Come As You Are with Emily Nagoski, PhD

In Come As You Are, sexual health educator, Emily Nagoski, PhD,  says that the most important factor for women in creating and sustaining a fulfilling sex life, is not what you do in bed or how you do it, but how you feel about it. This means that things like stress, mood, trust, connection, and body image are not peripheral factors in a woman’s sexual wellbeing; they are central to it. Join me in this episode of Natural MD Radio as I talk with Dr. Nagoski about what we can do to cultivate sexual wellbeing in our lives and for the next generation. On this page you'll find the audio of the our interview, a excerpted transcript of some of the juicier stuff we talked about, show notes, and links. I always love to hear your comments, so feel free to tell me what you found interesting and important. 

Emily began her career as a sex educator in 1995 as a peer health educator at the University of Delaware, trained to teach her fellow undergraduates about stress, nutrition, physical activity, and above all sex. Emily attended Indiana University where she received a Master's of Science in Counseling Psychology, completed a clinical internship at the Kinsey Institute for Sexual Health, and then earned a PhD in Health Behavior with a concentration in human sexuality. She worked as a lecturer and Director of Wellness Education at Smith College before transitioning to full time writing and speaking. Her job now is to travel all over the world, training therapists, medical professionals, college students, and the general public about the science of women's sexual wellbeing.

Emily is the author of a New York Times bestselling book which I couldn't recommend more, Come As You Are. Her newest book, co-written with her twin sister Amelia is Burnout: The Secret to Unlocking the Stress Cycle. She and Amelia are also launching a podcast in 2020 called The Feminist Survival Project.

The Interview with Emily Nagoski

Aviva: Emily, welcome, I'm so excited to have you on the show. Before we jump in: What is the most inclusive language that you like to use that we can use together in this interview?

Emily Nagoski: The way I typically approach this question of bodies versus cultural identity is with a caveat that almost all of the research that exists on sexuality is on cisgender people. These are people who on the day they're born, the adults around them look at their bodies and go, it's a boy or it's a girl and then they raise that person as a boy or a girl and that person grows comfortable in the psychological identity and the social role of man or woman. And we all know by 2019 surely that there are people who identify as men or women for whom at least one of those things is not true. And there are people who identify as something other than men and women. Those people deserve to be represented in the research. They deserve access to high quality evidence-based sex education and the research is not there yet. So if we can include a caveat that when we talk about the research on how sexuality works, when we talk about evidence-based interventions around sexuality, we are just talking about cisgender people. And at the same time I have no particular reason to believe that these things are different for trans or non-binary identified folks. There is no particular reason why that should be true, but because the research isn't there yet, I can't necessarily say.

Aviva: It's really exciting though, like times are changing. I feel that we're even having this conversation is really exciting.

Emily Nagoski: Yeah. I think it is absolutely getting better. If we take the long view, like the last hundred years we've made so much progress, but it's hard to remember that when you're here on the ground looking at how far we still have to go.

Aviva: What got you to actually teach your fellow undergraduates about the things you were teaching about and how did sex become the center of your focus?

Emily Nagoski: I was going to be a clinical neuropsychologist. I wanted to work with people with traumatic brain injury and stroke. I love the brain stuff. I still do. I use that science all the time. I'm grateful that I have that intellectual background, but when it came to the end of my undergraduate degree, I looked at what I had done over the previous years and the work I was doing as a sex educator made me like who am I as a human being in a way that the academic intellectual brain stuff just couldn't. And so that's the path I chose.

Aviva: We both agree like if you look at a hundred years ago, even we look at let's say the turn of the century, the 20th century where women could be locked up for hysteria, which could mean having a baby and not being married, right. Or female circumcision was done in the United States. We've definitely made some progress here, but where are we now in the scheme of healthy sexuality as women?

Emily Nagoski: When I think about what it feels like to be a sex educator now as opposed to 20 years ago or even just 10 years ago, the main thing that I feel like is different is the presence of sexual violence survivors in the room talking about sexual pleasure. The “me too” movement in particular has made I think a permanent difference, a real shift in validating the stories of sexual assault survivors. They are coming to classes that are focused on sexual pleasure. They are talking about survivorship and the way it impacted their relationship with their sexuality, sexual pleasure, their own bodies. And they are taking steps to reclaim access to sexual pleasure in defiance of everything that our culture says a woman is supposed to do. They're just going ahead and being like, you know what, I have a right to control my own body and to access the pleasure that is my birthright. That has felt like a really big change in the last 10 years.

Aviva: That's very huge. It's good sharing that. It's really, really good. Yes.

