Could “mommy porn” have value in the doctor’s office? Unless you live in a cave (and we physicians sometimes do), you have heard of British author E.L. James’ modern erotic 50 Shades of Grey trilogy, 30-plus million copies sold, overwhelmingly to women. The trilogy is an erotic love story about a naïve college graduate who rescues an abused billionaire – a blend of the Story of O, Pretty Woman and a Danielle Steele novel. Not great literature, but clearly having some effect on the libido of millions of women. Do we finally have a safe and affordable clinical tool for women with blunted libidos and hypoactive sexual desire?
The prevalence of decreased female sexual desire and responsiveness has been estimated from 15 – 53%, higher in menopause and perimenopause. In one study, half of women with these symptoms spoke to their doctors about the problem, yet doctors have very few tools for women with hypoactive sexual desire. The phosphodiesterase inhibitors (nitric oxide agonists) such as Viagra increase genital circulation and can effectively treat erectile dysfunction in men, but have shown no benefit in women. Testosterone patches may increase sexual desire and satisfaction in both surgically and naturally menopausal women, but side effects can be uncomfortable, and long-term safety has not yet been established. The jury is still out on the effectiveness of adrenal hormone DHEA replacement, and herbal remedies such as gingko biloba.
So into the office walks a middle-aged female with a normal amount of stress, in a relationship that is comfortable but not passionate, and she wants her mojo back. Where does the doctor start and what is there to offer?
First, the differential diagnosis for diminished sexual desire and responsiveness in women: stress, relationship problems, depression, diabetes, endocrine (thyroid, prolactin, sex hormones), medication side effects (particularly antidepressants and blood pressure medication), vascular disease, nutritional deficiencies (and side effects of too much junk food), substance abuse, past history of trauma for starters. Eventually everything correctable has been corrected, you and your doctor have made a joint decision about the pros and cons of hormone replacement therapy … and still … no fire. Now what?
Think the missing hormone … oxytocin. That old induce-labor bag of pitocin IV hung on all those moms-to-be who weren’t progressing. Oxytocin, a major player in female sexual desire and responsiveness, released during any kind of cuddling – romantic, parental, puppies, and released during orgasm. And most importantly, released while reading romantic, erotic literature. But oxytocin blood tests are largely experimental and oxytocin replacement is not easily available at the pharmacy. How do you know if you have an oxytocin deficiency, and if it can be behaviorally corrected?
You take the oxytocin challenge test – read the entire Fifty Shades trilogy (all 3 books) in one week’s time, and see how you feel. (Don’t stop at the first book, it takes the next 2 books for the desired effect).
One middle-aged woman reported her animals sat next to her while she was reading, and she felt more connected and cuddly, but it didn’t save her relationship. She realized her lack of sexual desire was not physiological, but a result of relationship issues.
A younger woman reported more intense bonding with her young children and husband, and the “biggest orgasm” of her life.
A post-menopausal woman reported that she started to feel desire for her husband again, and had an increase in frequency of intercourse “like 20 years ago,” without hormone replacement, and with no change in their marriage. (He was delighted).
No meds, just books.
The key to the success of these books in women is not the abundant sex scenes, but the romance, and the massive release of oxytocin women experience as a result of immersing themselves in the “love” part of the book. Hearts and flowers increase desire in women; thus the success of the “chick flick” for dates.
Let’s face it. Pornography, written and visual, has existed forever, but remains a greater male stimulant than female. That difference is driven by physiology – women are not aroused by visual pornography to the degree that men are aroused. Male libido is stimulated more by visual and tactile erotic images and sensations – leading to a massive release of norepinephrine (energy/aggression) and dopamine (pleasure/reward). For men, increases in dopamine and norepinephrine appear to play a greater role in arousal than in women, whose arousal seems to be largely oxytocin driven.
What about men? Is there a diagnostic and treatment role for Fifty Shades and the like genre? As a sex manual, Fifty Shades has merit as a “touch here, kiss there, try this” benefit. As a male turn-on … maybe, but don’t count on it. Cuddle? Pleasant, but not erection-inducing.
