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Abundant Practice Podcast
Episode #634: What the Heck is Sex Therapy, feat. Erika Miley
01:01:25
In today’s episode of the podcast, we’re doing something a bit different. This episode features a course from my new company, (don't worry - Abundance isn't going anywhere). At Not Boring CEs, we offer an engaging way to earn your...
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- [00:00]
Dr. Erica Miley
So I started a new business to help therapists with the clinical side of practice. It's called Not Boring ces. And what you're about to hear is one of our trainings. You can listen and learn for free. And if you want to get CES afterwards, you can head to notboringce.com and join us because you're an abundance person. You can get $50 off our annual membership with coupon code Abundance. We already have all the asynchronous trainings your license allows, with more coming every month. Actually, enjoy your CES and do it on the go at notboringce.com Dr. Erica Miley, also known as Dr. E, has helped professionals with their discomfort treating patients sexual health concerns for the last eight years. She provides intimate training through workshops, keynote presentations and writing as a subject matter expert in neurodiversity and sexuality, Dr. E presents sexual information, easy to understand ways so healthcare providers can give access to the higher quality care their patients need. Her background in research and as a professor for institutions such as Whitworth University and modern sex therapy institutes make Erica uniquely qualified to train healthcare providers. Welcome, Erica. I'm excited to have another amazing CE today. I'm here with Erica Miley of, say, your website again? Because it just fell out of my head.
- [01:18]
Unknown Speaker
You're good. The center for Mental and Sexual Health. There we go.
- [01:22]
Dr. Erica Miley
Thank you. And from the title of this podcast and also from the website, we're going to talk about sex. Today.
- [01:29]
Unknown Speaker
We're talking to all things sex.
- [01:32]
Dr. Erica Miley
I feel excited.
- [01:34]
Unknown Speaker
So this is why the boring stuff, like we're not doing boring, like sex can't be boring when we're training about it.
- [01:41]
Dr. Erica Miley
Please. No, I mean, I think people make sex boring, which is why I was like, I need to see company that doesn't do that. So yes, let's keep these things that are inherently interesting, interesting, please. So where can we start with like human sexuality? Let's just start there. Let's just start with one of the biggest, most misunderstood things in the world. Let's go there.
- [02:06]
Unknown Speaker
I, I mean, I, you're, you're talking about something that I, I feel like, especially in the United States now, I, I will stick specifically to the United States because there are other countries that do sex education and how we see human sexuality and human development, human sexual development, they do it better. There are quite a few Nordic countries, Germany. There's a level of comprehensive sex ed and human development education that starts from the time people are children. And in the United States, we refuse and we refuse for A very, very long time. And so there is an entire field of study called sexology, which I have my PhD in clinical sexology. So all things sexuality and how our mental health and our bodies are all connected. Those of us who are sex therapists, we are coming at mental health issues from a frame of how is it impacting your sexual interests, your desire, your identity? How do you incorporate those things into your life? Because again, to bring us back to all of us really don't have a sense of really good sex education from the time we're young children. So so many people have taken their sexual selves, their desires, their, their identity, who they're attracted to and pushed it as of lack of knowledge. Trauma. I would say 80% of my caseload has a religious trauma that is associated with sex. And they're in marriages, long term relationships, couples, throuples, like all kinds of different kinds of relationships. And those experiences and not getting information absolutely is impacting their ability to grow, their ability to incorporate their own identities in their lives. And so essentially what we do as sex therapists is tackled this big, big thing of human sexuality and we incorporate it every single, I mean, most of us, I would say, you know, I'm speaking kind of grandly for our, my field. I would say every session I am going to bring it back to gender identity. I'm going to bring it back to how are you experiencing desire? Oh, you went to a form of, of church or a religion or your family ascribed to a religious doctrine that kept you from understanding that? Oh, I'm attracted to primarily AFAB people assigned female at birth or AMAB people assigned male at birth. Or actually I might be pan. I'm attracted to lots of different kinds of people with lots of different kinds of presentation. You and I, we've talked many times about how I could be here all day. But ultimately we use sex as our lens to try to understand so many other parts of our mental health and our experiences with our body.
- [05:38]
Dr. Erica Miley
Absolutely. So, so when we talk about human sexuality, there are a lot of dimensions to it. Is it helpful to find some of those dimensions so that anybody who is listening, which, I mean, I think there may be some dimensions, I don't know, but anybody who's listening can be clear about exactly what we're talking about with human sexuality. So we've talked about like gender identity, we talked about who you're attracted to sexually, desire, pleasure, we haven't really talked about, but I'm assuming it's in there somewhere.
- [06:15]
Unknown Speaker
Yes, absolutely.
- [06:17]
Dr. Erica Miley
What are we missing?
