's obvious why she receives so many gifts.  If she were ugly, her rich boyfriends would be chasing someone else, not her.  This burns me up, because it is so unfair!  I don't know what I expect from you.  Maybe I just wanted to vent (a woman's prerogative, you know), but I'm wondering . . . hoping, really, if you could say something to make me feel better.  Can you?  Angela

A:  Yes.  First, let me attest to the veracity of what you said.  The world is unfair:  it rolls out the red carpet for beautiful women.  Anyone who doubts this should watch ABC TV's 20/20 exposé on how people are influenced by beauty.  This program showed hidden-camera footage of two women applying for jobs at various businesses.  They wore identical clothes, and presented comparable educational backgrounds.  One woman was gorgeous, one was not.  The gorgeous woman always got the job, was offered more money, and told that company policy about the duration of lunch breaks was flexible — apparently just for gorgeous women, because the other woman wasn't told this.  The interviewers seemed overly eager to please the stunning applicant, and one went so far as to say he'd do everything he could in the future to promote her.  The sun, the moon, and the stars . . . just because she's beautiful.  It wasn't what she said, either; most of her replies were monosyllabic.  When you're beautiful, that's apparently good enough.

One of the truisms attributed to Bill Gates is, "Life is not fair.  Get used to it."  He should know, because if life were fair, he wouldn't have become the richest man in the world by selling buggy, exasperating, second-rate software that makes my life as an author, doctor, and inventor more frustrating and less productive than it should be . . . see, men can vent, too.  In any case, while I think his pithy comment about fairness is cruelly harsh, it aptly sums up the way the world is, and what you should do about it.  Neither I, nor you, nor anyone else, can do anything to temper the boundless affinity that men have for beautiful women.  You realize how immutable this preference is, so you just want cheering up.  That I can do.

First, you can take comfort in the fact that if you're a "6," you're a fox compared to some women.  You might be a Plain Jane relative to your ravishing sister, but some women would give a million dollars, if they had it, if they could look as good as you.

Second, you can take comfort in the fact that beauty is often ephemeral.  With each passing decade, the prevalence of beauty in women drops significantly.  So, while your sister and similar women may now have the world at their feet, they probably won't for long.  When this loss of beauty hits, women who've coasted through the early years of their lives on their looks often panic and think, "Yikes, what now?"  Unfortunately for women, the traits that our culture defines as being attractive for women erode more quickly than the attributes that define an attractive man.  Hollywood executives, with tens of millions of dollars at stake, have no qualms about casting a 50- or 60-year-old male as the leading man in a movie, but how often do they cast a woman of similar age as the leading woman?  They're usually in their twenties or thirties.

Third, you can take comfort in the fact that there is some truth to the cliché about how beautiful women often don't have as many other attributes as less attractive women.  The "beautiful woman syndrome" doesn't affect every beautiful woman, but there is some statistical merit in this stereotype.  To tell you the truth, had I been born a beautiful woman, I wouldn't have busted my butt in medical school and spent years working on other things in my "spare time."  Unfortunately, I have to work for a living.  I'm not averse to work, but if someone handed me things on a silver platter, I'd take them.  So would most people, I suspect.  You and I can't get away with this, but beautiful women can . . . so they do it.  People who win the lottery always collect the check.  Can you blame them?

Fourth, you can take comfort in the fact that no matter how beautiful, smart, rich, or talented a person is, there is always someone who is even more gifted.  Most of those beautiful women who you think spend their waking lives nodding in agreement as the world praises them aren't dwelling on how fantastic they are, they're moaning the fact that some women are even more attractive.  I think people should stop and smell the roses, instead of wanting more, more, more — whether it's looks, money, fame, or whatnot.  What's the point in having more, if getting it only means that you keep setting your sights a notch higher?

Fifth, you can take comfort in the fact that a gorgeous woman never really knows if the man who loves her does so because of her personality and mind, or just because she is beautiful.  This is similar to the uncertainty that plagues rich men, who often wonder if it's them or their money that is so attractive.  As a doctor who was privy to the private lives of thousands of patients, I know that true love sometimes exists, but it's not as common as conditional love:  "I'll love you if you're attractive," or "I'll love you if you're successful."

Finally, you can take comfort in the fact that you're a better, more competent, more deserving person than your level of success might otherwise suggest.  Conversely, gorgeous women are sometimes haunted by the fact that they aren't as competent or deserving as their level of success seems to indicate.  I suppose some of the really vacuous babes out there suck up all the accolades, gifts, and attention without giving it a second thought, but I think most beauties have some nagging doubts about how great they really are.  Sans their stunning bodies, I think most of them are honest enough, at least with themselves, to admit that their lives would be a whole lot different if they weren't so attractive.

Feel better now?