Is there anyone who should NOT read the Fifty Shades series? Yes – it may be too intense for younger women, even if sexually active, and it may be a trigger for women with sexual trauma or abuse histories, or it may simply be offensive. That said it’s certainly worth having a conversation with your doctor, and maybe getting a prescription for the bookstore or the library (if the waiting list isn’t too long!). You’ll love your doctor in the end.
This blog was originally posted on kevinmd.com
I am on an Obesity Mission. I’m going to single handedly (with lots of great help) change the way we treat obesity. And the way we treat obese people. The following is an open letter to all the skinny doctors, trainers, dieticians and therapists in the world …
WITH ALL DUE RESPECT DOCTORS AND COLLEAGUES…YOU ARE WRONG ABOUT THE MEDICAL EVIDENCE!
Listen up. (That’s me BEFORE circa 2003). A fat doctor. Imagine. (Scroll down to see the AFTER).
Obesity is NOT simple thermodynamic imbalance. It’s not how many calories we eat and how little we exercise. That may be true for people who are overweight and have 20 or 30 or 40 pounds to lose. Any diet and exercise program that is basically healthy nutrition and movement will work for them; it’s just a matter of matchmaking – the right program for the right person.
For the rest of us, the obese…Eat Less Move More fails 95% of the time. Worse yet, severe restrictive diet and exercise may worsen, not improve, the obese person’s health. Emotional Eating and Behavioral Control don’t fare any better, but at least they don’t ruin someone’s health!
Here’s me with a recent 2010 AFTER (down 100 lbs). Winning an award because I figured out how to lose weight and how to apply that knowledge to every patient I see and how to teach to anyone who will listen. (Thanks Kaiser!)
Here’s what I know about Obesity. I’ll share it all with you in the hopes that you will go back to your exam rooms and order some labs for starters.
Obesity is a medical condition of serious inflammation, chronic pain, disordered endocrine function, changes in insulin metabolism, altered brain chemistry, food sensitivities, serious vitamin and mineral deficiencies.
Obesity is a psychosocial condition of depression and hopelessness and isolation and loneliness.
Obesity is a spiritual condition of broken hearts and broken souls and broken families. It’s not how we feel inside, but it’s how the outside sees and reacts to us. It hurts to be fat. Physically, psychologically, socially and spiritually.
Now…does that sound like gluttony to you?
Yet, if I go to any one of you, even the most esteemed physician or medical center, you will tell me Eat Less, Move More. Or you’ll send me to your behavioral health department because clearly there’s something wrong with me. There I will receive medication for depression and six weeks of therapy about how I’m a good person and I should love myself and not eat chocolate. Or you’ll throw up your hands and say I can have surgery, but I’m not sick enough to qualify yet. Wait a few years.
You can treat obesity, it’s easy. You already know how. But it’s not Eat Less Move More. And it’s not emotional.
It’s replacing Vitamin D, detecting Vitamin B12, A, Zinc, Iodine deficiencies, finding food allergies even when the lab tests are not sufficiently sensitive, treating pain and weakness with gentle movement therapy, jumping on that sleep disorder, correcting inflammation and insulin resistance, helping that sluggish thyroid, changing obesigenic medications to those with a more neutral weight profile. And yes, sometimes it’s sending us to behavioral health, but not nearly as often as you think.
You can treat obesity by understanding the many pathways and reactions that have been altered in response to excess inflammatory adipose and its causes. And one by one, correcting them. Just like you learned in medical school. Imagine that.
And I’m here to tell you, if you do that, your patients will lose weight. And feel better. And love you forever.
Announcing the opening of Stein Wellness Centers in May 2011, dedicated to comprehensive and integrative treatment of obesity. In person and distance.
Offering free consultation to any medical professional.
See one, do one, teach one.
Sara Stein, M.D.
Stein Wellness Centers (opening May 2011)
http://SteinWellness.com (under construction)
(An obese psychiatrist analyzes an obese comedy, A Matter of Size, the heartwarming story of four obese Israeli men and one woman who decide to quit dieting and become Sumo wrestlers)
They had me from the opening scene. The obese little boy gingerly lifting his foot, hoping the scale will drop down a bit at the school weigh-in. Thirty years later, morbidly obese, single and living with his mother, taking off his watch at the diet club weigh-in wishing that an ounce will matter.