- [06:19]
Unknown Speaker
We, there Are there are parts of our experience if you live in the world. Like I'm kind of using a case study in my head as we're talking about this. And I kind of pull from different clients as we're talking about this, not sharing their personal information, but giant themes that come up. So I have had many black clients have to try to understand their familial trauma, but also being in a relationship where neither person was able to experience desire without fear, desperately attached to it. And sometimes it was because of their systematic experiences they've had, sometimes it's because of the religious upbringing that they've had. So I'm kind of using a broad framework. But race is part of how we experience sexuality. Pleasure, you've already identified it. Pleasure or how do you experience pleasure sexually or non sexually? Because a lot of times our brain will put it all together and not really understand the difference, especially if you have a trauma history. If you have. We've already talked about the religious framework of what desire or not experiencing desire could look like. That includes pleasure. The dimensions of human sexuality touch. I would argue every part of us as humans, I tell, when I'm working with, when I'm doing consulting with therapists, I am constantly telling them when you open the can of sex, you are pouring gasoline on all of their issues. If you talk to your clients about sex out the gate, you absolutely will find out things you never would otherwise. You will see in a relationship how they're tearing themselves apart on the inside, individually and together. It is, it truly is the gasoline to all of our other stuff.
- [08:28]
Dr. Erica Miley
Right. So okay, we talked some about cultural, social. Can we talk some about individual factors aside from maybe like maybe trauma experiences? Like I'm thinking about how neurodivergence might impact sexuality or eating disorders or all of these or even non clinical things that are just temperament based that might be impacting sexuality. Can we dive into some of that?
- [09:02]
Unknown Speaker
Absolutely, absolutely. I mean neurodivergence in particular is my wheelhouse. So my entire dissertation is about ADHD and how it, how ADHD symptoms impact AFAB people's sexual functioning. So again, that lens is super narrow. We're looking very specifically how ADHD for a body that was born female would maybe even look different for their symptoms could look different, but also how, how those symptoms impact their ability to access sexual desire with a partner might look different than maybe a neurotypical person. The people I've worked with with eating disorders, the, the shame about body truly, truly impacts how they can actually access non sexual pleasure and Sexual pleasure. So the tendrils are and can be very, very deep. And I truly think that I will continue to come back to you. If we're not including human sexuality in our initial screening, it doesn't mean that I think every person needs to be a sex therapist, but I do think we need to, as clinicians, have a comfortability with asking these questions to be able to suss out, oh, this is where maybe a person in eating disorder recovery has recovered to a certain amount, but they start to try to have a sexual relationship with somebody and they might actually take 10 steps backwards.
- [10:39]
Dr. Erica Miley
Exactly. Yeah, yeah, absolutely. I've seen that as an eating disorder therapist, things were going so well and then all the old stuff comes right up because it was also linked with trauma or it was linked with all sorts of things with body. Are there some temperamental differences that have been studied or that you've seen anecdotally with sexuality?
- [11:05]
Unknown Speaker
I would, I mean, some of the, this is the, this is the, the baby parts of the field of sexology. Because those of us who, because I also do sex research. So there are lots of mental health issues we have never explored. Oh, how does it connect to sexual behavior, sexual interests, sexual identities? For instance? There is some more recent research that's coming out that's putting correlating the likelihood of queerness with neurodiversity. Like, we gotta, we got a new frontier here. And I'm not going to be bold and say it is, it's always connected because we don't know. We don't know now if someone tends to be a more. If they lean on anxiety to deal with life that usually follows suit with sex. So they may struggle with, oh, I, I really get in my head when I want to initiate any kind of pleasurable activity with my partner, whether it be sexual or non sexual, or I need a certain type of interest, like a kink interest to even clear out some of the anxiety I might experience from sex. So oftentimes when I'm working with people who. Initiation is one of the big, huge things that comes to us as, as sex therapists. They, they come in and go, I don't know how to initiate any kind of sex with my partner. Or we've hit a roadblock together where we're really struggling to initiate together. So we essentially rewind and we go, okay, so how do you know what you're interested in and can we figure out what you're really, really interested in to be able to help you get through that anticipation paralysis that you hit before you let yourself engage with sexual pleasure. So I'm kind of like, I'm giving a lot of examples of like what a sex therapists do and kind of the lens we look at. But the, the reality is, is that every clinician is going to come across some sexual issue, some issue around identity, attraction or not. Like the asexual population of our planet has. There is not a near enough research on, on all of those folks and how they experience desire and romance and it's deeply connected to whether they were given permission to just exist as themselves. So I think especially when we come back to things like neurodiversity and eating disorders in particular, that's kind of you and I's wheelhouses together, that it's kind of a microcosm of what kind of shows up in our offices when a therapist gets to the point where they feel like they're outside of their depth and, or they have gotten to the point where they are uncomfortable because they're facing a client who's dealing with some of the similar things sexually that they are.
- [14:28]
Dr. Erica Miley
Yeah, I'd love to talk about that therapist discomfort. I mean, it's just, it's the clinical version of what we have going on in our culture around sex. It's, it's something I talked about in my graduate program aside from forced sex or you know, it was like trauma, trauma lens exclusively, but never from a pleasure lens, rarely from a connection lens. So what I'm thinking about therapists right now who were maybe raised in households that didn't talk about sex, who surrounded themselves with friends who didn't talk about sex. Or if it did, it was like maybe this kind of like taboo, exciting thing that only that one friend talked about. You know, I was that friend. And then, you know, they're, they're adults who are maybe have been in relationships, they've had sex, but they've still got some discomfort around other people talking around, talking about sex around them. And so the idea of in an intake with a client when you're just finding out anything at all about them, to dive into this conversation that they don't even have with their best friend. How, how can we support them? What would be helpful for them to baby step their way in? Teach us everything.
