Does a good washing before anilingus remove bacteria?

Dear Reader,
As your professor said, anilingus (also known as "rimming" or anal oral sex) — kissing, sucking, licking, tonguing the anus with the lips or tongue — presents a risk of getting or spreading potentially harmful bacteria. If someone ingests these germs, they may experience symptoms such as fever, cramping, and diarrhea. Intestinal parasites and sexually transmitted infections (STIs) such as herpes, gonorrhea, human papillomavirus (HPV), human immunodeficiency virus (HIV) and hepatitis, which can infect the anus, also present a risk. It's also possible to be exposed to blood if there are cuts or tears in the anus, or any traces of bloody feces, which heightens the risk of bloodborne illnesses and infections. While a good washing can help "freshen" the area before anilingus, it won’t necessarily "rid" the area of germs and doesn't reduce the risk of spreading or contracting STIs. Therefore, as you mentioned, when rimming, a latex barrier, with a dab of lube on the side covering the anus, can reduce risk for both partners.
In most cases, as long as fecal matter is well-formed (not too watery or too hard), it doesn't spend time in the rectum and anal canal until right before a bowel movement. This means that, as long as someone is avoiding engaging in anal play when they need to use the bathroom, large messes are unlikely. However, people who have regular bowel movements generally still have trace amounts of feces in the canal. Before rimming, some people wash the anus with a moist, soft cloth to be sure that the area is as clean as possible. It's preferable to choose gentle products that won’t irritate the anus or cause cuts and possible infection.

Some people use a mild enema, which releases warm water into and then out of the anus to initiate a bowel movement, or clean out any traces of feces and bacteria from the anal cavity. Some options use chemical laxatives to help expel everything in the rectum, while others simply use warm water. In any case, these liquids are inserted into the rectum to help clear out the anal cavity. Using an enema two to three hours before anilingus allows the body some time to reabsorb the water before the activity takes place. It’s worth noting that frequent use of enemas can disrupt the rectum, bowels, and gastrointestinal tract and the disturb body's own elimination rhythm. It’s also good to use warm water without soap as it’s the least likely to irritate the anus. Additionally, some research has shown that enema use may be associated with increased STI risk as it may damage the tissues around the anus, which can help facilitate transmission.
In addition to preventing bacterial infections, it’s also good to take precautions against STI transmission (some of which are also caused by bacteria). In combination with barrier methods, ensuring that both partners are regularly screened for STIs can be a useful prevention measure. A person who engages in anal play or anal sex may want to inform their health care provider so they can receive rectal testing for STIs, as anal STI infection won’t be detected through specimens tested from the vagina or urethra. While the recipient is at some risk, the partner with the active tongue is more at risk of contracting an STI. However, if the giving partner has a cold sore or has blood, semen, or vaginal fluid in their saliva and there are cuts around the anal opening or in the anus through which bacteria and viruses can enter, the receiving partner may be at an increased risk. 
Whether you’re trying to prevent bacteria or STIs from spreading, some safer sex barrier options include using a dental dam or a dry condom with the tip and elastic ring removed and cut along the length. Balancing safer sex measures, hygiene, and personal preferences with rimming can get a little messy, but with some key information, each individual can find a way to make anilingus fun and safe for all partners.

HIV from oral sex with no condoms?

Dear Uneasy,
First, it's good to note that gay men aren't the only population infected with HIV — many men, women, and non-binary people, regardless of their sexual orientation or the gender of their sexual partners, are living with HIV every day. Generally, the risk of HIV transmission during oral sex, even without using a condom or dental dam, is quite low, although there are some factors that may increase the likelihood of transmission (more on this in a bit). While transmission can occur due to having anal sex without a condom, it's not the only reason that men who have sex with men (MSM) have higher rates of HIV. There are complex factors that contribute to this such as not knowing their HIV status, substance use, social discrimination and cultural issues (such as not having access to quality health care), and there being an already existing high prevalence of HIV among the MSM community. As for why your friends have oral sex without condoms, it could be for any number of reasons.
Your friends also could mistakenly have confused a lower risk of contracting HIV from unprotected oral sex with no risk. It's true that unprotected oral sex carries a lower risk for HIV transmission than either unprotected vaginal or anal sex. Although the virus can enter the body through the mucous membranes that line the vagina, rectum, urethra, or the mouth, transmission through the vagina and the rectum are most common.
However, even though the risk for oral sex is known to be relatively low, the Centers for Disease Control and Prevention (CDC) states that a number of other factors, such as open sores in a person's mouth, may increase the risk of oral HIV transmission. A person living with HIV may have semen with relatively high concentrations of the virus. Sexual partners of individuals who produce semen, can reduce their risk of contracting HIV by not letting semen contact any mucous membranes,

 including the lining of the mouth. Pre-ejaculatory fluid (pre-cum) also contains HIV, but because the concentration is lower, and there is generally so little fluid, it isn't considered a significant risk factor. In terms of cunnilingus (oral sex performed on a person with a vagina), menstruation is the time of greatest risk of HIV transmission for the person giving since there's a high concentration of HIV in the blood of a person who's HIV-positive. There's also a smaller risk during times other than menstruation because vaginal secretions can contain the virus as well. An HIV-positive person giving oral sex could also theoretically transmit the virus to the person receiving, but this risk is very small. Using condoms or dental dams during oral sex significantly reduces the risk of transmission of HIV. Additionally, the use of pre-exposure prophylaxis (PrEP) can help lower the risk of people getting infected, particularly for those who may be at a higher risk.
Finally, your friends may want to consider that other sexually transmitted infections (STIs) that can be transmitted through oral sex. Herpes and gonorrhea, for example, are transmitted orally much more easily than HIV. And these other STIs are often asymptomatic (meaning that a person doesn't experience any symptoms despite having an infection), so it can be hard to tell if either partner has an infection. If a person is sexually active, it's wise to get tested for STIs regularly, even if they aren't actively experiencing symptoms.
You're a caring person for trying to look out for the health of your friends. If you're concerned about their behaviors, you may try having a conversation with them about their perception of risk. You may want to share this information with them to encourage them make a more informed decision, but ultimately, you can't make decisions for them.
Here's to safer sex,
Alice!