Dating a woman, but sexually intimidated by her because she's a doctor

Q:  I'm dating a woman who is an MD.  Everything is great in our relationship, except for one thing.  I'm reluctant to have sex with her, because I am quite frankly intimidated by her medical knowledge, especially as it pertains to sex.  She must know every intricate detail, and I have this old-fashioned notion that the man should be more of an expert in this area.  Any advice?  Scott

A:  Yes.  First, chill out.  Second, learn at least the basics about sexual anatomy.  Doctors know the correct terminology, and they sometimes assume that other smart people know as much as they do.  Sometimes they do, but sometimes they don't.  If she mentions a certain term during sex, it'd be better if you didn't need to ask, "Um, what's that?"  Third, take comfort in the fact that while docs possess an extensive knowledge of sexual anatomy, disease, and reproduction, they usually don't know much more than an ordinary person about how to have sex.  I suspect this is the cause of your concern.  You may imagine that your girlfriend is a sexual dynamo, brimming with arcane knowledge taught only in cloistered medical schools where it is passed in hushed tones from one generation to the next.  That isn't likely.  The medical school that I attended emphasized sexual education, but what I learned there was less than 1% of what I've learned on my own.  Frankly, there is so much to cram into four years of med school that there isn't time to dwell on any one topic.  Hence, your friend obviously knows the rudiments of sex, but she is most likely not an expert.  If you read my book, you'll know countless things that she doesn't know, and likely has never considered.  For example, in medical school every student studies the various types of nerve receptors, but they're too busy with other things to contemplate how to use that knowledge so as to optimize sexual pleasure.  Years after medical school, nerve receptors are but a distant memory in the minds of most physicians, and expecting them to connect the dots and apply that shaky knowledge to some novel application is asking a lot.  I do this, and a lot more, in my book.  If you read it, you'll have a phenomenal knowledge of sex, and you can teach her hundreds of things.  Have fun.

How did I learn so much?

Q:  How did you become such an expert on sex?  Jill

A:  It's probably not what you think — I'm no profligate Charlie Sheen. How did I learn so much? To begin with, I graduated in the top 1% of my class in medical school. So, compared to other doctors, I learned more about not just sex, but also more about anatomy, physiology, biochemistry, nutrition, pharmacology, endocrinology, neurology, urology, gynecology, histology, and embryology — which are the underpinnings of knowledge about sex. Second, in terms of sexual education per se, I attended a medical school that emphasized sexual education more than most medical schools. Third, I've read extensively on this subject, going far beyond the material presented in medical school — which I consider to be merely introductory Sex Ed 101 stuff. Fourth, I excel not just at memorization but also at integrating knowledge. To put this in colloquial terms, I'm good at "putting it all together" or "connecting the dots." Incidentally, I think that ability explains why I'm so creative. Fifth, I've conducted novel research, from which I've garnered some groundbreaking information. Sixth, I have a naturally curious mind. Everyone knows that sex does not feel the same with different partners or even from time to time with the same partner. I was intrigued by what accounts for this often remarkable difference in pleasure, so I dug deep — very deep. In the process, I learned some fascinating things.

Afraid of marrying a man who might become bald
Pezzi wonders, "Does she think that only men age?"

Q:  How can I tell if a man will become bald?  It'd be a nightmare for me if I married some great guy, then he lost his hair . . . because my love for him would go right out the window.  I can't see myself ever being attracted to someone who is bald, so I want some foolproof way of knowing in advance if he'll keep all his hair.  Can you help me, doc?  Kristen

A:  Yes.  You need it.  I have a number of answers and responses to your question.  In no particular order, they are:

1.  First, all men and women lose hair as they age.  Hair loss in women is less apparent because they usually sustain a diminution of hair density over the entire scalp, rather than in the discrete, progressive pattern that is the hallmark of male pattern baldness.  However, even in people who don't "go bald," hair density decreases with age.

2.  While everyone has the right to determine what they want in a partner, I hope — for your sake — that you don't develop some of the maladies that plague women when they age, such as wrinkles, cellulite, stretch marks, varicose veins, sagging breasts, loss of breast size, a "tummy" that is refractory to sit-ups, and excessive fat on the hips, thighs, and buttocks.  Men can get fat, too, but they're less apt to wrinkle, much less likely to have cellulite, stretch marks, or varicosities, and almost immune from sagging breasts — for obvious reasons.  The scorecard?  Presuming that a man keeps in shape, his one major sign of aging is hair loss.  Women face more risks, which may be why our society thinks that older men can still be very attractive, but older women are rarely coveted.  If you disagree with this, don't kill the messenger.  I'm just relaying what is common knowledge.

3.  Baldness actually complements the faces of some men.  Take Dr. Phil (of Oprah fame), or the actor who portrays Admiral Chegwidden on JAG.  I am not gay, or bisexual, but I can tell if a man is attractive or not, and I think both men are handsome in spite of their baldness.  Furthermore, in my opinion, I think they'd look worse with more hair.

4.  Baldness is now more treatable than ever, with hair transplants and various anti-DHT meds and whatnot.  The bad news about the anti-DHT drugs is that while they may restore hair, they can decimate a man's sex life by reducing his libido, impairing erectile performance, and inducing a very gradual shrinkage of the penis.  Any doc who is unaware of these risks is either brain dead, inexperienced, or gullible enough to be hoodwinked by the pharmaceutical industry.  One of my pet peeves is stupid drugs ads.  One ad that I recall was when the maker of Propecia^® (finasteride, an anti-DHT drug) attempted to make men believe that taking Propecia every day was something as innocuous as taking a daily "vitamin pill."  How ridiculous.  Vitamins are essential for life and generally just beneficial, while anti-DHT drugs have plusses and minuses.  However dismal it is to face the dilemma of choosing to benefit one's hairline at the risk of impairing one's sex life, there is good news on the horizon.  A doctor in France discovered a way to clone a man's own hair cells, obviating the problems of tissue rejection, and avoiding the quagmire of social issues that plagues other cloning endeavors.