- [15:49]
Unknown Speaker
We need 25 more hours. But I think I, I honestly think that this actually begins. I mean, we wish it would begin in graduate school. There's so many things, there's so many things that we would wish would begin in graduate school so that you could at least dip your toe. So you wouldn't be in the intake with a client for the first time when you might hear about sexual pleasure or orgasm or, oh, I'm on a bipolar medication that is completely. It's given them anorgasmia, which is the inability to experience orgasm. And the medication is the absolute thing. And therapists, when they get uncomfortable, they dismiss those things quickly because of that discomfort. Like I said, it is the gasoline. Sex and human sexuality is the gasoline to our own stuff. And more than likely a therapist is going to come up against their own lack of information and feel that impostor syndrome. Like, how could I possibly help this person if I don't know what any of this is? So I, I wish it was grad school. My next step is I wish every clinical supervisor did their due diligence to become really, really at least informed around sexuality and come see a person like consultation, get their own supervision about it and then also doing their own therapy work about it. Because the gift they could give is being sitting with that baby therapist coming up in the field, not necessarily in age, just in just an experience. And they can give that gift of those conversations individually. So it's not so overwhelming because I did have a human sexuality. Oh, I had one human sexuality class in my master's degree, and it was taught by a person who, one, was deeply uncomfortable with sexuality themselves, and two, the people in the room who were the most uncomfortable took all of the oxygen out of the room. I'm not angry with them about that because I see why, I know why. And the, the discomfort then overtook every part of it.
- [18:09]
Dr. Erica Miley
Right. Because there wasn't a leader who was comfortable enough to address it.
- [18:13]
Unknown Speaker
Exactly. Or talk about how that it was going to impact them when they were in with a client. And my wonderful, wonderful mentor, Dr. Ricky Siegel, he was my sex therapy supervisor. He talked about, and he doesn't say this with judgment, but with, with a similar perspective. He loves to see LMFTs come and get good sex education, even if they don't decide not to be sex therapists or certified sex therapists. Because he said, he always says, hey, look, it's a plumber who can work on toilets. When it comes to the LMFTs, I'm like, if you are working within relationships in any way, shape or form, you absolutely need to have a really good background in human sexuality because it's so integral to how we connect as human, non, sexually and sexually. Pleasure. I talk to my clients all the time about how pleasure, joy, some of the more intense experiences of feeling can Actually be just as disruptive as deep, deep depression or sadness because it's intense in its experience. And if you don't know how to work with absolutely would avoid it just like you would try to avoid any other feeling that you would deem as negative.
- [19:41]
Dr. Erica Miley
Right, right. What is the most common reason that people come into sex therapy? Clients?
- [19:52]
Unknown Speaker
There's now for me I'm, you know that I'm the nerd. So I'm going to get the, the neurodiverse folks, the, the folks that are, that have either diet been diagnosed or not and they are coming up against sensory issues. They're coming up against things that trying to focus during sex and that they're, they're wondering why because they enjoy sex and are eager to have a sexual life with their partners. But as far as on average what we all see, the most common things that we see are initiation. So initiation with, with any partner. And we would also see desire discrepancy. Those are kind of the two big pieces that comes in our office. I would say I get at least a call a week about especially desire discrepancy. And a lot of that comes from the initial feelings of a relationship. There's the big chemical swings that make us all feel really, really great. And a lot of times people think that in a long term relationship the way that your relationship started is that sexual connection should be taking place the entire time. And so we break down how you know that's, that's kind of a myth. And it takes you anywhere from what are the God, what are the gotlands call it the, the limerence phase. Is that what they, is that what they say? So they, they, they don't know that oh you could be at six to 18 months before y'all get used to each other's hormones which cause them one another. And the sex will probably start to change around that time. It doesn't necessarily mean that frequency would necessarily change because our how we experience desire and the way that I really like to think about it and Dr. Emily Nagaski's book come as you are is really, really great way to kind of introduce yourself to this idea which is that desire is like gas and brakes and they're going all the time. It's not just one or the other. And I think understanding that oh this is happening all the times, oh when you're at work the brakes are on more than the gas is on doesn't mean the gas isn't on. Especially if you're, if your partner's sending you nudes or Your partner's like sending you interesting things they'd like to do to you later. Yeah, there might be some more gas that day, but most of the time at work you're going to have a lot of brakes on. But as if you don't know what your gas and brakes are. How will you know when you're with your partner that those initial flood of hormones as they start to dissipate, how will you know how to lean on the gas when you want to rather than when you feel like you have to in the beginning?
- [22:57]
Dr. Erica Miley
Right, Right. I think about too Emily Nagoski talking about, oh, my brain just went like spontaneous arousal versus responsive arousal. Can you talk a little bit about that?