DES (Diethylstilbestrol)

Dear Reader,
You’re right on the money with your intel on this drug. Diethylstilbestrol (DES) is a synthetic, lab-made form of the hormone estrogen. When the drug was first introduced, researchers theorized that low levels of estrogen contributed to pregnancy complications such as miscarriage and premature births. From 1938 to 1971, DES was prescribed in the United States to anywhere from five to ten million pregnant people in an effort to prevent miscarriages, premature labor, and other pregnancy complications from occurring. Later, it was found that DES didn't prevent the conditions it was meant to curtail, and, in 1971, researchers sounded the alarm that the drug was linked to serious health issues. Following these findings, the U.S. Food and Drug Administration (FDA) advised all health care professionals to avoid prescribing this medication. Although health care providers were encouraged to also alert the patients they previously prescribed DES about the problems associated with the drug, it’s possible that many people who were exposed to DES, both while pregnant and in the womb, may not be aware.
It has also since been revealed that DES disrupts the body’s endocrine system, which is responsible for the body's hormones. Substances that interfere with the endocrine system are known to increase the likelihood of cancer and problems during fetal development. With this in mind, a person who used DES during their pregnancy is 30 percent more at risk for developing breast cancer. This equates to a rate of about one in six cases of breast cancer in those who took DES, as opposed to one in eight for those who did not. DES was found to affect the babies of those who took DES as well.
The children assigned female at birth of pregnant people who were given DES may experience or develop the following heath concerns:
•Abnormalities of the cervix, uterus shape, and tissue that lines the vagina
•Abnormal cells in the cervix and vagina
•Increased risk of developing an otherwise rare form of cancer of the vagina or cervix, called clear cell adenocarcinoma
•Difficulty becoming pregnant
•Increased risk of miscarriage, pre-term labor, ectopic pregnancy (pregnancy that occurs within the fallopian tube instead of the uterus), and preeclampsia (a condition that results in protein in the pregnant person's urine and high blood pressure, which, in turn, may require early delivery)
•Slightly increased risk of breast cancer

Some studies indicate that the children assigned male at birth of those who took DES may experience or develop abnormal testicles (e.g., non-cancerous cysts on the epididymis or undescended testicles), and may be at increased risk of infection or inflammation of the testicles, and hypospadias (atypical development of the opening of the urethra). However, these risks haven’t been found in all studies.
In addition to folks exposed to DES in the womb, the effects of the drug on the third generation (referred to as DES grandchildren) are now being investigated. Current studies aim to determine whether the changes to DNA potentially caused by the drug may be passed down from generation to generation, and whether it may increase the risk of fertility issues, pregnancy concerns, and other health issues among this population. Right now, it's unclear whether the third generation is at greater risk than children whose parents weren't exposed to DES. However, some studies do indicate that the male offspring of those who were impacted by DES in the womb may have a higher risk of developing hypospadias.
Those who have used DES are advised to let their children and health care providers know about their past use, and to seek regular health and breast cancer screenings (as recommended of all those assigned female at birth). However, knowing for sure that they were exposed to DES may be a challenge. The American Cancer Society has more information to help track down the information needed to verify or determine the likelihood of exposure. It's also recommended that anyone who was potentially exposed to DES in the womb let their health care provider know, and to undergo routine exams. For female offspring, this may include pelvic exams, Pap smears, iodine stainings of the cervix and vagina, colposcopies, biopsies, and breast exams. Although it's recommended for those who’ve been exposed to DES during fetal development to tell their health care provider before becoming pregnant (to ensure that extra precaution is taken), many are able to have full-term, healthy pregnancies.
Hope this information is helpful! If you have additional questions, consider also checking out the National Cancer Institute website, which has a handy fact sheet with a number of commonly asked questions about DES exposure.

Cervical cancer info online

Dear Reader,
With the abundance of resources that exist online, it may be difficult to find accurate information. Fortunately, Go Ask Alice! can do some of the work for you! To start with the basics, the cervix is the lower part of the uterus, which connects to the vagina. Cancer of this body part has been linked to the human papillomavirus (HPV), of which types 16 and 18 cause approximately 70 percent of cases of cervical cancer. In most cases, the immune system works to inhibit the virus from harming the cervical cells over time, but sometimes HPV may cause the cells to become abnormal or cancerous.
There are certain factors that increase an individual’s risk of contracting HPV, which may also increase the chances of developing cervical cancer. These risk factors include having multiple sexual partners, early initiation of sexual activity, contraction of sexually transmitted infections (such as chlamydia, gonorrhea, or human immunodeficiency virus), having a weak immune system, and cigarette smoking.
If detected early, cervical cancer is often curable, which is why it’s critical to get screened regularly. Screening helps to prevent the development of cervical cancer and to initiate treatment early. The two types of screenings are the Pap test (also known as the Pap smear) and the HPV test. Both tests are available through a health care provider. The screening recommendations for those with a cervix as indicated by the American Cancer Society (ACS), American College of Obstetricians and Gynecologists, and United States Preventive Services Task Force include:
•Under 30: begin screening at age 21 with a Pap test, rescreen with a Pap test every three years until age 29
•30 to 65: Pap test combined with an HPV test every five years until age 65; or every three years with just the Pap test

•Over 65: discontinue screening at age 65 if they've had regular screening in the previous ten years and no serious pre-cancers found in the last 20 years
In addition to age, individuals at higher risk of cervical cancer may be encouraged to get screened more frequently. Those with abnormal cervical screening results may need to have a follow-up Pap test done in six months or a year. If someone assigned female at birth has a total hysterectomy (removal of the uterus and cervix) they probably no longer need to be screened, unless the hysterectomy was done as a treatment for cervical pre-cancer or cancer. If the individual had a hysterectomy without removal of the cervix (called a supra-cervical hysterectomy) it’s recommended that they continue cervical cancer screening according to the standard screening guidelines.
To reduce the risk of contracting HPV, individuals between the ages of 9 and 45 can get vaccinated. This series of shots allows for protection against multiple strains of HPV that are highly associated with cervical cancer. However, it’s recommended that those who have been vaccinated still follow the general screening guidelines. For more information, check out the American Cancer Society’s page on cervical cancer and the Centers for Disease Control and Prevention website on the HPV vaccination. The ACS also has an extensive list of links to other reliable information sources.
Hope this provides you with some clarity on cervical cancer!

