#35 | Sex: From Pain To Pleasure: Interview with Women's Physical Therapist, Dr. Lauren Crigler

So a lot of people are coming to me for either painful intercourse or they come to me because they have really low desire. And there is actually things that we can be doing differently with our pelvis and mindset for sure. I'm working on desire. And then the other one is low pleasure, like you just like this just doesn't feel good, doesn't hurt, but it's not getting you there. You're not getting the big O at the end.

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Sex after childbirth, the topic everyone's thinking about but doesn't want to bring up. Whether it's pleasurable or painful, we can put a lot of pressure and guilt on ourselves to do things a certain way or in a certain time period. Dr. Lauren Crigler is a sexual wellness therapist specializing not only in pelvic floor physical therapy, but also in helping couples have more pleasure and connection during sex physically and emotionally. talking to women about painful intercourse, feeling disconnected from their partners or feeling too exhausted to even think about sex is Lauren's everyday life.

So Lauren, thank you for being here with us today. And and before we get into the hot topic of the day, can you just tell us a little bit about the pelvic floor, explain to our listeners what the pelvic floor anatomy is, what it's made up of a part of the body and give us some background there.

Yeah, sure. So I always say that pelvic floor is basically what you sit down on, because that kind of clears it up for most people that, you know, when we look at the bony things in the pelvic floor, you have things like your pubic bone and the back of it would be your cock six or your tailbone. And then you have sit bones on either side. And then there's all the fun structures like your labia majora menorah, you know, the bigger and smaller parts and then, you know, of course, the super fun parts like the clitoris and the vagina. You know, the anus to goes that far back. So even men have a pelvic floor, what are some of the most important functions of the pelvic floor?

Yeah, so one of the really important functions is regulating all the ins and outs, you know. So if you want to be, you know, being able to release the pelvic floor so that you can be when you want to, and also not be when you don't want to write the same with You know, having a bowel movement, you know, it's really important that, you know, some people I see would have difficulty initiating about movement, you know, or they have constipation issues, and sometimes it's what they're eating, but sometimes it's the pelvic floor. And then of course, one of the ends would be you know, during penetrative sex that, you know, you'd want to be able to relax the pelvic floor enough for that to be a comfortable, you know, and fun experience instead of, you know, not so good experience like some of my patients are experiencing. But the other main function of the pelvic floor too, is just holding up all the organs inside your pelvis. So without that, that's when you get pelvic organ prolapse, which is, you know, pretty common among women, especially women that have had children.

And your focus is primarily in pelvic floor sex therapy, is that right?

Yeah. So a lot of you know, I do work with all those other issues as well. Secondary issues, to, to women's needs. But the main area that I work in is with sexual wellness. So a lot of people are coming to me for either painful intercourse, or and that could be like so painful that you can't have sex or it could just be you're having sex, but it hurts. Or they come to me because they have really low desire. And there is actually things that we can be doing differently with our pelvis and mindset for sure. I'm working on desire. And then the other one is low pleasure, like you just like this just doesn't feel good. Doesn't hurt. But, you know, it's not getting you there. You're not getting the big O at the end. Mm hmm.

All right, let's talk about all three of those. Let's take them one by one. So let's start off with painful sex. Can you describe where the pain is for women and what's causing it in many cases, where the pain is, varies from woman to woman, and that's something I'm always trying to decipher. So I do a lot of online coaching. And so I'll ask somebody, well, at what point does it hurt? Does it hurt with initial penetration? Does it hurt with just touch before there's even, you know, something trying to push in? Or does it not hurt until it's very deep? And all those things? Tell me a little bit about what's going on in the pelvic floor. And then also, I asked what positions it's painful and because sometimes, you know, if you flip over and it goes away, then we Oh, okay, well, then that must be in the back of your pelvis and not in the front. And that tells me a lot too.

How many women do you think out there actually are suffering with painful intercourse? how prevalent is it in the population?

So that depends on who you ask. In medical studies, 20% of women have pain with intercourse, in cosmopolitan, and those sorts of you know, surveys, where I think people are a little bit more open 40%. The thing is, in medical studies, they use qualifiers So for example, if you have pain with sex, but you're still able to have sex, you might not count. So it is like, functionally she's able to have sex or if you're able to have if you're able to have sex, and it doesn't change the frequency of how often you have sex, like so you just suffer through it, then you don't get counted. So I think that's part of the lower number with medical studies versus surveys.