- [23:13]
Unknown Speaker
Yes. So as far as. And we have arousal non concordance too. We could be here just all day gist about this thing. But something to understand is that not all of us experience spontaneous desire. Not all of us experience desire that kind of comes on over time. We might experience a little bit of like a different versions of both. And also no one, no one taught us. No one. And I learned more about this when I did sex offender treatment than I did anywhere else, which is that your body, your genitals can react, but your brain can be doing something altogether different. Your brain can be in terror. It can be doing a grocery list, which is what a lot of my AFAB people with ADHD do. It's their task lists that they run, run, run, run, run through their heart. So. But your genitals will still respond when stimulated. So I wish any therapist just even knew that part, which is that desire and arousal is different and experienced differently by different people, especially depending on who they are aroused, to the kinds of identities that they're attracted to, or even just if they have a kink interest, which we absolutely know today that the interest in kink and power dynamics during sex consensually is incredibly erotic for a lot of people and a vast majority of us, rather than thinking that only a small group of us like kinky things or kinky power dynamics. So again, I need like an hour on each one of these.
- [25:13]
Dr. Erica Miley
Maybe we'll schedule one. Well, can we. Would it be helpful to talk case studies? I know that you have some in your head. Would that be a good way to kind of flesh out some of these points?
- [25:29]
Unknown Speaker
So the case studies that I'm the one in particular that I'm thinking of because it is something that I see so frequently, this case study is kind of like a combination of at least 15 clients in my brain. So this person is an AFAB person who grow up. It grew up in a very religious and I would say, toxic, patriarchal, structured family. And once you became a certain age, you were expected to act like an adult woman without any guidelines for what that actually looked like. And once you started developing physically there, all of the interests of this person had to be the idea of, like, only girls can do those things or only boys can do those things. I'm using binary language because this is the language of these clients. When they finally get to a place where they're in puberty and they start exploring masturbation, they hit this point of deep shame because no one is either talking to them about what masturbation looks like and how early it begins, or they're actually shaming them using religious doctrine to even, like, you can't touch your body because it is a sin against God. It is a fill in the blank with your religious toxicity of choice. So by the time they get to a place where they're in high school and they're experiencing desire, the desire connection is with sin. Or that is bad and wrong. And I'm bad or wrong for wanting to engage in those things. And so. And on top of that, for any of my queer clients that are experiencing the same thing, not only that, like, oh, I'm supposed to only like this version of a human. And if I do, that is also bad and wrong, and I am broken. So we go from having no education, and all of the education that is there is either absent or abusive. And it results in then this tie for a client between desire, their bodies and sex and identity that then they shut down every sexual interaction that they have with themselves and they become physically numb to the idea of sexual pleasure until they get to college. If they did go to college and they start having partners. But then fast forward spoilers. This person has never experienced an orgasm and is 40 in their 40s. This person, again, a bunch of people in this one person is the pipeline I see as a SEC therapist again and again and again and again. And so they come into my office, this person is in tears because for the first time in their entire lives, they've actually met somebody that they're attracted to. And their body is doing things that they've never experienced before, and they're in deep amounts of pain and shame, and their partner wants to support them and has no idea how. And so we spend a lot of time doing education individually together with our partner, and then we build the bricks of sexual pleasure slowly but surely depending on the person and Their trauma history. Sometimes we have to start with non sexual pleasure, which really sucks. As a therapist, when you come across a client, and I know you, you get this when somebody comes to your office and they are honestly telling you they have no idea what non sexual pleasure feels like.
- [29:52]
Dr. Erica Miley
Yeah. Yeah. I've definitely seen a lot of that in my clients with eating disorders.
- [29:58]
Unknown Speaker
Yeah. I should add on top of that, somewhere in there that AFAB person has had a, a dieting history that is usually immense.
- [30:11]
Dr. Erica Miley
Yeah. I mean I even think in my other business, helping therapists build private practices, in conversations with therapists where I'm like, you know, how are you? You did the thing, you built this amazing practice. You don't have to scale, you don't have to do some other course or whatever.
- [30:27]
Unknown Speaker
Yeah.
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Dr. Erica Miley
What are you doing with your life? You've got all this time and money now and the, the. They also don't know what's pleasurable because they've been following a path for a long time and didn't. It wasn't encouraged, explored, discussed throughout their life. That pleasure daily is a wonderful thing for all of us.
- [30:50]
Unknown Speaker
Yeah. Yes. And I think that that's one of the biggest. When I tie our sex to that idea of pouring gasoline, our problems, I think that's one of the cruxes of it, is that pleasure was seen especially in American culture. Pleasure has been seen as something bad, wrong, or if you're not constantly striving, you're lazy, your fill in the blank. But then you get to a point when you're in adulthood like, oh, but now what I, I did all the things, now what I did the things on paper that says I'm supposed to be filling the blank. But here's all this other stuff that I have yet to let myself have.
- [31:47]
Dr. Erica Miley
Yeah. Yeah. So in working with this client who doesn't have non sexual pleasure yet much less sexual pleasure, they found this magical person. This magical person is loving and supporting them through this hard work that they're doing with you. What are you doing that's helping? How do you introduce them to the safety of pleasure?