5.  Keep in mind that one's perception of beauty changes with age.  When I was 15, I thought women aged 40 were antiques.  Now that I'm that age, I know some 40-ish women (all married, unfortunately for me) who are mesmerizingly beautiful.  I suspect that when I'm 60, women of that age will look a lot better than they do now.

6.  OK, to answer your question.  There is no simple inheritance pattern for baldness, as people sometimes believe.  Many genes contribute to this, so you cannot assume that a man will be bald just because his father or grandfather was.  My advice?  If you love the man, marry him.  In twenty years, you'll probably be more worried about your own beauty problems than his.  Plus, as I mentioned above, medical science is nearing the time when people can choose to have as much hair as they wish . . . or can afford (I assume cloning won't be cheap).  However, we haven't made comparable progress in combating many of the beauty issues that women face.  Consequently, some day you might actually welcome some erosion of your partner's attractiveness, because yours will surely erode, too.  If his appearance never waned, he'd probably eventually dump you and choose a younger partner.

Bottom line?  I assume you think you either won't age, or that if you do, a man shouldn't care how much you go to pot.  Just hope your future husband is a lot more forgiving of human imperfection than you are.

Phytoestrogen myth

Q:  I heard a naturopathic doctor on television say that phytoestrogens can be anti-estrogenic or pro-estrogenic, depending on what a woman's needs are. Is what she said true?  Anna

A:  No. While it is true that phytoestrogens can either increase or decrease a woman's overall estrogenic effect, phytoestrogens have no way of knowing if a woman has just the right amount of estrogen, too much, somewhat too little, or very little. How did this myth about "depending on what a woman's needs are" get started? If a woman has an estrogen excess, adding phytoestrogens can indeed reduce her overall estrogen effect via the process of competitive inhibition, which I thoroughly explained in my book. If a woman has very little estrogen, phytoestrogens can indeed increase her estrogen effect. So far, so good for the naturopathic doc. Here's where her statement falls apart. If a woman's estrogen level is good or somewhat less than is optimal, adding phytoestrogens will reduce her overall estrogen effect, once again via competitive inhibition. Consequently, the woman who originally had just the right amount of estrogen now has less than she should, and the woman who had somewhat too little estrogen now has a worse deficit. Did phytoestrogens "balance" the needs of these last two women? Hardly. That's why I cringe whenever I hear this "balancing" baloney. I don't know if that doc truly believes it, or if she was just trying to simplify it enough to squeeze it in the ten seconds that seems to be the limit for sound bites during media interviews.

More semen, better orgasm?

Q:  Is it true that if a man ejaculates more semen, his orgasm will be more intense?

A:  No.  I don't know how that myth began.  Perhaps it originated from people who mistook cause and effect, and noticed that more intense orgasms are sometimes associated with a greater volume of ejaculate.  However, it wasn't the extra ejaculate that intensified the orgasm, it was the more intense orgasm that created stronger contractions of the genitourinary tract, thereby expelling more semen.

A one-hour orgasm?

Q:  I've seen books and videos that speak of a one-hour orgasm. Is that possible?

A:  That is just marketing hype. Once they've drawn you in with the hyperbole, they begin equivocating, saying something along the lines of, "It's not really a one-hour orgasm, it's a prolonged period of heightened awareness and pleasure." If that is the case, then I had a three-hour orgasm when I was in fifth grade and I'd gawk for hours at a Ski-doo snowmobile catalog. Heightened awareness? You bet. Pleasure? Ditto.

While some orgasms can be unusually prolonged, a one-hour orgasm is a pipe dream. The reason for this is simple:  orgasm involves the release of neurotransmitters. The brain cannot store enough neurotransmitters to permit a one-hour orgasm. Here is an analogy. Imagine that you pump water into a water tower; that's like storing neurotransmitters in preparation for their eventual release. Now imagine that you blast a hole in the side of the water tower, and the water gushes out — that's analogous to the orgasm. There is a limit as to how long the water will flow, because the water tower has a finite size. Similarly, there is a limit to the duration of an orgasm, because the brain does not have an infinite neurotransmitter supply. Some nutrients and drugs can "pump up" the neurotransmitter stockpile to permit a longer and more intense orgasm (as I explain in my book), but nothing currently known permits a one-hour orgasm.

Status orgasmus is an orgasmic state lasting twenty seconds to one minute. Having witnessed this, I can attest that the woman did indeed appear to experience an unusually prolonged orgasm. However, I'm skeptical of women who claim to have fifteen-minute orgasms. I think they experience a prolonged preorgasmic sexual peak that feels very good, but does not deliver a fifteen-minute period of true orgasmic pleasure.