Oxytocin: The love hormone?

Oxytocin is a hormone and a neurotransmitter that is involved in childbirth and breast-feeding. It is also associated with empathy, trust, sexual activity, and relationship-building.
It is sometimes referred to as the “love hormone,” because levels of oxytocin increase during hugging and orgasm. It may also have benefits as a treatment for a number of conditions, including depression, anxiety, and intestinal problems.
Oxytocin is produced in the hypothalamus, a part of the brain. Females usually have higher levels than males.
Oxytocin is a neurotransmitter and a hormone that is produced in the hypothalamus. From there, it is transported to and secreted by the pituitary gland, at the base of the brain.
It plays a role in the female reproductive functions, from sexual activity to childbirth and breast feeding. Stimulation of the nipples triggers its release.
During labor, oxytocin increases uterine motility, causing contractions in the muscles of the uterus, or womb. As the cervix and vagina start to widen for labor, oxytocin is released. This widening increases as further contractions occur.
Oxytocin also has social functions. It impacts bonding behavior, the creation of group memories, social recognition, and other social functions.
Oxytocin as a drug
Oxytocin is used as a prescription drug under the brand name Pitocin. Under medical supervision, an oxytocin injection is sometimes used to start birth contractions or strengthen them during labor, and it helps reduce bleeding after delivery. Side effects include a rapid heartbeat and unusual bleeding.
If too much oxytocin is delivered too rapidly, it can lead to a rupture of the uterus.
Oxytocin can also be given to make the uterus contract and control bleeding after a delivery or a termination.
It can be used medically to induce a termination or complete a miscarriage.
The love hormone?

In 2012, researchers reported that people in the first stages of romantic attachment had higher levels of oxytocin, compared with non-attached single people. These levels persisted for at least 6 months.
Sexual activity has been found to stimulate the release of oxytocin, and it appears to have a role in erection and orgasm. The reason for this is not fully understood, but, in women, it may be that the increased uterine motility may help sperm to reach their destination. Some have proposed a correlation between the concentration of oxytocin and the intensity of orgasm.
When oxytocin enters the bloodstream, it affects the uterus and lactation, but when it is released into certain parts of the brain, it can impact emotional, cognitive, and social behaviors.
One review of research into oxytocin states that the hormone’s impact on “pro-social behaviors” and emotional responses contributes to relaxation, trust, and psychological stability.
Brain oxytocin also appears to reduce stress responses, including anxiety. These effects have been seen in a number of species.
The hormone has been described as “an important component of a complex neurochemical system that allows the body to adapt to highly emotive situations.”
Is it that simple?
In 2006, investigators reported finding higher levels of oxytocin and cortisol among women who had “gaps in their social relationships” and more negative relations with their primary partner. The participants were all receiving hormone therapy (HT) following menopause.
Animal studies have found high levels of both stress and oxytocin in voles that were separated from other voles. However, when the voles were given doses of oxytocin, their levels of anxiety, cardiac stress, and depression fell, suggesting that stress increases internal production of the hormone, while externally supplied doses can help reduce stress.
Clearly, the action of oxytocin is not straightforward.
A review published in 2013 cautions that oxytocin is likely to have general rather than specific effects, and that oxytocin alone is unlikely to affect “complex, high-order mental processes that are specific to social cognition.” The authors also point out that a willingness to collaborate is likely to be driven by anxiety in the first place.
Nevertheless, oxytocin does appear to be associated with social behavior, including maternal care, bonding between couples, sexual behavior, social memory, and trust.
Behavioral effects
Delivering oxytocin through a nasal spray has allowed researchers to observe its effects on behavior.
In 2011, research published in Psychopharmacology found that intranasal oxytocin improved self-perception in social situations and increased personality traits such as warmth, trust, altruism, and openness.
In 2013, a study published in PNAS suggested that oxytocin may help keep men faithful to their partners, by activating the reward centers in the brain.
In 2014, researchers published findings in the journal Emotion suggesting that people saw facial expression of emotions in others more intensely after receiving oxytocin through a nasal spray.

Enlarged prostate and sex: Side effects and how to cope

Older men tend to have larger prostates than younger men because the prostate continues to grow as a man ages. Enlargement of the prostate that is not the result of cancer is called benign prostatic hyperplasia (BPH).
BPH can cause problems with urination, and some treatments can lead to sexual problems and other side effects.

Effects of an enlarged prostate
An enlarged prostate directly affects a man’s ability to urinate. These effects include:
a frequent need to urinate
a feeling of not emptying the bladder
intense urges to urinate
a weak urine stream
problems starting or stopping urination
Prostate issues can also cause sexual problems. The extent of any sexual problem varies according to the condition of the prostate. Some common sexual side effects include:
erectile dysfunction (ED)
reduced sexual satisfaction
problems maintaining an erection
decreased libido
These conditions may also vary according to:
age
genetics
anxiety

BPH and ED
BPH and ED are separate conditions that are connected. ED usually means that a man is not able to achieve or maintain an erection.
Although ED may be caused by a variety of health problems, such as heart disease, diabetes, low testosterone levels, or psychological issues, it can also be made worse by BPH.
Some medications used to treat an enlarged prostate can cause ED. However, some medications used to treat ED can help improve symptoms of BPH.
Although no medication prescribed for ED has been approved to treat an enlarged prostate, early studies suggest that men who take ED medications may experience some relief from their prostate symptoms.
Several ED medications have shown some success in treating enlarged prostates. These include:
vardenafil (Levitra)
sildenafil (Viagra)
vardenafil (Levitra)
sildenafil (Viagra)
tadalafil (Cialis)
For example, one study showed that men who took 10 milligrams (mg) of vardenafil twice a day for 8 weeks experienced marked improvements in their prostate symptoms, compared to a similar group who took a placebo.
Another study found that men who took up to 5 mg of tadalafil daily saw significant improvements in both their prostate and ED symptoms.
However, before taking ED medication to treat symptoms of an enlarged prostate, speak to a doctor. ED medications have potential side effects that can make them unsafe for some men, particularly those with a history of the following conditions:
stroke
unstable angina
heart attack
uncontrolled high blood pressure

What We Can Learn From Sexual Response Cycles

When it comes to sexual behavior, people frequently want to know what's "normal." There seems to be a natural tendency to want to compare one's own sexual experience to the average sexual experience, perhaps in an attempt to gauge performance.
Understanding what is happening physiologically during a given sexual experience may or may not enhance the sexual experience; but one thing is for sure, it isn't easy to understand what's "normal" when it comes to sexual response.