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Unknown Speaker
So oftentimes I start with. And this might sound counterintuitive, but I start with neutrality before I offer positivity.
- [32:24]
Dr. Erica Miley
Yeah.
- [32:26]
Unknown Speaker
Because often neutrality can feel closer to safety than pleasure ever would. So we usually work from the, the shame, the negative thoughts that are. Or the neighbor, what can feel like the negative experiences in the body. And we move to, oh, okay, I don't really have feelings in my body or mind about whatever this activity is. I I use my own. I, I use a chore. There's a chore in my mind that, that for me I am completely neutral about and it's mopping with my steam mop. I don't have negative, positive, I don't have any real feelings about it. And I, when I'm doing it, I can just do it without any kind of upset or feelings or even resistance. And I think that that takes time to really like, oh, okay. No, I, it's activities that don't seem to have something tied to them is usually where we begin. And then we'll move to third things like non sexual pleasure, non sexual self touch, like putting hands on body, maybe even looking in the mirror at body parts or like genitalia, if they've never done that before. But sometimes it takes, for some people it takes, takes some work. Or sometimes they'll, they'll jump, you know, right off the diving board and in the deep end and they'll be like, I looked at my genitals in the mirror and I have to tell you all about it. And I didn't even give him the experience, the, the homework to do. So it's, everybody's a little different. And how they have. Some people want to rip the bandana. Some people are like, nope, I need to put toes into this, this deep water. So sometimes we even do like, have you ever seen like the head scratchers?
- [34:27]
Dr. Erica Miley
Huh? Yeah. Yeah.
- [34:29]
Unknown Speaker
Sometimes I'll have them do things like that and like, okay, is this a pleasurable experience for you to use one of these? Because they're in complete control over it. Is it, how does your skin react? How does your body react? Do you enjoy it? Is it pleasant? The other places we can do, and I especially do this with my folks who have been or are in recovery from eating disorders is we try to find neutrality or pleasure around food. So we'll, we'll use some of the act techniques around like using mindfulness experiences with like foods that have texture that can be tolerated. Like a berry with lots of ridges in it and taking your time and experiencing the taste, the smell, the ridges. And then what does that feel like in the body? How do you let yourself have this? And are you enjoying it or is it actually a food you don't like very much? So those are some examples of how I'll use non sexual pleasure to kind of help the person move down the path to feelings of sexual pleasure. And oftentimes it depends on the partner. It depends on the relationship. It depends on if they're solo or not oftentimes we start with masturbation. And if a person can do that. Because the other thing that us therapists work with a lot is chronic illnesses or pain during sex. So I have a lot, I work with a lot of AFAB people who have either experienced endometriosis or have been in recovery after like a surgery from endometriosis if they've had access to it. Because it usually takes for endometriosis, in particular, seven to eight medical doctors to diagnose it. That they've seen seven to eight medical doctors before they get their diagnosis.
- [36:21]
Dr. Erica Miley
Yeah.
- [36:22]
Unknown Speaker
And so they haven't understood, like, you know, I have always wanted to have pleasurable sex. I have always wanted to feel pleasure in my body, my genitals and the lower half of my body. But it has been my enemy since I started menstruating. So every, every client's a little different, but that's kind of like the example of the path that someone like me, a sex therapist, would take. So I'm, I'm looking at their brain, I'm looking at their body, I am looking at the sex. And how are all of those things inter working or not?
- [36:59]
Dr. Erica Miley
Yeah. And then what are the inroads to helping them work? If that's the goal?
- [37:05]
Unknown Speaker
Exactly, yeah.
- [37:07]
Dr. Erica Miley
Are there other case studies that you think people would benefit from?
- [37:11]
Unknown Speaker
Absolutely. I think AMAB people often end up in our offices for erectile dysfunction. So the example I'm going to get give you is like again, like 25 clients in my mind. So often what will happen is someone will come in for kind of these two pipelines. So either they are struggling with.
- [37:41]
Dr. Erica Miley
How.
- [37:41]
Unknown Speaker
An erection will happen or they are struggling with not understanding how maybe their health is connected to that. They also might be struggling with a partner will accuse them of cheating. I've actually, I've also had people come in and say that, oh, my partner has a porn addiction, which is not a thing. And it's. We need a whole other, we need a whole other hour to talk about how porn addiction is not a thing. Us in this field, we say out of control sexual behavior. So we'll have a partner accuse an email person of out of control sexual behavior when it comes to sexual material. And so by the time they get to me, it is so often that an AMAB person has never ever gotten to talk about their sexuality or their feelings about sexuality unless they're in trouble.
- [38:42]
Dr. Erica Miley
Oh, yeah. So never thought of that before. But yeah, I so see that pattern in our culture.