Spot reduction/enlargement
Slimming thighs/enlarging breasts
Reducing cellulite

Q:  In your book, you discuss how it is possible to enlarge the breasts using a high-tech bra that actually modifies enzyme activity and blood flow.  Could this technique be used elsewhere in reverse?  I want to reduce the size of my legs, which are chubby in proportion to the rest of my body, which is slim.  I don't want liposuction for several reasons.  First, I can't afford it.  Second, I'm afraid of the potential surgical complications.  Third, liposuction doesn't do much for cellulite.  Since your technique preferentially targets the outer fat, it seems to be an ideal way to reduce cellulite.

A:  Yes, that technique can be used in reverse for spot reduction and treating cellulite, too.  Spot reduction acquired a bad name because the old recommendations were ineffective.  For example, men were told to exercise their oblique muscles to reduce the size of their love handles.  That just doesn't work.  A man could have the strongest oblique muscles in the world and still have love handles.  While the old ways were unsuccessful, this doesn't mean that spot reduction is impossible.  Just because man can't fly by jumping off a cliff and flapping some makeshift wings, this doesn't mean that man cannot fly.  Given the right tool — an airplane, a rocket belt, or even a hang glider — flight is easy.  The key is the right tool.  The same is true with spot reduction.  With the right device, it's possible to selectively slim or enlarge part of the body.  I discussed the science behind this concept in both The Science of Sex and Fascinating Health Secrets.

What can I do to climax during intercourse?

Q:  What can I do so that I can climax during intercourse?  I heard that only one-third of women regularly climax during coitus, so I'm not alone. I tried all the usual recommendations (such as more foreplay and the coital alignment technique), but they did not help.

A:  You might benefit from using testosterone or other drugs to improve sexual sensitivity.  Another possibility is using the Vag-TTS, which enhances vaginal sensation.  All of this is discussed in The Science of Sex.

Increasing height:  A good idea?  Nuts?

Q:  Hello Dr. Pezzi, about a week ago I stumbled across your site and everyday I've been coming back for a few hours to read more.  It is very well put together and extremely entertaining.  The sheer amount of information you've shared with everyone is staggering.  I've easily added 10 new bookmarks to my favorites list from your pages.  So thank you.  :-)

Anyway, I'm a senior in high school, and my question is this:  I read your "What Really Turns Women On" page, which you separated into four categories:

Brains:  I consider myself of above-average intelligence.  I do well in school, I ask a lot of questions, read a lot, etc.
Power/Wealth:  I come from a fairly well-off family and unless I manage to somehow majorly botch something up (which is always a possibility, eek) odds are I'll be successful too.  That's how it has been for generations.
Fame:  I'm working on that one.  :-)
Appearance:  This is where my problem is.  My body is in good shape, and I'm very athletic.  As far as facial features on a scale of 1 to 10, I'd probably give myself an 8.  By no means am I going to be appearing on the cover of any magazine, but I also won't turn a woman into stone if she looks at me.  I've always been a reasonably popular guy.

My problem is that I'm short.  I'll be 18 at the end of November and I'm only 5'4".  Every male on my father's side of the family going back many generations has been 6' - 6'3" or so, but my mom's side is relatively short.  I got the short end of the genetic stick on that one (pun intended of course).

It's a problem though, and I'm embarrassed (even in e-mail) to ask about it.  I've spent more time than is probably healthy trying to find some statistic somewhere that said it didn't matter, but everything I found said things like "95% of women wouldn't date a guy shorter than them" and "97% of women polled say their spouse must be taller than they are" — things like that.  And those blasted platform-esque shoes that are in style now only make it worse.

I've looked online and in the library, but I can only find web sites that will "sell me the secret to growing taller for only $9.99 a month" and then spam me with a dozen popups — those are sites I tend not to trust.  I'd also heard about a young woman who wanted to be an airline stewardess but she was too short so she had some doctor crank apart her legs and thighs a tiny bit twice a day to add a few inches leaving her bedridden (with multiple fractures in both legs and thigh) for 9 months.  The scary thing is I'd almost do the second, so I figured I'd ask you.  Is there any way you can improve height?  I know I'll never be 6'.  I need to be realistic, but if there's a way to add 3 or 4 inches I'd be ecstatic.

Anyway, thank you for reading this far.  This was a bit longer than I'd intended and again, I know you're busy so if you can't respond I'll understand completely.  Thanks, (name withheld by request).

A:  At your age, the only way I know to add three or four inches of height is via surgery. There are two ways of viewing whether it's nuts to consider such an extreme option:

Yes, it's nuts:  Even if 99.9% of the women turn their noses up at you, to get married and have a successful life in terms of emotions and love, it takes only one woman who adores you.  Some women are short and prefer a man who does not tower above them.  That makes kissing, hugging, and lovemaking more enjoyable.  Even in women who aren't short, some don't give a hoot about height.  For example, one of the women in my "Beautiful Women in the ER Contest" is exceptionally attractive, but she told me that a man's physical attributes mean nothing to her.  Want another example?  Years ago, I worked for a man whose birth defects left him with one of the smallest, most deformed bodies I've ever seen, yet he was married to a woman half his age who was very attractive in every way (about 5'6", 115 pounds, pretty face, enticing breasts and legs, and a great overall shape) . . . and no, he wasn't rich.  His secret?  He had a dynamic personality, and did not feel handicapped by his handicaps.  Bottom line?  You could get married and not have to settle for the leftovers.