Like many things sexual, there isn't really a normal. To quote Kinsey:

"The only unnatural sex act is that which you cannot perform."
Many are familiar with the Masters & Johnson sexual response cycle. This was the original sexual response cycle, published in 1966, based on observations of sexual responsivity during partnered and solo sexual activities. This model of sexual response is still the most commonly taught model, despite its mid-60s debut.

Masters & Johnson found that sexual response was divided into four phases: excitement, plateau, orgasm, and resolution. These four phases happened in a linear way, with one coming after the other. The sexual response cycle wasn't complete without all four occurring (but women had the capability to have multiple orgasms, putting off resolution until all orgasms were complete).

Despite its (even current) wide use, there are some issues that have been identified with this model of sexual response. The model is entirely linear, with one component occurring prior to the next, in the same order. This is problematic because we just don't work that way! The model completely ignores sexual desire and requires an orgasm to have occurred during sexual response (a very unrealistic expectation). Finally, the model is entirely physiological with no mention of relationship factors, cultural attitudes, or any other external contributors that may be crucial when considering sexual response.


In response to these criticisms, other researchers stepped up to try to explain human sexual response. First, Kaplan proposed the Triphasic Concept in 1979 by creating a model that included desire, excitement, and orgasm. However, this was still linear, still required orgasm, and raised the question of whether desire really came before arousal. Then, in 1997, Whipple & Brash-McGreer created the Circular Model that was specific to women. This cycle acknowledged that pleasure and satisfaction during one sexual experience can feed into the initiation of the next sexual experience. If pleasure and satisfaction were not met, it would decrease the desire for subsequent sexual interactions.

Though the Circular Model is an interesting approach, there is a newer model that myself and many other sex researchers and therapists rely on for explaining how sexual response works. This model was proposed by Basson in 2000 as the Non-Linear Model of sexual response. It is typically referred to for explaining women's sexual response, but I think it proves equally useful when looking at men's sexual response. Afterall, too often we think of men as overly-simplistic beings when it comes to sex.

Basson's Non-Linear Model of sexual response incorporates the need for intimacy, acknowledges that desire can be reactive or spontaneous and may come either before or after arousal, recognizes that orgasms may contribute to satisfaction but aren't necessary for satisfaction, and considers relationship factors that may impact the cycle as costs or rewards.

The inability to really define "normal" is one of my favorite aspects of Basson's model. Women (and men) can experience sexual response in a variety of ways. Parts of the model are linear (e.g., arousal and stimulation occur prior to the experience of satisfaction), but other parts are circular and bidirectional (e.g., sexual desire may come before or after arousal and the two may feed into each other).

Three main take-home messages we can learn from studying sexual response cycles:
1.Sexual pleasure and satisfaction aren't reliant on orgasm, though orgasm may certainly be a nice bonus.
2.Sexual desire doesn't always have to come before sexual activity or arousal...sometimes getting physical and experiencing arousal will elicit desire.
3.External factors such as relationship dynamics, intimacy, and weighing rewards and costs of sexual experience may play an important role in sexual response.

Try not to focus on "normal." Instead, shift that focus to you and your partner's sexual response and communicate your needs both inside and outside the bedroom.

Sneezy Does It

Woman: (sneezes and moans several times)
Man: "Excuse me, but is everything OK?"
Woman: "Yes, it's just that I have this condition where every time I sneeze I have an orgasm."
Man: "Are you taking anything for it?"
Woman: (smiling) "Yes. Pepper."
Apologies for starting this blog with an old joke but I thought it was a good way to bring up the relationship between sex and sneezing. There are reports in the medical and psychological literature dating back to the 1890s of sexually induced sneezing in both men and women. The phenomenon is characterized by sneezing during sexual arousal and/or orgasm. In such cases, these individuals sneeze as a direct result of sexual thoughts, arousal, intercourse, and/or orgasm. Furthermore, the sneezing may occur at any point during a sexual experience, and most importantly occurs independently of any external nasal stimuli or allergens.

The first verified report of the phenomenon was thought to be in 1898 when John Noland Mackenzie wrote about the phenomenon (“The physiological and pathological relations between the nose and sexual apparatus of man”) in the Journal of Laryngology, Rhinology and Otology. A few years later (1901) reference was also made to the condition in George Gould and Walter Pyle's Anomalies and Curiosities of Medicine. I managed to track down the original quote about a man:

“who, when prompted to indulge in sexual intercourse, was immediately prior to the act seized with a fit of sneezing. Even the thought of sexual pleasure with a female was sufficient to provoke this peculiar idiosyncrasy”.
More recently, and based an a paper submitted to the American Medical Association, Dr. Jeffrey Wald, a specialist is asthma and allergies, was quoted in the US newspaper Pittsburgh Post-Gazette (September 6, 1988) about the of case of an American middle aged man who continuously sneezed following sex. He attributed the sneezing to “vasomotor rhinitis”, a condition in which the nasal passages are chronically inflamed (and characterized by hyperactive or imbalanced control of the central nervous system responses).