The loving, interfering, nagging, long-suffering, conflicted mother. Why are you eating that, she asks him as he unloads the refrigerator in the night. He argues until she begrudgingly gives in, if you want there’s rice to go with it.
The brand new pants in the used-to-be right size that fit like sausage casing.
The diet club. The misguided skinny diet director who thinks tough love and sarcasm will make fat people lose weight. That’s because we haven’t had enough bullying in our lives.
The looks, the nasty comments, the derisiveness, defensiveness, the loneliness, the rejection.
They had me back in my childhood, in my adulthood, in pain and embarrassment and agony. I felt so badly for the people in the movie. I felt so badly for me. Obesity is the heart of loneliness.
And then everything changed. These weren’t fat suffering people. These were resilient, strong, courageous people. People who took lemons and made lemonade. They fell down time and time again, and picked themselves up from the insults and the sneers and the disdain. Just in order to have a life and love and happiness. Out of obesity came sumo.
Obese people kissing on the screen. Fat people in love. In tears and fears. With hopes and dreams. Imagine that.
A film that depicts obese people the way we are… simply human beings, divine creations, with perfections and imperfections that allow us to stand out as individuals, and combine into relationship and community.
A film that depicts our struggles the way they actually exist.
In all of my pounds and all of my years, believing I deserve a good life has been my biggest struggle. Losing those pounds one at a time did not increase my feeling of worth.
What changed my life was accepting those pounds. One at a time. And allowing those same pounds to leave – one at a time – because they no longer represented who I was inside. The essence of me was not how my body looked or acted or felt. The essence of me was how I loved and cared and created. The essence of me was not fat. It was life.
And for that reason alone, obese people
Deserve love in our relationships
Deserve success in our endeavors
Deserve respect for our efforts at making a life.
“My heart is not a muscle.” My soul is not obesity.
The lesson of sumo, and of comedy, is acceptance and deserving…and seeing the divine romance of it all.
Dr. Stein will be facilitating a community discussion on obesity following the screening of A Matter of Size at the Cedar-Lee Theatre in Cleveland, OH on October 9, 2010 beginning at 9 pm. Please join us!
Stress is society’s greatest modern affliction. We have completely lost control of our workdays. A workday used to be dawn to dusk. It used to be from the time you arrived at your workplace until you went home. It used to be 5 days a week. Not anymore. We work constantly, 24 hours a day, 7 days a week. We work at our jobs, in our homes, at school, in traffic, at the grocery store. We work shopping on the Internet.
When we are resting, we are working: making lists, setting goals, reviewing today, and planning for tomorrow. We are not resting.
We continually increase our workload because work is addicting. We physically experience an increase in adrenalin, and energy and focus that expands our productivity. It’s a rewarding feeling to do a good job at something.
We add more work so we can feel even better. We start multi-tasking: the dishes, and the laundry, and the homework and the science project.
We add more forms of communication: television, radio, email, Internet, regular mail, newspapers, magazines, cell phones, voicemail, text messaging.More lives to keep track of, including people we don’t even know. Pretty soon, there is no time and we are multi-tasking every task, including some that should be enjoyable.
We read while we eat, we talk while we drive, we work on three things at once. Simple pleasures are eroded by a sense of urgency and the need for more adrenalin to keep us going. No time to say, “Hello”, “Goodbye”.
We work this hard because our society sets up overwork as a model of success. “Supermoms”, mandatory overtime, full-time students with full-time jobs.
One day I saw a 40-ish single mom who was working two jobs, going to school full-time and raising her children. She was exhausted, stressed, depressed, gaining weight and forgetting things.
“Why are you doing all of this”, I asked.
“For my kids, so I can get a better job.”
I looked at her without any humor, and replied, “If you live long enough”.
We are operating at a level of INTENSITY that causes DISEASE.
We have lost our ability to play, and live and love. We have lost our ability to experience emotion because we are so busy working. We have lost the ability to relax, and think and be alone with ourselves. We have lost the ability to feel content with our circumstances. We have forgotten how to look at the sky and wonder about the stars.