No, it's not nuts:  Sure, it takes only one such woman to fall in love with you . . . but good luck finding her.  Even in men who aren't short, finding a great match can be incredibly difficult.  Since most women do care about height, this problem will be compounded.  Apart from the romantic aspects, height is a major attribute in other areas, too.  Statistically speaking, taller men get better jobs and make more money.  If you've read some of the comments on this web site that I made about appearance, you know that I think it's crazy how the world showers some people with gifts just because they look a certain way.  However much I think it's nuts, most of the world evidently does not agree with me.

What may reduce vaginal tightness?

Q:  Dear Sir:  I am in need of help answering a question about my wife's vaginal size.  I'll be brief and to the point.

We have both been married before.  My wife has three children.  Our sex life has been very good until now, nine years after marriage.  Her vagina is no longer tight enough for me to enjoy.  She lost weight due to dieting, and she is 51 years old.  But the change in her vagina seems to have developed suddenly.

I have always trusted my wife, but doubt has moved in because of this.  I am not very well endowed, and as most men I have always been bothered by that.  But my wife has made me feel secure, until now.

Please advise me as to the ways a woman's vagina can change, other than childbirth and sexual intercourse.  My wife is in good health and looks great, and is on hormone therapy and is not experiencing many problems from the change of life.

Your help is needed.  Thanks, (name withheld by request)

A:  First, let me assuage your apparent concern about the possibility of your wife being unfaithful.  It is very unlikely that her reduced vaginal tightness is attributable to intercourse.  Given the scenario you presented, the most likely culprit is weight loss.  Dieting induces a loss of both fat and muscle.  Muscle loss is more pronounced when the diet is more extreme.  When muscles are catabolized (broken down) to provide energy, the muscles atrophy.  This affects most muscles in the body, including the muscles around the vagina.  When they atrophy, vagina tightness decreases.

In The Science of Sex, I discussed weight loss because it is a subject that most people approach in the wrong way, and because obesity affects sexuality.  There is a correlation between obesity and a number of diseases (such as heart disease, diabetes, cancer, and arthritis) that can negatively affect sexual pleasure, performance, and libido.  I give numerous tips for achieving weight loss without torturing your body or torturing yourself with hunger pangs.  One of the tips reveals how to lose weight without dieting, drugs, herbs, exercise, or surgery.  That may seem to be impossible and it may seem too good to be true, but it works and it is not unpleasant.  Somehow, this fact escaped notice by the weight loss “experts," who recycle the same old tired advice year after year.  Surprisingly, some of these supposed experts are themselves fat, which suggests that they are clueless.  When I was an intern, I was so fat that I could not see my feet when I stood up.  Now, I am in good enough shape to be an underwear model.  Back in the days when I was a blimp, I thought I'd never be able to lose weight.  I grew fond of my doctor's smock, which camouflaged the blubber fairly well.  Eventually, I was so disgusted by my potbelly that I decided to lose weight, and I did.  Painlessly.  The key is knowing what to do.

OK, back to the subject of vaginal tightness.  While dieting likely triggered your wife's vaginal laxity, stopping the diet won't immediately improve vaginal tone.  It takes time for muscle to regenerate.  This process can be accelerated by performing Kegel exercises, which are discussed in my book and myriad other sources.  However, my book discusses Kegel exercises and vaginal muscles in far more detail than you will find elsewhere.  Most of these discussions are trite, simplistic, and sometimes even laughable.

If you want an immediate improvement in vaginal tightness, your wife could use a vaginal wedge or the Vag-TTS, both of which are discussed in my book.  You could also use a penile vacuum cylinder (colloquially termed a "peter pump").  Correctly used, this device can produce slight to moderate long-term enlargement and pronounced short-term enlargement (the latter effect is accomplished via induction of penile edema).  The edema is relatively ephemeral, but it typically lasts a few hours — certainly long enough for intercourse.  The edema does almost nothing for penile length, but it can dramatically increase diameter.  Naturally, this increases subjective vaginal tightness.  For reasons that I explain in my book, tightness improves more than size.  Thus, when the penis is thicker, or the vaginal diameter is decreased, tightness increases more than the change in size.  This may seem like Greek to you now, but the book makes it crystal clear.  The bottom line is that relatively small increases in penile diameter (or a relatively small reduction in vaginal diameter) can produce a substantial improvement in tightness.  However, this works both ways, too.  A relatively small reduction in penile diameter (or a relatively small increase in vaginal diameter) can substantially diminish tightness.  Thus, it may be that your wife's vagina isn't much larger than before.  She may be just a bit larger, but this may seem like a big change because of the disproportionate variation in tightness with changes in size.  If she was near the threshold at which a small change in size produces a big change in tightness, you could easily interpret her vaginal looseness as developing "suddenly," as you mentioned.