I also read an interesting paper by Dr. Mahmood Bhutta and Dr. Harold Maxwell entitled “Sneezing induced by sexual ideation or orgasm” published in a 2008 issue of the Journal of the Royal Society of Medicine. Bhutta and Maxwell’s paper cited a case from 1972, a letter to the Journal of the American Medical Association involving a 69-year-old man who suffered severe bouts of sneezing after orgasm or whenever he thought of sex. In their paper, it was noted that both men and women were using online forums to seek out help or explanations for their experienced phenomenon. These people often felt embarrassed about bringing up the matter with the medical profession, and preferred to seek help and advice anonymously. They also reported on these online data and noted (i) three people who claimed they always sneezed after orgasm, and (ii) 17 people who reported that they sneezed immediately when they thought about sex. They speculated that the link between sex, orgasm and sneezing was most likely caused by a fault in the autonomic nervous system (i.e., the part of the nervous system that is involved with heart rate, blood flow and digestion). They argued that the nerves that control breathing, blood pressure, pupil construction, sneezing and digestion run close to each other in the brain stem. They speculated that light-sensitive sneezing and sex-related sneezing occurred when these signals became “muddled”. Dr. Bhutta told the BBC in an interview:

"[The relationship between orgasm and sneezing] certainly seems odd, but I think this reflex demonstrates evolutionary relics in the wiring of a part of the nervous system called the autonomic nervous system. This is the part beyond our control, and which controls things like our heart rate and the amount of light let in by our pupils. Sometimes the signals in this system get crossed, and I think this may be why some people sneeze when they think about sex".

Dr. Bhutta also told the BBC that embarrassment or social inhibition may have prevented others from admitting the problem to the medical or psychological community. Another potential explanation may relate the fact that – like genitalia – the nose also has vascular (erectile) tissue, which has the capacity to become engorged during sexual arousal, and triggering a sneeze. Others have noted the ejaculatory-like qualities of the sneeze, and 1980s television ‘sexpert’ Dr. Ruth (Westheimer) observed that “an orgasm is just a reflex, like a sneeze".

On a related issue, there is also a condition that has been coined “honeymoon rhinitis” in which men and women experience nasal irritation and inflammation of the mucous membrane inside the nose during sex. Spanish medics led by Dr J. Monteseirin published a small article in a 2001 issue of the journal Allergy. They reported a study of 23 allergy sufferers (9 women and 14 men), all of whom had experienced sneezing, rhinorrhea, and nasal obstruction immediately after (but never before or during) sexual intercourse (lasting for approximately 5-15 minutes). The research team also got all 23 participants to climb two flights of stairs on three separate occasions to equate to the energy expenditure during sex but none of them suffered any rhinitis following the task. The exact mechanism by which sex initiates and/or facilitates honeymoon rhinitis is not known. However, the authors speculated that emotional excitement and anxiety may be the trigger factors for post-sex rhinitis rather than exercise.

For most people, sneezing is just a common every day biological act. However, for some, a sneeze appears to be much more and something sexual. If you think sneezing fetishism is rare, just type 'sneeze fetish' into Google and see what you get. There are loads of dedicated websites on sexual and sensual aspects of sneezing.

Sneeze Fetish Forum (“Celebrating the sensual sneeze”)
Serotica (“Dedicated to fiction combining sneezing and sensuality”)
Diary of a Sneeze Fetishist (“Exploring the origins, development and impact of one woman's fetish for sneezing”) 
Here is one snippet I came across from a male (Greg, from Arlington, Virginia, USA):

“A gentleman with whom I have a mutual interest in companionship told me that he becomes sexually aroused when an attractive man sneezes. He said it makes no difference whether the sneeze is authentic or simulated. (He has never asked me to "fake" one for him; I told you, he's a gentleman. And no, as fate would have it, my allergies have remained in check during the times we've been together, so I've not had occasion to observe his reaction firsthand.) My friend tells me that other folks, gay and straight, have this fetish”

Despite the many sites, I know of only one academic paper on sneezing fetishes. This was published over 20 years ago by Dr. Michael King in a 1990 issue of the journal Sexual and Marital Therapy. Dr. King reported the case of a 26-year-old homosexual male who was sexually aroused by observing other people sneeze and who also had an obsessive fear of vomiting in public. He was treated for his fear of vomiting with desensitization techniques, resulting in a rapid improvement in the man’s vomit phobia. Treatment was also attempted for the sneeze fetish through the use of covert sensitization. However, it had little effect on the man’s fetishistic impulses. Following this, he was taught to use thought-stopping techniques to reduce his preoccupation with fetishistic sneezing.

“I do know that my first love of sneezing came from the Smurfs. I doubt anyone else ever looked twice at a little blue sneezing midget (aptly named Allergic Smurf). Then, there was that scene in Disney's Alice in Wonderland, the one where Alice is trapped inside White Rabbit's house and has her nose tickled by smoke. I remember sitting entranced in front of the television set, watching that scene over and over and over again. As I grew older, I kept on watching out for sneezes on television shows. If I happened to see one, I would rush over to where the blank cassettes in our house lay and whip one out for the express purpose of taping the sneezes. [I married a man with] the most adorable stifled sneeze I've ever heard [and then divorced because] there was a hell of a lot more to making a relationship work than enjoying a great guy's sneezing over the weekends"

Achieving Equality in the Boardroom and the Bedroom

On August 26, 1920, the 19th Amendment to the Constitution was certified, thereby granting women the right to vote. To commemorate this critical day in women's history, in 1971 the U.S. Congress designated August 26 as Women's Equality Day. As explained ​by the National Women's History Project, the observance of this day "...not only commemorates the passage of the 19th Amendment, but also calls attention to women’s continuing efforts toward full equality."Gender inequality still exist in many realms in the U.S., as do many other societal inequities including (but not limited to) those based on sexual orientation, gender identity, disability, and race. When talking about racial inequities in the healthcare system, Dr. Peter Slavin made the brilliant and powerful statement that "There can be no quality without equality."  This applies to all realms of inequality. It applies to equality in a realm often considered quite personal: Sexual pleasure. As I say in Becoming Cliterate, "Quality sex is only possible with true sexual equality. We've never—at any point in Western History—had a time where the majority of the population valued women's way of orgasm as equal to a man's. It's time to change history." 