So that's a lot of women. And what Yeah, causing the pain in some of these cases, what exactly is the dysfunction underlying the pain?

So that again, varies from person to person. Some of the women I work with have had trauma, and that could be you know, sexual abuse types of trauma. Some of the women I worked with have had damage and injury during pregnancy. That's probably the number one reason why I see patients with pain. And then I actually have a good number of patients though that have never had sex. So they have like primary dyspareunia, which is let they've never been able to have sex ever. And so because it hurts because it's so painful. Yeah, yeah, that just, it just won't go, you know, wait, wait, why would that be happening? How does that? How would that happen? It looks like literally penetration cannot even occur. So why would that be?

Usually with those women almost always it's because their pelvic floors are very, very tight. What would cause that tightness.

A lot of it can be stress anxiety, like I relate the pelvic floor a lot to the muscles at the top of your shoulders. So when we are stressed, we raise our shoulders, right? And if you think about your dog or your cat, if they get scared, and it's like that moment, their shoulders go up, their tail tucks under, we do the same thing. Our shoulders go up and the muscles that would pull our tailbone down, they those muscles are attached onto our tailbone. Ours just isn't long, so you can't See it, but it would tuck under our pelvic floor contracts. Now that's fine if it's at that moment, right? But when it goes beyond that and you're stressed and you've been sitting at your computer for four hours like that, then you know you walk away with shoulder pain sometimes because you you feel like you just can't let go. The problem is when that happens in the pelvic floor, you can't see the difference. So you don't really know that that's happening. If that makes sense. And you don't feel it like you do with a stiff neck or tight shoulders right. You wouldn't necessarily feel that ache. Right, well, some women do wind up with chronic pain. But other people know they are walking around just like people walk around with their shoulders two inches too high, you know, and they don't have pain. So some women are also having pain because of tightness and our pelvic floor again, just, you know the same reason why women might not be able to have sex. They also sometimes just they can have sex, but it's so tight that they can't relax. And what happens is, the minute we experience pain, we tighten up. So we, it makes the problem worse, unintentionally, it makes it even more painful. So, and usually by the time someone comes to me for help, they've had months if not years of bad habits and kind of doing the wrong thing and reaction to pain or and so fear also sets them it's almost like a muscle memory thing. Like where they're conditioned to have those muscles tight. And if they the longer they wait, the more the muscles. Yeah, get used to staying tight. Yes, yes. In fact, I talked about that, like this is your pelvic floor is new normal, it's higher than it should. And so we have to train it to get down to you know, it's like the opposite of kegals. People say cake. Okay, okay, all the time. Like, you know, when people hear what I do, they're like, Oh, I bet No, you do. He goes all the time.  No, I don't.

so you're trying to do the opposite of the kegal and actually relax the pelvic floor. Right? Right. So if it's not muscle tension, but it's something related to pregnancy or birth, can you help us understand why that pain would come about where that comes from?

So I think I mentioned abuse and pregnancy. So with pregnancy, it's like the, the weight of the baby alone can put just a lot of pressure down on the pelvic floor. And sometimes people are either have no contraction to it, so it stretches out a lot more than it should. Or and those are the people who wind up with prolapse, you know, or they do sense that and they're contracting all the time in response to it. And that also sets up problems. It's like any other muscle in the body. We want them also to be strong, but relaxed. You know, like if you see this people who walk around the gym and they look like gorillas and they're really muscular, but they can't put their arm, either sides. Like that's not healthy. We want to be strong.

We need yoga for the vagina. Yoga instructor will bring up the pelvic floor in certain poses. Yeah, but I'm still curious about birth related pain when when you say trauma Do you mean tearing in the vagina or so it's interesting because sometimes I see a lot of issues after pregnancy and somebody who's had a C section, so clearly, it's not just having a vaginal birth and having that sort of trauma, but it definitely is, you know, a little bit more common if they've had a lot of tearing a lot more common if they've had a lot of tearing, especially like a, you know, grade three or four laceration if you've got tearing, you know, back to that Enos for people who don't know what a grade four is, you know, that's, that's going to cause a lot of issues. But again, there's great treatments. I love walking People through how to solve that with them. And if their partners willing how to solve it with them and their partner, like, telling them how to do hands on things that will, will help them through that. Meaning release the scar tissue or relaxing the muscles both Mm hmm.