Some medical problems can affect vaginal tightness, such as Cushing's disease, some neurological diseases, and diseases that induce cachexia (wasting), such as certain cancers and AIDS.  Several medications can affect vaginal tightness by causing muscle atrophy or reducing muscle tone.  Simple aging is usually associated with loss of musculature, and this atrophy is accentuated if testosterone is deficient (as it so often is).  Other hormonal problems (such as thyroid disorders) affect muscle strength, and this can manifest as reduced vaginal tightness.  Hormone replacement therapy can itself affect vaginal tightness unless both estrogen and testosterone are given.  Typically, women receive estrogen only.  While this is better for the vagina than receiving nothing, replacing estrogen but not testosterone increases production of a transport protein (sex hormone binding globulin, or SHBG) that binds to, and inactivates, testosterone.  This lowers the bioavailable testosterone level, and can exacerbate a testosterone deficiency.  This can accelerate muscle loss (thus decreasing vaginal tightness) in addition to affecting bone density, mood, sleep, confidence, certain aspects of intelligence, libido, and other things.  The route by which hormones are administered (oral, transdermal patch, etc.) affects SHBG production.  I discuss these subjects, and hundreds more, in further detail in The Science of Sex.

Is love a social construct or sexual attraction?

Q:  Dear Doctor,
I am doing a term paper on love.  My question is: "Is love a social construct or sexual attraction?"  Paul

A:  Neither.  Marriage is a social construct.  Love is much more instinctive.  If you were born into a world in which marriage did not exist, there is a good chance that you would never conceive of that construct.  If you doubt me, think of the millions of people who did just that.

Love is not a social construct.  It has tangible roots in our biology.  Definable changes in hormones and brain neurotransmitters occur when a person is in love, or is on the path leading to it.  This is discussed in The Alchemy of Love and Lust: How Our Sex Hormones Influence Our Relationships by Theresa L. Crenshaw, MD, and to a lesser extent in my book (The Science of Sex).

Love is also not sexual attraction.  Sexual attraction is one of the key ingredients that spark feelings of love, but sexual attraction per se is not love, nor anything even close to it.  Offhand, the most attractive woman I can think of is Helene Eksterowicz from the second The Bachelor miniseries.  Am I attracted to her? How could any red-blooded man not be attracted to her?  On the day that looks were handed out, she won the lottery.  But do I love her?  No.  Lust is essentially a synonym for sexual attraction, but love is not.

So what is love?  Rather than discuss this from a hormonal/neurochemical perspective, I will address it in shirtsleeve English.  Love develops when the following three conditions are met:

1. There is attraction.  This is usually predicated on physical attraction, but sometimes on an appreciation of brainpower, talent, personality, financial resources (think Melinda Gates), social status (think of the women who went gaga over President Clinton), or fame.
2. The feeling is reciprocated to some extent.
3. And, most importantly, a little voice in your head tells you that this is the best person you can hope to get at the current time.

This latter point is key.  I could be attracted to many women, and some of them could be attracted to me, but I would not fall in love with someone if I thought I could get a better catch.  Incidentally, this "best catch" requirement explains why people usually fall in love with ONE person, since there is just one best catch.

It is interesting to consider how self-perception narrows the field of candidates for love.  This is all the more interesting when you realize that self-perception influences not just this nebulous thing called love, but also hormones and neurotransmitters.  What is so intriguing about this is that when self-perception is less, the field of potential (not necessarily likely) candidates widens.  A man who is a "5" (and views himself as such) could be attracted to women whose appearance is average, above-average, or beautiful.  Assuming his interest was reciprocated, that man could potentially fall in love with any one of millions of women, ranging from a Plain Jane living next door, to Helene Eksterowicz.  However, if that man were a "10" and realized it, he would likely turn up his nose at less attractive women — even 7's and 8's that most men would be thrilled to have a relationship with.

Get yourself a cup of coffee, sit down, put your feet up, and ponder this matter for a while.  It has broad implications for contentment, happiness, and targets that you set for what you want to get out of life.

Some causes of diminished libido

Q:  I am a 26-year-old woman and my partner is 32.  We have been together for five months and last month decided to get married.  Yet I have problems with him in terms of sex.  At the beginning of our relationship, he was horny.  A month later he began to lose interest in sex.  We started to do it less often (like once in ten days). When I talked to him about my worries, he told me that he had this problem in his past relationships.  He also revealed that his fiancée left him because they were having sex only once per month.  He has been seeing a therapist for the past three months.  This doctor gave him an antidepressant as a part of therapy.  Since then he cannot come at all.  He does it only for my pleasure, I guess.  We have sex once every seven to ten days.  This depresses me a lot.  What do you recommend?  Is there any hope?  Should I be patient?  How should I behave?  Thank you.

A:  This matter is obviously troubling to you, and for good reason.  At your age, you should be having the time of your life in the bedroom.  If things are bad now, and they are, they will only get worse in the future unless he is treated.  Being patient and waiting will do no good.  Based on what you said, there is no indication that this problem will spontaneously resolve.