For the vast majority of men, the most reliable route to orgasm is penile stimulation (oral sex, intercourse) whereas for the vast majority of women, it is clitoral stimulation, either alone or coupled with penetration. Indeed, about 95% of women need some form of clitoral stimulation to experience orgasm. In Becoming Cliterate, I argue that our cultural silence, devaluing, and ignorance about the clitoris (our cultural illcliteracy), combined with other aspects of gender socialization (e.g., slut shaming), our sorely lacking sex education system, and false media images of women having fast and fabulous orgasms from penetration alone are fueling an orgasm gap. I provide data regarding this gap, including for example the striking statistic that 55% of men versus 4% of women experience orgasm during first-time hookup sex and that this gap closes, but still remains, in relationship sex. I argue that to close this gap completely we need both cultural and individual change. Cultural changes advocated include a linguistic sexual revolution—changing our language around sex and female genitals, and calling an end to slut and body shaming. Personal skills and information provided include information on women's genital anatomy, sex-positive thinking, mindfulness, learning one's own most reliable route to orgasm by "taking matters into one's own hands," sexual communication skills, and new sexual scripts to replace the outdated "foreplay, intercourse, game over" routine that we currently use.  All of this information is then reflected in and culminates in "Twelve Commandments for Orgasm Equality and Quality Sex."

I hope you will be inspired to follow these commandments in your own life (and as applicable, teach them diligently to your children, now or in the future). Perhaps you will even make a copy and display them where someone will see them or ask about them. (I recently had a friend tell me she displays Becoming Cliterate on her coffee table, just for this purpose—to spur conversations about orgasm equality and quality sex).Orgasm equality is certainly not the most critical or serious inequity that need attention on Women's Equality Day.  There are many serious and horrific inequities in our culture, some life-threatening to those who face them. Because of this, I've at times wondered if my quest to close the orgasm gap is worthwhile. I've concluded that it is. I've seen the pain, confusion, and sadness that comes from a lack of sexual pleasure, with many women even enduring sexual pain due to lack of knowledge or agency around their own sexual response. Closing the orgasm gap doesn't render the other inequities as less important and in fact, we can trace all gender inequities to the same root source. Feminists have long explained that the personal is political. The very personal lack of sexual pleasure that women have is no exception. What differentiates it from other inequities, however, is that with some simple knowledge and skills, you can close this gap in your own life. Do it today—in honor of Women's Equality Day.

Stamp Your Sex Fantasy "Normal"

Whatever your sex fantasy is with your partner, consider it to be normal.  People tend to go with "whatever works" to get aroused or to push themselves over the top.
No one reaches orgasm by fantasizing that they are holding hands with their partner during a romantic, moonlit walk on the beach. Your partner may be your best friend whom you love more than anybody, but it doesn't necessarily follow that he or she is the one you're thinking about when you're trying to rev up your arousal or have an orgasm.
Making love involves two people but having an orgasm involves a single individual who takes full responsibility for getting there. Some people sink into erotic sensation without fantasy. Other's open their eyes and have eyeball-to-eyeball sex. Other people latch on to fantasies that are as odd and quirky and far ranging as the human imagination in order to bring themselves over the top.

What you fantasize about may say nothing about what you actually want in real life. You may boot yourself into an orgasm thinking of your dentist tying you down and ravishing you in the chair, but you'd run for you life if that situation actually presented itself. Nor are your fantasies a measure of how much, or how well, you love your partner.
Fantasies are only fantasies. They evolve from a place in the unconscious mind that has nothing to do with your adult capacity for love and intimacy. They are not a sign of disloyalty to your partner, nor an indication that you are some kind of weird, sexual pervert.

Sex: Faking It

It's one of life's great mysteries, right up there with is there an afterlife and how do they get a ship inside such a tiny bottle. Research consistently shows that more than half of women resort to faking an orgasm at one time or another, even in long-term relationships. The question is why.
Empirical evidence is scant. Researchers surmise that women have many motives, depending on circumstances: to get the deed over with, to hide their own sexual insecurities, or even just to be nice. "A big one is protecting the male ego," says sex educator Betty Dodson. "A woman doesn't want to hurt her partner's feelings."
While nobody knows for sure what leads women to pretend, a study reported in Archives of Sexual Behavior offers a new theory: Women in relationships might be faking orgasms as part of a largely subconscious attempt to keep their partners faithful.
After surveying more than 450 women, a team of psychologists led by Columbia University's Farnaz Kaighobadi found that those who questioned their man's loyalty were far more likely to fake it in bed. Women who suspect they're with a cheater often engage in a number of tactics to hang on to their man, like monopolizing his time or flirting with others in front of him. Pretending to orgasm might just be one more mate-retention strategy.

Not everyone, however, thinks the threat of infidelity explains why women feign sexual excitement. Indiana University's Elisabeth Lloyd, author of The Case of the Female Orgasm, suspects that faking it has to do with changing cultural expectations. Historically, men have not cared about a woman's orgasm until recent times, she says. "Now we have a widespread belief in our culture that men like it when a woman orgasms," which means that women may feel pressured to either vocalize their pleasure or put on a convincing performance.
Women who fake it, in and out of relationships, may be responding to social pressure, say researchers at the University of Kansas. In a survey of college students, they noted a sexual script that both parties tend to follow. "Many women said that they pretended because their partner's orgasm seemed imminent," says Charlene Muelenhard, professor of psychology. "They generally endorsed a sexual script in which the woman was supposed to orgasm before the man, and when the man orgasmed, sex was over."
Sure, a few men fake orgasms, too, but why exactly anyone fakes it remains an open question. Whether it's to hold on to a mate or prevent embarrassment, most experts agree on one thing: Women should drop the act. "When a woman is really into sex and really having an orgasm," says Dodson, "an experienced man will know it—and there's not a bigger turn-on in the world."