We have lost the ability to experience emotion when we are under severe chronic stress.
Hard at work and numbed out to everything and everybody.
When it’s time for me to relax and have fun, I often cannot. Unless I eat. Then I relax. The food pours out dopamine and GABA and serotonin and acetylcholine into my parched brain until I am positively serene. Am I relaxing because I’m healthy? Or am I relaxing because the food just drugged me into forgetting what I was doing.
For the five or ten minutes that you are stress-eating, your brain is transported to a lower-stress zone. You give your body, your brain, and everyone else in your life a break from the jagged energy you are projecting.
If you are eating all the time in response to stress, “all the time” is simply a reflection of HOW STRESSED YOU ARE!
Just in case you thought this was only about your own personal stress, there’s more. You can also absorb other people’s stress, particularly if they are close to you. Stressed people have a tendency to pour out their problems in rapid-fire succession, one after another, with great energy and emotion.
Relief from stress is about learning to say no: no to demands, no to internal goals, no to family expectations, no to overzealous work projects. Saying no does not mean quitting your job in a bad economy, nor does it mean walking away from a difficult supervisor and getting fired. Saying no means acknowledging your physical and emotional limits and respecting them.
Relief from stress is about recognizing your body’s signals. When you cannot sleep, and you cannot relax, and you cannot stop thinking about work, you are overworked.
The solution to stress and overwork lies in learning and practicing proper endings. To be able to say this is my workday and I am now off. This is my homework time and it is now over. The day’s work has ended and this is my sleep time. This is my stress, and this is yours and I cannot accept it. These are boundaries, yours, mine, and ours.
The solution for stress is to recognize that for your body, rest is as essential as exercise.
For your brain, quiet is as vital as thinking.
For your spirit, solitude is as healing as company.
The solution to stress is to accept your humanity and all its limitations.
excerpt from Obese From The Heart: A Fat Psychiatrist Discloses ©Sara L. Stein, M.D 2009 http://obesefromtheheart.com
This is the question I am most often asked. My patients come dragging in reluctantly, sent to Obesity Clinic by the primary care doctor or their own frustration and failing health. They are certain they will be given a lecture and a diet or told to go have surgery. They are surprised when they leave my office with directions to eat chocolate, take these supplements, get some more rest, and stop working out so hard.
“WRONG” says the medical world and the diet industry and every magazine you read. Restrict your diet! Quit eating things you crave! Work out harder! No pain, no gain! YOU MUST SUFFER!!!
Puhleeze. As if obese people aren’t already suffering. Apparently all those skinny trainers and nutritionists and doctors think we were having a great time during those lonely nights by the refrigerator or trying to run in gym class with our thighs chafing.
I have news for you if you are obese. You have suffered enough. You have struggled enough. It isn’t difficult to lose weight, it’s just different than what you have been told.
By the time a person has become obese, they have an ailing body, even if there are no visible end-stage diseases such as diabetes or hypertension. Pain, inflammation, changes in metabolism, nutritional deficiencies, altered brain chemistry. It’s not fun to be morbidly obese. It hurts physically and emotionally.
If you push a broken body (or a broken car) too hard, it breaks down further. To your body, exercising and nearly starving feels like incredible stress. So does divorce, bankruptcy, unemployment, problems with your kids, or working two jobs. Your brain doesn’t make a distinction between one bad stressor and another bad stressor. To your million-year old brain, bad stress means the famine is coming. (Remember that one? 7 lean years?) “OMG,” says your brain to each one of your body’s many trillion cells, ”We’re starving to death…HOLD ON TO OUR FAT!!! We need it!”
Ever see the program where the fat people stop losing weight as the workouts get harder, until they go home, relax and eat? It’s called stress relief.
Welcome to the No-Stress Zone. Here’s where you start, and this is the first of many blogs that will help.
You start by determining what very small change in your food you can make today that will not send your brain into a starvation frenzy. If you drink 5 sodas a day, can you drink 4 and one water? If you skip breakfast and binge every night, could you move a little food earlier in the day? My first change was drinking coffee instead of lattes. And if I really wanted a latte, I would have one.