Yep. And how, how they can start to have this conversation about that. And here's the the cues that you're going to use physically inside. And also, you know, here's how you're going to respond. And so I have this plastic model that I'll show people, you know, and this is what you're going to be doing inside it's actually, you know, something that I wouldn't even be able to show someone in person because if I were doing this on a real person, the minute my finger was inside, you wouldn't know where it was. Right? So when I have a plastic model that I can actually then tip forward and you can see where my finger went inside the pelvis. If that makes sense. That's really, that's really helpful. And what I love, I know you're probably going to get to this later, but I love it. Working with couples and walking them through that because I say I swear your relationship will be so much better because you've had to struggle with this. Because most people don't. They don't know what the word pelvic means. They don't know what half the things down there are. They don't talk about sex, they don't talk about anything about sex. And so having this great conversations with your partner, you know, I think your relationship will wind up stronger than it ever was. So that's a silver lining.

It's always interesting to imagine that some couples can have sex but can't talk about, oh my gosh, that is so conscious and so ironic when you think about it, because you would think that the greater intimacy lies in the having of sex, and that talking about it would be easier and a precursor to it. But that is not necessarily the case.

And that's why their relationships got so much better once they go through this type of counseling and develop those skills to actually talk about that.

And let's talk about that a little bit like what is going on emotionally for women. That stage when they talk to you and tell you they're not talking to their partners. I mean, can you talk about what's happening emotionally when women are going through this?

Yeah, it depends. Because the women with pain, well pain and low desire really, they have a lot of guilt, because they can't do the things that their partner wants them to do, you know? Or they can't do it as frequently or they can't do it in the right position, or they can't do it, you know, they have all these thoughts and what's really interesting when you talk to the couples when you know, the partner is willing to come in and and have the conversation now some of them aren't they even on video, they don't even on the phone call and want to be part of it, but with their part of the conversation, and you ask them how they feel about it, you can relieve so much of that guilt because women tend to put that on themselves. Absolutely. And, you know, they might have a husband who's totally understanding about it and totally fine doing other things or what he really wants is for her to have a good time. Right? Hopefully, you know if you're with the right person. Yeah, absolutely. But for her to feel guilty, like she isn't serving him, I would think that his biggest pain would be that she just isn't having fun having a good time. Mm hmm.

Yeah, for some women, another big emotion is shame around sex, specifically around their body in general. You know, and I think that that's something that's pushed into us probably trained into us when we are, you know, kids, really the emphasis on what women look like and their bodies and weighed and all of that and then you have this time in your life when of course, you're going to gain weight, you know, of course, your body's going to change shape, of course, things are going to stretch out and, you know, might settle in a little bit different location. And instead of embracing women and rallying behind women, you know, you see a lot of the opposite and the media and, and all of that. So, again, You know, it's like breaking women out of that. And you know, talking them through that is fantastic.

Let's segue into libido. I texted a group of my friends before this episode and said, What would you like me to ask? Lauren? And it's like they each responded libido, libido, libido, and then they fade into some other things, too, that I'll bring in. But what can you say to that it's just this ever present issue for postpartum women.

Yeah, and that's, that's exactly what I mean, when I'm saying low desire that it's that, you know, just wanting to do it in the first place, right with your libido. And there's a lot of reasons why women struggle with that. And some of it is, you know, I'll say some of it could be hormonal, especially if you know we're perimenopausal or menopausal. But that doesn't mean that we can't do something to change it. You know, and that doesn't have to necessarily mean hormones. So actually, this is the topic of my my book that's coming out. It's all about how do we, you know, that's part of it is how do we get that desire back and some of it is looking at stress, right? Because stress kills libido. Like When's the last time you felt totally stressed out, but you wanted to have sex?

It's such a funny thing because having a good orgasm is such a good stress reliever, right? We're getting right backwards.

Right? I say that all the time. But it's like the last thing you want to do and you feel really stressed. But I'm like, you know, if you would just do a little roll in the hay, you know, that might make you feel a little better. But you're saying stress actually lowers the libido in the first place.