Fortunately, loss of libido is almost always correctable.  I don't know if doctors in your country at adept at treating it, but if they aren't, either you, your fiancé, or his doctor should read my book (The Science of Sex) for information on how to proceed.  Given that his doctor prescribed an antidepressant which worsened his problem, I doubt that his physician is knowledgeable about sex — or if he is, your fiancé is not telling him about his sexual difficulty.  Some antidepressants interfere with sexuality, but one increases libido and orgasmic potential (I discuss this in my book).

However, changing his antidepressant is not the sole solution to this problem since his difficulty with libido preceded antidepressant use.  As a doctor, I am concerned that he might have some medical problem that is lowering his testosterone level (testosterone is the primary hormone governing libido in both sexes).  Testosterone production can be reduced by testicular trauma, radiation, chemotherapy, or tumors.  Orchitis (testicular inflammation) can also lower testosterone levels; this may occur in men who develop mumps after puberty.  Pituitary tumors and AIDS can decrease testosterone levels, too.  Men may have low testosterone as a result of some genetic diseases, such as Kallmann’s syndrome, Klinefelter’s syndrome, Prader-Willi syndrome, or myotonic dystrophy, the most common form of muscular dystrophy in adults.  Testosterone levels can fall because of stress, long-term exposure to cigarette smoke, excessive alcohol consumption, obesity, sleep deprivation, sleep apnea, overtraining, and a diet that is excessively deficient in protein, fat, calories, potassium, or zinc.  Phytoestrogens, xenoestrogens, and exogenous estrogens can also reduce testosterone output.  Exposure to cadmium can reduce libido, too.  Here is an excerpt from my book:

Cadmium is a toxic metal that can partially block the action of zinc in the body. Thus, even if your intake and absorption of zinc are adequate, you may be functionally deficient in zinc if you have ingested or inhaled cadmium, which functions as an anti-nutrient. Everyone has been exposed to cadmium in food (particularly shellfish[1]), water, and air, but cadmium levels vary considerably depending on your occupation, location, and other factors. Cadmium is present in rechargeable nickel-cadmium batteries, pigments, polyvinylchloride (PVC) stabilizers, and some metal coatings, paints, inks, ceramics, and glass. Cadmium can also be found in other metals as an impurity, and in some fertilizers, nematocides[2], pesticides, and fungicides. Burning coal, oil, gas, or wood can release cadmium, as can soldering, welding, smelting, and waste incineration. The latter need not be on an industrial scale; even a neighbor burning trash might send cadmium wafting into your yard. Incidentally, cadmium is most easily absorbed through the lungs.

Here are some more facts you should know about cadmium:

· Cadmium is widely distributed throughout the body, but it accumulates primarily in the kidneys and liver of humans and animals. It is inadvisable to eat liver or kidneys since there is no practical way for you to know the cadmium content of those foods.

· Cadmium is present in cigarette smoke. The cadmium level in people who smoke is substantially higher than in nonsmokers.

· Galvanized water pipes can significantly increase cadmium levels in drinking water.

· Oysters are reputed to be an aphrodisiac (perhaps because of their zinc content), but they are often contaminated with cadmium and hence may hurt your sex life.

· In experimental animals, low dietary levels of calcium, iron, or zinc increase cadmium absorption.

· Cadmium can be released from nickel-cadmium batteries if they are put in backwards, crushed or otherwise damaged, burned or subjected to a short circuit, or even just overheated. According to a representative of the Eveready Battery Company, nickel-cadmium batteries can release cadmium at temperatures as low as 113° F[3]. Since batteries heat up when they are used or recharged, the ambient temperature need not exceed 113° F for cadmium emission to occur.

And here are a few tips for doctors:

· Since cadmium has a long persistence in the body (its elimination half-life is 20 to 30 years), you cannot count on the passage of time to reduce cadmium levels. Since cadmium is so easy to acquire and so difficult to get rid of, older people generally have higher cadmium levels.

· Chemet®, also known as succimer or dimercaptosuccinic acid (DMSA), is a chelator that can remove cadmium from the body.

· Blood levels show recent exposure to cadmium, while urine levels show both recent and long-term exposure.

· An early sign of cadmium-induced nephropathy is increased proteinuria, especially beta-2-microglobulin.

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[1] To minimize cadmium ingestion from eating shrimp, choose farm-raised shrimp.  Some Midwest farmers, fed up with the vagaries of raising traditional crops and animals, now grow shrimp in ponds in their fields.

[2] Nematocides are substances that kill nematodes (a.k.a., roundworms), such as hookworms or pinworms.

[3] As a longtime electronics enthusiast, I was skeptical that cadmium emission could occur at such a comparatively low temperature.  However, the Eveready representative insisted that was true, adding, “That’s one of the reasons we stopped making nickel-cadmium batteries.”

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My book contains much more information on ways to enhance libido, sexual pleasure, orgasmic ability, and sexual performance.

She is attracted to her doctor — how should she proceed?

Q:  I was attracted to my doctor the first time I met him.  I have never before had this kind of instant attraction to any man.  I think I like him so much because I really go for smart men with a compassionate side.  While I am normally shy, I have managed to flirt with him a little bit.  He kids with me and seems not to mind my flirting.