- [38:52]
Unknown Speaker
And so they were caught masturbating when they were young or they were caught by, by a parent using sexual material, or they were caught by a partner masturbating or using sexual material. And so the oftentimes for AMAB people, how they engage with their sexual selves, desire, identity comes from a place of fear. So that often results in erectile dysfunction. But one of the first things I'm doing when I, when somebody who's AMAB comes into like my virtual office is I'm actually talking about health conditions first because most people are unaware one first that we all have erectile tissue. But to that when there's an actual physiological reason for erectile tissue to not be working, that sometimes it is the first sign of a cardiovascular issue. So I have had people in their late 20s, 30s who are actually having a cardiovascular issue and it's showing up first because that's where they would notice it in a penis. So the between the combination of how they got to me, which is usually a partner or they got in trouble or some. They got caught or something, we have usually a lot of shame deconstruction to do around sexual and also teaching because so many of them don't know their own anatomy. That, and this is a whole other conversation about the patriarchy are all deeply threatened by me as a, as somebody who identifies as a woman having more information about sex than they do. And, and so there's that dynamic you have to navigate in therapy like yo, like this is like my actual wheelhouse. How does it make you feel when men are often taught that they are supposed to be all knowing about sex and want sex all the time and experience desire at all times, when in reality their gas and brakes is exactly the same as ours and all other identities that they're not experiencing desire when they're at work because their brakes are mostly on. They might experience desire differently than their partner, but that doesn't necessarily have anything to do with them having a penis or not. So I think it's helpful to kind of understand and deconstruct that idea that all, every case that kind of comes through our office as sex therapists, you again can see what those issues are very deeply and quickly if you're asking them about their sexual life. Right.
- [41:56]
Dr. Erica Miley
I'm thinking about. Well, I want to give you opportunity. Are there other, other case studies you want to talk about?
- [42:03]
Unknown Speaker
I think those are. I mean I could definitely give you some of my favorites. And I wish that this case study wasn't as, as often as it is. I can't tell you how many People, queer people who have come through my door, who we are having to heal all of the internalized homophobia, queerphobia generally because they had, they went through and were forced to go through conversion therapy. So that case study I wish was not as common as it is, but it is a deeply traumatizing experience for them. And the untangling that trauma from their sexual experiences and their desire for whomever they desire is difficult, hard work for them. But I can tell you that I see so much success from people who get to actually embrace who they truly are and who they want to have sex with.
- [43:14]
Dr. Erica Miley
I'm thinking about that could be a niche unto itself of just working with people who've gone through conversion therapy. And a therapist was quite busy. Yeah, I wonder. I worry too about everything that's going on in this political climate and what therapists 20 years from now will be unwinding with people because they were, you know, 10 years old when they had to move states in order to stay safe or.
- [43:46]
Unknown Speaker
Exactly. Yeah, exactly.
- [43:52]
Dr. Erica Miley
Like we'd mentioned having amazing supervisors who can really help walk you through these things. But I know there's. The other option would be a peer supported setting for helping you work through that. How do people find that? Where do people begin?
- [44:11]
Unknown Speaker
I mean, as far as a peer supported one. Now, now let me say this. I am officially an ASEC certified sex therapist, which I very much. It takes a long time. So if you see somebody in your town that is ASEC certified, just know that it takes forever. And it is. They have done a lot of work to get to the place where that they can be as they can inform your community. And so that, that's what happens for a lot of us sex therapists. We end up doing so much consulting. And so I love to do that. I love teaching therapists, I love helping people understand human sexuality directly. But. But a peer supported one would be like, say you're in a group practice, maybe it's time for that. The book club that you've all developed that it's time for the sex book. It's time for Emily Nagoski's Come as you are or Ian Kerner's she comes first. There's also Ray McDaniel's book Gender Magic is fantastic. So that would be a really good peer supported way to be able to kind of explore some of these ideas clinically, maybe even in a smaller group setting. That is a little less daunting than feeling like you need all of the information at once. Doing ceus like this one, like trying to get in little bits of information where you can, because I know how busy we are.
- [45:50]
Dr. Erica Miley
I know how busy all these therapists out here are.
- [45:54]
Unknown Speaker
And those of us who are sex therapists, our caseloads are never, never empty, which is not a flex. It is there. It is something that is deeply necessary for the American culture. And so, and maybe when you're a therapist and you're looking for your next therapist, maybe it is time to go find that sex therapist because most of us do telehealth and start tackling some of his own, your own internal issues around sex so that they can ask you these questions and you can do it in what feels like a safe environment.
- [46:32]
Dr. Erica Miley
Yeah, I'm thinking too about how it doesn't. Seeing a sex therapist doesn't mean you're having some sort of functioning issue. You can be a sex therapist also just to get comfortable talking about sex. Because if you're not comfortable talking about sex, there's some stuff there.
- [46:48]
Unknown Speaker
Exactly. And I, I used to start. So when I was working in the prison setting with people who committed sex crimes, one of the first things that I would have them do is we would be using language and I would let them all get out the, the, the slang and I used to, and I still do from time to time collect the slang that people use for genitals or sex or. There's a wonderful show, if you ever, if you're a history nerd like me, called Betwixt the Sheets by Kate Lister. And she talks about all of the historical representations of sex and gender and culture, but she also goes through again and again, like all of these historical words that we've always used around sexuality and gender and, and sexual actions and behaviors. So in my groups I would like, okay, give me all the words you know, what are all the words you actually know? Okay, so now we're going to use the actual word and we're going to repeat them and you're going to use the words in here so that you can get more and more comfortable with the words around your body and how your body actually works.