Think Oh, it's the chronic stress that really gets involved. If you if you don't have chronic stress, and you have a stressful moment or a stressful day, then you might be able to like release that stress through a good orgasm, but it's that chronic chronic low grade stress that's deteriorating your drive over the long term.

Yeah, and then you You know, right along with that as fatigue, one of the things that I suggest them always walking my clients through with stress is getting rid of the overwhelm. You know, because right after you have a baby, there's so much going on. And then on top of that, you know, we put these ideals on ourselves like, Oh, well, people are going to come over and visit the baby and I need to have a spread of food and I need to have the house clean and I need it. It's like, No, no, you don't realign yourself with the thoughts that does this person really want me to do all this for them because no woman wants you to, you know, no woman wants a her postpartum friend or family member to do all this stuff in preparation for them coming over. I make it a point to you know, when my friends have had babies to call and say, when I come over, you better look like you haven't showered because I'm holding the baby will you take a shower and I'm going to start Last night, you know, like, people want to do things for you, but women tend to not. It's hard for us to say yes, it's hard for us to say we need help or even to accept it when it's offered.

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Let's talk more about this a stress. This is the first key issue Or, overwhelm, exhaustion. What is a woman to do when she's listening to this? And she has a four and a half month old? And she's like, Well, yeah, I agree. What can I do in the meantime, Hey, baby is is here to stay.

So I think for some practical advice, I usually say okay, let's, let's talk about all the things you have to do. Like literally write down a list of all the things that you are doing most days, you know, and then go through and figure out what things you can completely eliminate. Like what things you're doing that honestly, you just don't need to do. Does this really? Do you really have to, you know, I have a friend who does not fold laundry, and that one, I can't get myself around, but she's like, you know, you're just gonna wear it again. Like she washes it. But she and then she sorts it into different baskets for each family member. And then they just have they just bring it upstairs and they just have the What do you see coming up for those women when they have to make those decisions to let go of things? Do they give himself permission?

Usually we start with like, really little things like, you know, the nails is a great example. Like people who keep up with painting their nails and everything, especially because you're changing diapers and washing your hands and doing all this so much more like you're washing your hands so much more than you did before that it's not very practical to keep up with these fancy nails. It's like can we let that go? Some people are major bed makers, you know, like stop making the bed like just close the bedroom door and you know, like those things don't matter so much. So, we go through and we eliminate those things and I'm like, Okay, next step, like what things can we automate? You know, what things can you make? Easier do this in an easy way. I mean, if it's your bills, things like that. You know, once you see what can be automated then you look at what can be delegated, you know if this has to be done and you can't make it automatic.

So what I love about this is that it's making clear how we can take responsibility for our own overwhelm. It's, it's so easy to just be like I have to do at all, it's so much on me, me, me, me, me, me, me. And why don't they just might, why doesn't my partner just know? or Why does my life have to be this busy, but this is like mapping it out and being like, these are the things that I am willing to give up. These are the things I am willing to automate. These are the things I'm willing to delegate and once you write it down on paper, you're responsible for that and you can't, you can't, you know, that eliminates so much of that overwhelm because you have clearly identified where you can take responsibility and move it away from yourself.

The other thing is, you know, looking at other just pressures that they're putting on themselves like I need to return to a certain body weight to You know, in a certain amount of time and you know, I, I'm a huge fan of breastfeeding. So I you know, and with both my kids I struggle with milk supply. And so I for me I was that actually made it easier for me to not worry about my weight because I was like, how many oats Can I eat? How much like, What do I have to do like mother's milk tea? Like what do I have to do to get this milk up? You know, I can't worry about my body right right now I need to produce more milk. But, you know, not every woman sort of can do that, like kind of throw that thought out of her head about, you know, bikini seasons coming up. That sort of thing. I always look and say the what things are real pressure, like real stress and what what things are we just making up here You do not need to be back down to that size or that weight. You know, you do not need to get back to sex by a certain amount of time. You know, that's something that people ask me a lot. They said, You know how how How long after birth? You know, can we have sex as cash that that varies so much. And you know, there's this six week idea because there's this postpartum checkup, it's possible that you might be able to have sex sooner. But it might take you much longer because one woman might have had no terrine and you know, had the easiest labor and another woman might have had a very different experience. And so to make this blanket statement that you know, well in six weeks, like you're good to go, try to climb back on that horse and you're like, no, and it says nothing of where she is.