Sex: Peak Experience

The most forceful explanation of recent years comes from philosopher Elisabeth Lloyd, who, in her 2005 book, The Case of the Female Orgasm, argues that there is a scientific bias toward seeing an adaptive purpose for it, and that every prominent evolutionary theory of female orgasm is in fact flawed. The most plausible explanation, she posits, is what's known as the "byproduct theory"—that because male and female embryos develop similarly in the early months of gestation, the same developmental processes that result in the male orgasm incidentally produce its female counterpart as well. Rather than serving any grand evolutionary purpose, this theory goes, female orgasm is analogous to male nipples.
Since Lloyd's book appeared, however, scientists have continued searching for an adaptive reason for female orgasm, and new evidence has slowly accrued to suggest that it might be more than a blissful byproduct after all. The most prominent explanation is that orgasm enables women to covertly evaluate and select high-quality males in order to ensure the fitness of resulting offspring. "There is still no definitive evidence either way," says David Puts, an evolutionary anthropologist at Pennsylvania State University and a leading researcher on the origins of sexuality, "but as new evidence accumulates, it generally seems to support the mate-choice hypothesis."
Puts offered some of that evidence in a study published in Evolution and Human Behavior in 2012. It reported on an experiment in which the female in 110 heterosexual couples on a college campus rated her partner's masculinity and level of dominance, while computer software objectively measured the male partner's facial masculinity and symmetry, markers of attractiveness and genetic quality. The results showed that women with more attractive partners had more frequent orgasms during or after their partner's ejaculation, a time window believed to be optimal for sperm retention. Women partnered with particularly masculine and dominant partners, meanwhile, also reported more frequent orgasms. Because of the correlation between orgasm and men of high genetic quality, researchers cautiously concluded that the results supported the mate-choice theory.
For female orgasm to serve a function in mate selection, it should also increase the odds of conception, an assumption that is hotly debated yet has also gained some scientific support. In 2007, a team of researchers led by obstetrician Georg Kunz at St. Johannes Hospital in Dortmund, Germany, examined the effects of oxytocin—the hormone that causes uterine contractions and is released into the female bloodstream after orgasm—on sperm transport. Study participants received a dose of oxytocin followed by a vaginal injection of a marked, sperm-like substance. Supporting the theory that female orgasm evolved to enhance fertility, oxytocin increased the flow of the substance to the dominant (egg-producing) follicle's oviduct during the fertile phase of the menstrual cycle, a process believed to increase the odds of conception.

There's evidence that orgasm abets fertility another wa
y—by reversing uterine pressure from outward to inward. The inelegantly termed process, "sperm insuck," is thought to push sperm into the uterus. Still others have suggested that the purpose of women's orgasm is to reverse the "vaginal tenting" that occurs during sexual arousal—a physiological change in which the uterus is pulled upward—by bringing the cervix back in contact with the sperm pool.
Yet scientists have been unable to reach any consensus, as other evidence emerges to cast doubt on theories like the enhanced-fertility function of female orgasm. In one paper, published last year in Animal Behaviour, researchers Brendan P. Zietsch and Pekka Santtila reported a study of 8,000 female twins and siblings. After controlling for a variety of factors, they found no correlation between their subjects' orgasm rates during intercourse and number of offspring. The pair, who also published a 2011 paper that challenged the byproduct theory, is quick to add that their more recent paper didn't eliminate the possibility of any adaptive explanation, but did contradict the enhanced-fertility theory.
"The correct evolutionary explanation of female orgasm might be one that has yet to be thought of," Zietsch says. "It remains a mystery." If researchers can agree on anything, it might be precisely that.
David Barash, an evolutionary psychologist and the author of Homo Mysterious: Evolutionary Puzzles of Human Nature, has been a vocal critic of the byproduct theory and personally hews toward a version of mate-choice theory that suggests that the effort and selflessness it typically takes a man to bring a woman to orgasm is what the female orgasm evolved to evaluate. It may signal his inclination to be involved in "something beyond 'bim, bam, thank you, ma'am,' which may say something about his willingness to invest subsequently in the outcome of children," he says.
Still another adaptive possibility Barash would like to see further considered is whether female orgasm offered prehistoric women, who faced a high mortality risk during childbirth, a subjective motivation to copulate. "Orgasm may be that extra carrot dangled in front of them while they're thinking, I really don't want to have sex, because I could ultimately die."
Puts, for his part, continues to focus on ascertaining which characteristics of a mate are related to women's orgasm frequency. He also hopes to see more work done to clarify whether female orgasm promotes conception. For instance, tracking radio-labeled particles through women's reproductive tracts to see how orgasm affects their movement "could provide strong evidence that orgasm helps transport sperm to the ovum," he says. The long story of understanding female orgasm has yet to reach its climax.

Orgasm Remorse: Does the Desire for Sex Erode Our Sense of Morality?

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You may be shocked by the risk Edwards took to his family and candidacy. You might attribute this behavior to the occurrence of men in power; power which compels one to take larger risks while simultaneously believing himself immune to discovery. I, however, analyze Edward’s infidelity through a century-old framework. The argument suggests that nature compels men, average men, to take sexual risks. The argument is that while we are (on the one-hand) in charge of and responsible for our behaviors, we are simultaneously not ‘fully’ in charge of our own sexual destiny. Our biological makeup compels many (perhaps most) men to seek short-term, selfish sexual pleasures; and that this has at least ‘some’ basis in our long-term survival. Our rational decision-making processes erode in light of our bodies’ constant campaigns to partake in carnal delight.

While conducting the research published in my book, The Monogamy Gap: Men, Love and the Reality of Cheating (Oxford University Press, 2012), I heard these types of risky cheating narratives from approximately 3 out of 4 of the 120 men I interviewed. Men who often cheated when there was a very good chance that word would get back to their partner of the offense. I call this type of sex the “oh shit, oh shit, oooooh shit” orgasm because the psychological framework goes like this: “that feels good. That feels really good! (then, the moment after orgasm)… Oh shit, what have I done?” In my research there was a common narrative: the desire for orgasm temporarily squashed their socialized (and deeply held) sense of morality.

My research highlighted that when the men’s bodies craved sex, they—not always, but every now and then—eroded at the intellect that normally governs the rational side of our thought processes. They recognized that they should not be doing what they were, but the consequences somehow seemed dim. It is the same psychological apparatus that influenced them to have unprotected sex, when they knew they should not. It seemed okay — somehow worth it—for this particular circumstance. They were, in effect, drugged by sexual desire.

 This is why I suggest that culture cannot normally prevent what our genes desire. Culture might win much, or even the vast majority of the time – but carnal desires will eventually triumph. It is this same notion that led one early 20th century sex researcher, Robert Park, to argue that, given enough time together, if two people desire sex with each other, it will occur despite social censure.

The “oh shit, oh shit, oooooh shit” orgasm likely represents internal orders from thousands of years of honed survival. With so many men cheating in my study cheating while simultaneously not wanting to cheat, I’m not willing to condemn them all as simply immoral. There is something else at play here.