- [48:01]
Dr. Erica Miley
I love it. You did that with that population. I used to do that. I used to run a kids group for kids who've been sexually abused. And we would do that in the first group is like write all the words down like on a, on a whiteboard they could all see. And to hear a six year old say words that you wouldn't say in front of anybody else, you know, and to get it out and making it a little bit fun and a Little less scary. Then we would use the anatomical words going forward.
- [48:35]
Unknown Speaker
Yeah, yeah, I'm already. I'm already preparing my son's teacher. Yeah, he's 11. And I'm like, yo, when you all start talking about bodies, he's gonna have a lot of the words that some of these other kids may never have heard before. So I just think you should know that that's coming. Prepare yourself.
- [48:56]
Dr. Erica Miley
Absolutely. Yeah. I mean, my kids are very. So because of that work experience, they knew the anatomical names only because there was one circumstance where this. This little girl kept disclosing what was happening to her, but she was using the word purse. He keeps touching my purse. And so as a result, the teacher was like, well, you should just share. Nobody was taking her seriously. People were encouraging a behavior. She was posing was awful for her.
- [49:30]
Unknown Speaker
I have the same story. Just, I was working with the. The perpetrator and the child was reporting he touched my ice cream. And it was the same kind of thing. We actually have research about this. So any therapist out there that's listening, if you run into this question inside of yourself or with other people, like, why should kids know this? We actually have the data to show that kids who can describe their bodies and describe their genitals and words and know about their bodies, it is protective of them. It gives them a protective factor against sexual assault and sexual abuse down the line because they can disclose to a trusted person, a trusted adult, that if someone has harmed them or touched them or made them feel uncomfortable, this information is protective of us. It does not ensure that we are all going to. I always wonder, like, especially during the 80s and 90s, when purity culture became like this and it infected everything. It wasn't just the religious communities. It infected school education. And I always wondered what the. What they were trying to protect people from. Because the idea that abstinence was going to at all, or teaching abstinence only or giving no information was going to be protective or mean that. That teenagers and young adults and then adults wouldn't have sexual partners. It just. We're all still here. We're all still making babies. Like, how did you think this was going to go? No, now we just have a harder time trying to connect with bodies. And there's a lot of other reasons why we're all not making babies, why we're. There's a. Less babies being made. But their goal could never have been met.
- [51:31]
Dr. Erica Miley
No, No.
- [51:34]
Unknown Speaker
I could be on that soapbox all day.
- [51:37]
Dr. Erica Miley
That's another hour. Yeah, I'm. It's interesting. So I Was raised in a sex positive household. My dad edits the podcast I've had, as you know, and has been on podcasts I've done before. Like plenty of conversations about sex. I never feel squeamish about sending them to my dad because as an 80 year old man he's had plenty of sexual experiences in his life and doesn't imagine that I haven't given that I have two children and I am, I think about the freedom of that more and more. Like the older I get and the more clients I see and the more hang ups I hear about around sex and bodies, so. Thanks, dad.
- [52:26]
Unknown Speaker
Exactly. So you, you and I are case studies of exactly the opposite experience.
- [52:31]
Dr. Erica Miley
Right.
- [52:32]
Unknown Speaker
I was raised in a toxic evangelical household and my parents cannot listen to my show and have actually said it to me because they can't listen to their kid talk about sex.
- [52:46]
Dr. Erica Miley
Yeah.
- [52:49]
Unknown Speaker
I literally have a whole ass doctorate in it and they can't listen to their kid talk about sex. And I am 40 in like a hair's breadth of months. I have given them a grandchild. Like, this is like you and I are exactly the example of how it can go and how what can happen if it can go differently.
- [53:18]
Dr. Erica Miley
Yeah, yeah.
- [53:20]
Unknown Speaker
Maybe your kid won't become a sex therapist if you help them like become like okay with their bodies, but they won't guarantee that they won't be a therapist.
- [53:30]
Dr. Erica Miley
Yeah. And it's interesting because I have friends who are really squeamish about talking about sex or like they're okay with certain up to a certain part of puberty. They don't want to talk about masturbation or anything sexual or ultimately pleasurable with their children. I'm like, I'll talk to them about it. I don't have discomfort imagining my children as growing up to be sexual people. I want them to grow up to be sexual people. I want them to, they know that a big part of sex is pleasure. I wanted my daughters to understand that it wasn't about exclusively male pleasure. I didn't want them to certainly not to think it was only for procreation because no.
- [54:19]
Unknown Speaker
Whole part of later life that that's not the case.
- [54:22]
Dr. Erica Miley
Right.
- [54:23]
Unknown Speaker
As if we still believe that, oh, as you get older that you just give up sexual activity. No, it's actually entirely the other case. STIs are on the rise for people who are over the age of 55.