It's, it's we talked about this in our postpartum group a lot because it really is the six week visit is about the provider. It's convenient for them because it's typically the time when the uterus has properly involuted from birth, so they want to check that your bleeding is stopped and that the uterus is back to its normal. state but it has nothing to do with any of those others. Other issues, but because it's the providers last chance to see them, they give them the go ahead on all things. Even before women are ready, most of the time, they're not.

Well, and I think women have a lot of the women I speak to have a certain internal pressure that they feel like they need to get back to this really soon. And I think you made a great point about it's where they are emotionally. And also, depending on where you are physically, like if emotionally you're thinking I totally want to get back to that, but physically, you're not quite there. Then we can talk about other ways that you can be intimate, you know, sex isn't just penis and vagina sex. Very true. Can I say that on here?

Absolutely.

Okay. Yeah. As if they're bad words in the first place.

Right? Well, that's how I feel but not everybody feels that way. So sometimes like

I get like, Especially since I live in the southeast, I get the deer in the headlight look a lot.

Did she just say vagina? Right?

It always bugged me that Oprah made a joke about saying the word vajayjay I would just sit there like, please, you are a grown woman. I'm begging you. Please don't use that term. Yeah. Because it just makes everyone less comfortable.

Yeah, there are actually studies that show that the incidence of childhood molestation is higher and not found out as well and children who do not know how to describe their anatomy. So if somebody touches your penis or vagina and you don't know those words, then sometimes kids use words like stomach instead of in which seems so far off. You know, I have two sons and so we do penis and scrotum and we just say it like it is. And, and there's absolutely no shame in it, but so I can't imagine them. describing, like, their pubic area as the stomach because that seems like quite a distance away from me. But and then how would you not have shame if you? If it's so bad that you can't even say it? How are you not going to have shame? That's, you know, right.

That's so interesting. And somehow parents think that they're doing their kids like service a good service by not talking about these things, like they're teaching them the right way to be when in fact, it's creating such difficulty for them down the road, and we're just like passing it on generation to generation this, this shame around our bodies.

Yeah, it's time to stop it, ladies.

Yeah, just say the words. So the third of the three common issues you said come up is low pleasure. So now we're talking about I assume the woman who can have sex physically, and libido is not particularly an issue here. She's having sex. Now when you say low pleasure, do you specifically mean and do exclusively mean non-orgasmic or not necessarily. So some women can experience a lot of pleasure, like this feels really good, it feels very stimulating, and they just can't get all the way there. So they might, you know, not have low pleasure, but they are non orgasmic. And then some women, you know, just none of it feels good, like they just aren't getting the right sensations that they need. And I think that goes back to, again, not being able to really talk about our body parts. Nobody's ever told you where your nerve endings are, where you should feel good. Our sex ed is mostly geared towards scaring kids to not have sex. That's what, in my opinion, what sex that is in the United States. Nowhere do they talk about, you know, this can be this amazing, beautiful experience with someone you love, and it can feel really good and it's bonding and if it doesn't feel good, then there are ways that you could fix it. Not that you're going to tell kids how to do that in high school necessarily, but you You're setting the stage for like, this is something beautiful if it doesn't feel beautiful, seek help.

You reminded me of a scene from Michael Moore's movie called Where To Invade Next. And it's most of it is this fun look at how they're doing things in Europe. So they go to like French schools and the children have a one hour lunch and these beautiful four course meals with porcelain glass, and someone's even in the poorest towns in France. Yeah. Oh, yeah. It'll make your heart hurt to watch this and see how other countries are doing certain things. And you just want to cry for how we're doing them here. And it got to the part where they covered sex education, and they featured Texas in the US, as compared to how they were doing it in I believe it was France. You saw high school students in a classroom with a female teacher. And I'll tell you she was smiling. She was cheerful and if I'm recalling correctly, the name of their book was sex can be fun exclamation point. But I thought what everything here is about About shame and pregnancy and sexually transmitted infections and risks. And I thought it was just mind blowing to teach responsible sex and that the statistics pointed to it, like lower rate of teen pregnancy over there all of the things pointed to it. But I thought, what a concept that adults can sit around talking about how obviously sex is a matter of pleasure, but when we're teaching young adults about it, it's the last area we want to go like, we think we're encouraging the wrong thing. But we're really that's not teaching responsible sex, who is talking about right pleasure toward young adults in general, and especially toward women. So now, you're picking up the pieces 10 1520 years later, right.