I guess my concern is that what I see as possible interest on his part could just be a great bedside manner.  Maybe he is naturally nice to all his patients.

A:  That is possible.  I've had women misread my pleasantness, too.  Some of these situations were so memorable that I will include them in my next book of ER stories.

Q:  This would be so much easier if he were my cable guy or someone I met in a grocery store!  I have so little experience in flirting and reading men for positive signals because they will approach me first.  How can I tell if he really is interested?  Is there anything I can do or say to let him know I want to get to know him?

By the way, I'm being treated for anemia, so it's not like I have some scary disease that would be a turn-off.  Thanks.  Judy

A:  This is definitely a touchy situation.  On one hand, you don't want to create an uncomfortable situation if he is not attracted to you.  On the other hand, you don't want to pass up an opportunity for a potentially great relationship.

I assume he is not married, but he may already be involved with someone, unbeknownst to you.  Assuming that he is available and attracted to you, he still may not want to become involved.  Why?  State medical boards frown on doctors becoming sexually involved with patients.  I exhaustively researched this matter a few years ago when another reader asked me a similar question.  From what I determined, the only relatively safe course of action is for the doctor to terminate his professional relationship before he becomes personally involved.  I said "relatively safe" because there is always the potential for you to raise a stink with the medical board, regardless of when he last saw you as a patient, if things don't work out and he ends the relationship.  You strike me as someone who is not likely to do this, but some woman, somewhere, gave credence to the phrase "hell hath no fury like a woman scorned."  In fairness to women, rejected men can be equally malevolent.

I think the most logical way to proceed is to:

1. Determine if he is available.
2. If he is available, determine if he is willing to risk dating a patient who is agreeable to becoming an ex-patient.
3. If he is willing to date an ex-patient, determine if he is interested in you.

You can do this on your own, of course, but it may be a delicate situation, as I discussed above.  If you want, I will intercede on your behalf if you give me his name and e-mail address (I won't tell him your name).  Thus, if he is involved with someone, or not willing to date a former patient, then you needn't go through the uncomfortable situation of telling him that you are interested.

PS:  You've heard of the FOX network's Married By America? Well, this is Married By www.ERbook.net!  :-)
PS #2:  I just had another thought about your statement, "Is there anything I can do or say to let him know I want to get to know him?"  Yes, there is.  If you want to handle this matter on your own, you could look him in the eye, pause for effect, and then say, "I like you."  If he pats you on the shoulder, gives you a perfunctory brief smile, says "I like you, too, Judy," then resumes from where he left off, it is a safe bet he is not personally interested in you.  On the other hand, if he stops dead in his tracks and looks stunned, that is because he is searching for a way of letting you know he is interested, without doing something that might run afoul of the state medical board.

Reader heard a rumor . . . is it true?

Q:  Dr. Pezzi:  I think that your website is quite entertaining and informative at the same time.  I enjoy it very much.  I am a 19-year-old college student and I have a question regarding something that my friend heard somewhere.  He said something about a correlation between sexual pleasure and the size of a woman's posterior.  More specifically that a woman with a bigger ass will derive more sexual pleasure from sexual activities than one with a smaller ass.  Is there any truth to this?  Jared

A:  I consulted several female friends, including ones with slim behinds and others with steatopygic derrières (steatopygia = an extreme accumulation of fat on the buttocks), but the latter ones were too busy moaning to answer my question.  OK, I'll be serious.  There is no truth to this rumor.  If anything, the converse is true.  Women with more testosterone are likely to have smaller buttocks, and also a better sex life because testosterone enhances libido and heightens sexual pleasure.

Enlarged labia minora cause for concern?

I receive a surprising amount of e-mail from women who remain virgins because they're embarrassed about what they think are enlarged labia minora (the thin hairless inner lips that surround the vaginal opening, in contrast to the labia majora, which are the larger, fatty, hair-covered outer lips).

If you are one of those women, relax!  Men often think that large labia minora are sexy and desirable, so what you have is a definite plus, not something to be ashamed of.  I've performed thousands of pelvic exams, and I've yet to see any labia minora that are too large.  Nor have I seen excessively large labia minora in textbooks.  What you're worrying about simply doesn't exist.

If you're thinking about surgery to reduce their size, forget it.  Why would you incur pain, possible numbness, and the other risks of surgery (not to mention its cost!) to lop off something that men adore?

A woman who read the above explanation still wasn't convinced, and she wrote to say that I was minimizing the problem just to make women feel better.  Not so.  I'm not one of those doctors who feels a need to assuage the anxieties of my patients even when they have reason to be anxious.  If I thought large labia minora were a problem, I'd say so.

Copyright © 1991 - 2006 by Kevin Pezzi, M.D.  All rights reserved.  No liability is assumed with respect to the use of the information herein.  You should consult with, and obtain the approval of, your personal physician before instituting any of the measures presented.  No material intended for the general population can attempt to treat specific individuals, and no material in this web site should be construed as offering individual medical advice.  Given the innate variability of people, it is critical that your physician approves the adoption of any information herein contained as being safe and effective for you.  A physician's circumspection is his—and your—greatest asset.

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