Next, what movement can you do that WILL NOT HURT?? Can you stretch a little in your chair? Can you walk a little? I started out cycling my legs in the bathtub – it was the only place I didn’t have pain.
Finally, what joyful or relaxing moment can you treat yourself to today? When’s the last time you heard music you loved, or called someone you care about? Or took 10 minutes to read something beautiful?
And when you wake up tomorrow, do this again. A little further. A little longer. And again the next day, and the next.
That’s the secret to losing weight with obesity.
Small, easy, sequential changes that add up over time. And give your body and your mind a chance to heal with each small adjustment. From my husband who lost over 100 lbs: “Tell them this is the first of many small changes they’ll make, and they’ll be surprised how easily they rack up.”
Now that didn’t hurt, did it?
What difference does it make if a fat producer is kicked off an airline? Isn’t that a private issue between the passenger and the company? If he didn’t fit in the seat, he should get off the plane, right?
This one had me from the first tweet. Even if I had to ask my husband who is Kevin Smith other than a guy with 1.6 MILLION followers on Twitter? (Answer: a producer of movies that teen & 20 & 30-somethings love).
A lifelong big guy, returning home after speaking at MACWorld, is seated as a standby on a Southwest Airlines Oakland-to-Burbank flight and then summarily ejected because he is a “safety” problem. One that involves the width of his body in his seat. (I still don’t get that one, what’s the safety problem?)
Of course, they saw his body habitus when they ticketed him at the gate for standby. They sized it up again when they seated him. They saw that his seatbelt fastened without an extender and his armrests went down. They polled the two ladies on either side who didn’t object to his presence.
Yet they made him get up from his seat in front of 150 watching people, retrieve his carry-on luggage from the overhead compartment and get off the plane. Like the bad kid being sent to the principal’s office.
And he was FURIOUS!!! And tweeted all night long.
I’m pretty confused about this. I like Southwest. I fly them, their seats are comfortable, their service is pleasant. They were extremely nice to my 88 year old father who needed some extra assistance last fall. But I am also a person with lifelong obesity. And there have been times in my life, 90 lbs ago, when I needed a seatbelt extender. I did my best to stay within the boundaries of my seat and be invisible and non-offensive.
So why can’t the airline just say they screwed up?
Instead Southwest has created a public relations disaster in which they blog their apology by making fun of his comedic character “Silent Bob” and his real-life angry persona. They titled their blog “Not So Silent Bob”, and defended their customer size policy while intimating that his badmouthing the airline publicly was oh-so-unfair. Unfortunately, they also explain the parameters of the customer size policy which, in this case, appear to have been applied arbitrarily if indeed he successfully buckled and put his armrests down. I’m guessing he was profiled more on his hoodie & pants-on-the-floor look than his actual size.
Blaming the fat guy for discussing the anger-causing events never works well for the merchant. You’d think they would just say, “we made a mistake, you fit in the seat, we’re really sorry, we misapplied the policy, we’ll make sure it doesn’t happen again”. Doesn’t require they rescind the policy, just acknowledges they were overzealous in its application.
The story doesn’t end there – it gets worse.
Smith put up a long, rambling, profane “Smodcast” (his name for his podcasts) of the events. The ‘AHA!’ moment occurs more than 50 minutes into the rant.
On the next flight, he had two paid seats of his own. An obese young woman was seated in the third seat; his paid-for, empty middle seat between them. After she was seated and settled, the attendant took HER to the principal’s office. Where she was told that she had to ASK PERMISSION from our fat producer to spill over into his empty seat, or she would be ejected too. And next time, she should purchase two seats. Different flight, different crew, different passengers (except for our angry producer).
Bullseye! Kudos to the airline. You have now effectively destroyed the very shaky self-esteem of yet another fat person who will invisibly skulk away into the night in shame, never to fly your airline again without paying double.
Now I’m furious. Once is a misapplication of a policy. Twice is a pattern of pointless and opportunistic discrimination. No wonder they didn’t apologize. They feel righteous in their contempt for adiposity.