Right. Right. And, you know, it goes back to sometimes like lack of understanding anatomy and never having self exploration. Yeah, it's like most women are going to need more water. Up, they're going to need sensation in different areas besides just the vagina. One thing I do is I pull out a chart of like we're a lot of nerve endings are so that, you know diagram so you can see a picture of that and see, okay, well, you know, we can start with those things and, and I'll also bring out I like to go over a sexual menu with people and so I don't actually go over it with them. Usually I have them print out too. And each person fills it out. And then they trade and it's just like, I have three columns. And one is I would like that like, this would be enjoyable. This would make me feel loved as well first column and this would make me feel excited like this would be pleasurable. And this would be an O factor. And so because holding hands might make me feel loved. Probably not going to do pleasure or the overhang, right? Something might feel really good. Like I definitely want you to do that. You know, like in for some women that Give them an orgasm for other women that won't. And it's funny when you fill that out. And some people say, Well, I have no idea if that would give me an orgasm or not. Because there's all these different things, and it opens up the conversation so much, because I think people don't want to say like, wow, how would you feel if I did this? Or I would like you to do that, you know, people are so timid about asking for anything that's not very standard. But just so that, you know, yeah, it's like, oh, I would have never even considered you know, and you know, what, I've developed it over things that people have told me over the years, like things that I wouldn't have thought of, but that's why community is so valuable. And having groups of women together is so valuable, because if we all only have our own experience, we're missing out on so much understanding. So it puts you in a you're very, you end up you as a practitioner end up so valuable to any individual woman because you've received all this input from the women that you work with, and you share this with us too, because So many women don't talk about sex, even with their closest friends. Or if they do, it's definitely not in the, for a lot of women, it's not in the details. They might say, I had sex with this person, but not it wasn't good. And we tried this and that it just didn't work was most people don't go into those details is great if you have a friend you know or friends that you're willing to do that with. But the women that I work with, I find it's very uncommon.

The unfortunate thing is that it is so often the woman who has the low libido or the low pleasure or the woman who's never had an orgasm all her life. That's the woman who's so unable to speak about it or so ashamed to speak about it, and she's the one who could benefit the most from this.

Right. I'm a firm believer that we have the most problems with whatever we can't talk about. You know, whether that is finances or sex or whatever, if it's something that you feel uncomfortable talking about. Are you don't like talking about it? You probably have some problems there.

Yeah. Lauren, do you believe that every woman can have an orgasm? Or are there some women whose anatomy or for whatever reason, just are never able to get to that point.

I have never, I have never worked with a woman that we weren't able to get her to have an orgasm. It makes sense to me that with spinal cord injuries or maybe severe injuries to the nerves, that that is possible that you wouldn't be able to but outside of something like that. I believe every woman can have an orgasm.

So at the beginning of the episode, you mentioned that you're coming out with a book I didn't know about that. What's the book called? And what's it about?

The book is called good sex requires more than just doing it. So a fun title for some fun, you know, suggestions on how we can look at sex differently. And it's interesting because when I first started this, I did not know that we would then be homeschooling be shut down Coronavirus so you know if I can write a book about sex while having two kids at home and homeschooling them, you can definitely figure out how to have sex during all that stuff. Right?

That is a good point. This is the foundation when you think about that, like you want to be together as a family you have to put the time into working on your relationship. And if there are problems in the sex, the best thing is I think I said in the beginning I hundred percent believe that you will be better off when you get through this then if you had never had any trouble you know if you get through it well you will learn to communicate about things that other couples don't even talk about. So you're a level up.

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I have a friend who I was so impressed with. She shared with me the day her teenage daughter confessed to her shared with her that she and her boyfriend of two years had sex. And I said, What? It was so interesting to me because my children were so young when she told me the story and I said, What did you say what what would happen from there? So it's like so great that your daughter told you and she's like, well, I sat down with her and I said to her, you just make sure it's good for you too. I have never forgotten that. I'm just like, wow, what Mother sits down with her daughter and says you just make sure it's good for you. You too. Yeah. And you know what so much of the sex that goes on in high school.