- [54:37]
Dr. Erica Miley
Yeah, yeah. And I like the, the culture around not talking about sex unless it's like funny or it's scandalizing or something like that. Instead of it just being a part of things. Like, I don't think I need to be like, and I got laid today. It was great. I don't, I don't mean that kind of talking about it, but just talking about it as a part of our human development. Sometimes it's hard for me to relate when it's hard for people to talk about it. So I get to like, tap into my empathy and try to find. There are things that I'm not always easy to talk about too. You know, I just happen to be raised by. This wasn't one of them.
- [55:23]
Unknown Speaker
I know what's funny. What's funny is to give like the insider. Like when you're with a. When you're friends with a bunch of other sex therapists. We are actually kind of like, oh, I had great birthday sex today.
- [55:34]
Dr. Erica Miley
Right?
- [55:34]
Unknown Speaker
We will. We will. We. That's the level of comfort that I don't know that we all need to be yet. I don't, I don't. I, I don't even ask that of my clients. I'm like, my aim isn't to make you as comfortable with sex as me. Like, that's not. I. This, this is a level of nerd. I'm not asking you to get too. But being able to talk to your partner about it. Yeah. Yes. Being able to ask for what you want and need and be able to disclose to a partner when something isn't working or when your body has changed. Because guess what? It does. The body of 25 is not the same body as 45 and 55 and 65. We are just now in our culture starting to talk about perimenopause, menopause and postmenopause and that there are three phases to it. I didn't hear about that in sex ed. We barely got through puberty.
- [56:29]
Dr. Erica Miley
Right, right, right. Yeah. And. And I think about how as somebody who is at an age where I'm starting to think about perimenopause and feel like looking for doctors who know anything about it.
- [56:46]
Unknown Speaker
It's.
- [56:46]
Dr. Erica Miley
It's kind of mind blowing that it's not even something that's covered in depth in medical school that like we just.
- [56:54]
Unknown Speaker
Now got a whole ass clitoris in a medical book just now. Like in the last five years.
- [57:00]
Dr. Erica Miley
Wow. Yeah. Yeah. We've got a ways to go. For sure. I think too. So one of my really close friends who I've been friends with for maybe 15 years now, 14 or 15 years, is a sex. Certified sex therapist. And so just in conversations, because she's just very like loves to talk about sex, loves to talk about all of it. Super knowledgeable. I've been exposed to ideas, I've been exposed to kinks. I've been exposed to tentacle porn. Like I've been exposed to just in conversation, these things that I never in my normal day to day would have been exposed to. That also helps me broaden my horizons when I think about what if somebody comes into my office and says they're into tentacle porn? I'm not going to be like what's tentacle porn? You know, I'm going to be like, heard about it, you know, like what is it about tentacle porn that gets you excited? And so there's a certain level of comfort in just talking to people that have made their lives around sex or are comfortable enough talking about sex even beyond comfortable enough. Like I am right that I think if we can all have a good sex therapist friend, we can broaden our horizons either for ourselves or for our clients or for friends or family.
- [58:22]
Unknown Speaker
Yes, I, I, I am very glad that you, that you have that friend. And, and ultimately the most of us who, who do this work, we enjoy being that friend especially because so many of us, it's our like our special interest. It's like I want to know everything about this one thing. I want to know all of the narrow part of it too. And so I'm, I'm about to go to a conference that's all about the crossover between human sexuality and those of us who do like sex therapy or sex education and cybersecurity. And what, what do we need to do when we're doing those kinds of like when we're helping people on online or when people are disclosing their health information online or it gets exposed on because for profit by a company. Don't even get me started.
- [59:14]
Dr. Erica Miley
You want to get sued.
- [59:17]
Unknown Speaker
How do we as providers especially help keep our clients information safe? How do we keep our own information safe? And so I think the more and more that we as therapists are exploring it, you start to understand like oh yeah, I like I, I should know how like oh, I do do gender affirming care. I might not be a sex therapist, but yeah, I should know how to protect them because there are states that are actively trying to not and in fact trying to get their, their records in a centralized location. We live in a, we are living in a more and more dystopian looking time. And so the more that we kind of as, as therapists understand that oh, sex, sexuality, gender identity. All of these things are integral parts of our own education as therapists, but also that we. We can tackle our own issues around it. We really can.
- [60:23]
Dr. Erica Miley
Yeah. Yeah. I love it. Thank you so much for talking to us today. I think the more comfortable therapists can get talking about sex, which for many people is going to be working through some of their stuff with a sex therapist or with CES or whatever makes sense for them. I feel like it's going to help reverse some of the damage done by our cultures not talking about it because we are, as therapists, the place that you talk about the things we don't talk about in our culture. And so we need to be able to. To hold. Hold it all or at least have some level of comfort with it that allows it to be disclosed in a safe way for our clients.
- [61:08]
Unknown Speaker
Absolutely. Absolutely. Thank you for having me. Really?
- [61:11]
Dr. Erica Miley
Yeah, absolutely. I'm excited for more. I hope you enjoyed this not boring training. Grab your CES for it at not boring ces.com and use coupon code ABUNDANCE for $50 off.