And so do hundreds, if not thousands, of commenting passengers on forums, blogs, tweets. Thousands are in support of the producer (and by proxy, the woman on the second flight); some vow to boycott the airlines forever. But thousands others have seized the opportunity to be venomous and verbose slayers of fat people. (often anonymously, gee I wonder why).
The language is at best intolerant and unforgiving. Those are the people who are talking about being uncomfortable on an airplane. They have a point, although it could be expanded to include passengers who drink, smell of cigarettes or perfume, have screaming babies, or crack chewing gum among other encroaching habits.
At its worst, however, the language in these comments is frightening and revolting, almost horrific. If you changed the word fat to black or Jewish or female or gay or Muslim….the rhetoric would sound illegal. These people aren’t commenting about their crowded seat. They are taking the opportunity to express mindless, revulsive hatred against a group they feel is inferior to them.
Southwest needs to take a step back from this sizeable group, and from their uneven and discriminatory enforcement of “customer size policy”, and return to the idea of helping ALL people navigate the often difficult world of airline travel. With dignity and respect. Just the way they treated my dad.
If you have been a victim of obese discrimination, you are not alone. It is the last unanswered prejudice. Do what Kevin Smith had the bravery to do. Tell your story, even if just to a friend or a family member. Be assured that you do not deserve to be hated or hurt because of your weight. Or your skin color, religion, sexual preference, gender, political beliefs…
So to answer the question about why we should care because a fat producer got kicked off a plane…
Maybe we should care because it is uncovering the worst in us, both individually and corporately.
Sara L. Stein, M.D.
Author, Obese From The Heart: A Fat Psychiatrist Discloses (2009)
Today at noon First Lady Michelle Obama unveils a new Nationwide Initiative on Childhood Obesity. About 1/3 of our children are overweight, 1 in 5 are obese. In some states, the numbers are nearing 50%. These numbers go up as people age. Currently 60% of adults in our nation are overweight and 30% are obese.
Clearly this is a progressive condition. It’s getting worse. We’re getting worse. More people are getting fatter and sicker as they get older. The prevalence of obesity has risen 3000% in the last couple of generations. That is NOT an explosion of genetic illness.
It is convenient and absolving of responsibility to think that our DNA is causing obesity. While there are genetic obesity syndromes, they are rare – estimated at 1 in 7000 obese people. These syndromes present very early in childhood and are often accompanied by other developmental conditions. That means that 6999 out of every 7000 obese persons have to find another reason for their overweight besides their genes!
The genetics of obesity is how your body distributes fat, and what shape you are. Apple vs pear is genetic. Gaining weight as a result of eating too much is not.
Still, for those of you who insist on genetics as a cause of your obesity, you’re right. Sort of.
Most of the genetics of obesity involves on-off switches that regulate metabolism, inflammation, energy. Low quality foods, nutritional deficiencies, artificial additives and preservatives can flip the gain-weight or the do-not-lose or even the burn-calories-slower switch. If you are obese and dieting, it may not be your imagination that you are not eating much and still not losing weight.
Obesity IS generational and familial and cultural. We become overweight because we are served certain foods in an environment that encourages us to eat. It might be low quality food, or it might be the highest calorie home cooking of our dreams. We overeat because we attach meaning and emotion to our food, whether it’s the SuperBowl, Christmas or a funeral. Quickly we learn to use food to regulate our emotions, our energy, our happiness on a daily basis.
What about exercise? You need it! Your body is designed to move, and without movement, you become ill. It gets better though. When you combine healthier foods with movement, those on/off gene switches go back to where they are supposed to be, and your body weight begins to readjust. It doesn’t take starvation and boot camp and pain. It may just take a few less preservatives, a little more home cooking, and a walk after dinner. And a good nights sleep.
So what do you do for you and your children and your family? Here’s the good news.
If you come from a family that has always used food as a measure of the joy and sadness of life, try music instead. Use food for fuel, not emotional fullfillment. Use love as comfort, not ice cream. Use movement to blow off steam, not potato chips. Use prayer and meditation to find your bliss, not cookies. Use your family as your support, not your frustration. In the end, all we have is each other. With or without the meal.
Now you can live with that, can’t you?