Daily, multiple inherent biological drives compete with socially constructed notions of decency. The moment that orgasm happens, it is our culturally constructed ego that dominates; this is because the inherent drive has been temporarily satisfied. We feel guilt because society tells us that we should feel guilt. We feel remorse and shame because our instinctual actions have been socially coded as such. Once the carnal desire is met, the moralizing begins.

This battle between what the body desires and our socialized sense of morality wants plays out in other arenas, too: smoking, fatty foods, gambling, drinking, failure to exercise. It seems to land disproportionally on the side of what our genes desire when temptation is easy to obtain (such as food) and less with sex. But innate sexual desires nonetheless win out from time to time. Regrettably, whereas one can run a few miles to make up for eating a candy bar, the consequences of orgasm, as Edwards has learned recently, can be much more severe.

The point is: the desire for sex is so much a part of our nature that men unwillingly risk love, family, career—and in some Islamic countries—even their very lives for it. What would drive gay men to have sex in countries where they are killed for it? The answer is that it is human nature to pursue sexual pleasure, gay or straight.

So while it is certainly true that for Edwards to best serve his dying wife, he required greater obedience to his own notions of morality; when it comes to an inherent drives as strong as sex, millions of years of evolution have equipped us with a tool that socialized notions of morality cannot always handle. Thus, once we have that orgasm, and our deep-seated drives for sex subside, we are roused to the moral reality of our times, that this is not socially acceptable: oooooh shit!

Orgasms: From Solo Sex to Partnered Sex

The other day at Starbucks, I began chatting with a woman waiting in line for a caramel macchiato. She asked me what I do for work, so I told her that I am a relational and sex therapist. Her eyes widened, and her face lit up as though she had already had her coffee.
Then she leaned toward me and said: “I have no problem having orgasms when I’m masturbating, but I can almost never have them when I have (partnered) sex. Is there anything I can do about this!?”

You may be thinking this was an awkward conversation between strangers in a Starbucks, but I love that people feel comfortable enough to ask questions like this, given the opportunity. Unfortunately, I couldn’t help this woman during the time it took to make her caramel macchiato, but her question is one I am asked all the time, from across all genders and ages. The answer is, yes!

During masturbation, you may be able to relax and connect with yourself in a way that allows orgasms to happen. You may not yet know how to relax and connect the same way when you are with a partner.
There are many possible reasons that having partnered sex complicates things. During solo sex, there is no pressure to perform, or to have an orgasm, or to have an orgasm quickly, or to wait to orgasm until the other person orgasms. There are no distracting thoughts about your body, or your partners’ bodies, or what your partners are thinking.

However, when having partnered sex, there is more to think about. These thoughts distance us from our bodies, making it harder to focus on sensations, making it harder to sink into them slowly, to connect with them, to allow them to wash over us, leading us on a journey of pleasure (and maybe an orgasm).

Orgasms aren’t everything by any means. I’m a huge proponent of pleasure-focused sex, rather than goal-focused (orgasm-focused) sex. But if you’re able to have orgasms during solo sex, it can be very frustrating not to have them with a partner. If that is your goal, there are skills you can practice and strengthen during masturbation that will help you orgasm with a partner. By practicing these skills, they will then be easier to access when you have sex with a partner.

Practice the following skills while masturbating so that you can access them when you have partnered sex:
1. Pre-masturbation meditation: Before you begin touching your body and masturbating, do a deep relaxation meditation. I recommend using a guided meditation that leads you through a body scan. Being deeply relaxed increases the possibility of orgasming.

The link between anxiety and sexual dysfunction has long been established. If you are anxious, your mind will have many thoughts pulling you away from your body’s sensations and other elements of the present moment. Also, your body will be tight and tense, which interrupts the flow of sensations being created through touch and rhythm.

In order to be truly relaxed, your body needs to soften to allow sensations to flow and deepen. Your mind needs to be in a quieter state so that you can focus on sensations. Spending 5-10 minutes meditating before you begin masturbating will calm your mind and body.
2. Sink into your sensations: As you touch yourself, practice experiencing the sensations, rather than thinking about them. Thoughts about the sensations, such as, “That feels nice,” or “That doesn’t feel good,” are useful to guide you. However, it’s important to be able to be with the sensations without thoughts. This takes practice!

Allow the sensations to fill your body. Just notice them, and try to allow them to wash over you as you connect with them. Notice where they are, and follow along with them as they move and change. Try to allow them to be where they are, without judging them or evaluating them—other than to guide your movements. Practice sinking deeper into the sensations.

3. Release tension and tightness in your body: As you are touching yourself, pay attention to your body. Notice areas of tightness. You may notice that you are holding your shoulders up or back. You may notice that your breath is shallow. You may notice that your stomach muscles are tight.
While touching yourself and experiencing sensations on and/or in your genitals, repeatedly check in with your body. When you notice tightness or tension, take a deep breath, let it out with a sigh, and literally sink into the bed, couch, chair, or floor beneath you. Let yourself be held by what is beneath you, rather than trying to hold yourself with tightness and tension. Practice allowing your body to let go of tension and soothing yourself with a few deep breaths.

4. Practice shifting back into your body again and again: Each time you notice that your mind has wandered to thoughts, it is an opportunity to shift back to experiencing sensations in your body; it is a chance to reconnect and sink into yourself.
Your mind will wander, as that is the nature of our minds. Noticing that you’re thinking, letting go of the thoughts, and shifting back to sensations is the practice. The goal is not to stop your mind from wandering. It is to be willing to bring your attention back to your sensations over and over again, without judgment.

If you’re a porn lover, that’s great! But for the purpose of strengthening these skills, it is necessary to turn off the porn so that you can practice being entirely present with yourself. If porn really does it for you, and you don’t like the idea of turning it off, I suggest that you practice masturbating without it at least every other time you masturbate. On the alternate time, bring back the porn.

Once you’ve strengthened these skills during masturbation, you will be able to access them more easily with a partner. These skills will make it more likely for you to have orgasms with a partner by helping you stay present, connected with your body, and relaxed! It will take time to build these skills, as is the case with any new skills you are working on. Practice, practice, practice!