Emily Nagoski: There's more good news too around trans folks and non-binary. 2014 is when Come As You Are went to press and I had to fight through three copy editors to keep the singular “they” in my book and to even have a caveat that mentioned that the science is pretty exclusively Cishet men and women. [*Cishet describes a person who identifies as the gender they were born as and experiences attraction to the opposite sex.] My editor was really worried that it was going to be alienating and certainly they weren't going to use the singular thing because it was ungrammatical. I think Come As You Are was the first book Simon & Schuster published that has the singular “they” throughout. As of 2019 and I was able to take out some of the more hedging language around trans and non-binary folks and I can just assume that a reader has an awareness that trans and non-binary folks exist and they deserve sexual pleasure too. Things have absolutely gotten better in terms of like the mainstream visibility of and acceptance of trans and non-binary folks. That's getting better slowly.

Aviva: There's a definite shift in women's sexuality that I'm seeing and what is sometimes being called the sex positive movement. On the one hand, I feel like there's amazing liberation happening, for example 60% of women own at least one vibrator. And we can read about it in a news stand magazine. You can be on the train and read about it if you want to – with somebody looking over your shoulder. We're in a different time than let's say even 10 or 15 or 20 years ago. We talk about masturbation in a way that I jokingly say would make pastors of the earliest 20th century go blind if they heard about it. For those of you listening, it used to be said that if you masturbate, you go blind. Even anal is a sit-com topic, right?

This is like a great shift in one way. But on the other hand, I'm seeing something and hearing something from women who are coming up to me, you know, at conferences, if we're talking about sexual health in my patient population and especially from young women in hetero relationships, but from women in general, that this new normal is pushing them in a way that they're not comfortable with. They feel like they're not prudish, but there are things they don't necessarily feel comfortable with or want to do.

I'm just really curious personally what you think about all this. I usually just say to women, look, if you're not comfortable with something, then talking about it is the most important thing to do. And if you're in a sexual relationship where you can't talk about this, then that's something to think about too.

Emily Nagoski: For me, the definition of sex positivity is simply that everyone gets to choose how and when their body is touched and they get to choose how they feel about their body. Just basic bodily autonomy for me is what sex positivity really means. Everybody gets to be in control of their own body and part of what comes with that is you may have an emotional reaction to the idea of what somebody else likes. It may appeal to you, it may make you sexually drawn to them. It may disgust you and make you want to create distance between yourself and them. It doesn't matter because their sex life has nothing to do with you in the same way your sex life has nothing to do with them. So for me, sex positivity is just this neutrality.

Part of my training as a sex educator is exposure to lots of bunch of porn, every kind of porn you can imagine – and some you don’t want to imagine – from all across history. And a lot of it is really violent. Almost all of it is misogynist because that's also true of the world that produced the porn. It's my job to be able to hear a person's stories  and not react in a judgmental, critical, emotionally disgusted way, to be really neutral and to hear like if you want to talk about poop play, you can talk about poop play and I am not a person who's going to respond negatively to that. If you want to talk about how you like to have the shit out of you, okay, you can talk about that with me and I'm not going to have a judgment one way or the other. That's my job. Because if I have a reaction, then are you going to trust me as a sex addict?

The other piece of it is that porn is really terrible sex education. I tend to say that trying to learn about sex from porn is like trying to learn how to drive by watching NASCAR, professionals on a closed course with pit crews; you are not going to learn how to drive on a regular highway by watching professionals do a spectacular thing, or like learning how to wrestle by watching WWF. That's entertainment. People don't necessarily have sex in those positions that they do in porn. Those are positions that look really interesting on camera or those are positions that give the camera access to the genitals. Those are not necessarily positions that give the people having sex a great deal of pleasure.

In fact, the focus of porn is not the pleasure of the people who are engaging in that sex with each other, but rather on what it looks like on camera. It's really bad sex education and in a context where in America in a lot of states we’re still allowed to lie to children about the efficacy of contraception or about sexual orientation. We're still allowed to talk about abstinence until marriage. Our sex education is so terrible. Of course, young people are looking on the internet. They're finding porn and that's filling in the vacuum that we have left for them. Add to that adult caregivers who don't feel awesome talking about sex with their kids.

I had a person who read Come As You Are tweeted at me that she was watching her adult brother change his baby daughter's diaper. She was all clean and ready for her new diaper – Dad goes and gets the new diaper. When he comes back, she is touching her own genitals. Dad says, “don't touch that.”

Aviva: I was just talking about this on a podcast interview the other day. Someone asked me about sexual health and I said, well, you know, it really starts at that moment. Our own sexual comfort starts at that very moment. I think with little boys, we tolerate it more actually than we do with little girls.

Emily Nagoski: 100%. What would that dad have said or done if his little baby had a penis and when he came back his baby was touching his own genitals. Totally different reaction. Or if his baby had found her feet instead. We love it when babies find their feet and put them in their mouth. Right. Like all that. So what if we had that same emotional reaction when they find their genitals? Genitals are wonderful. What a gift they are.

Aviva: What is really great sex education? What does that look like?

Emily Nagoski: For me, when adults are trying to communicate effectively with young people about sexuality, the most important thing is that they be aware of and try to process their own emotional baggage. All the crap we absorbed from our culture about sexuality, that we begin communicating to our children without even knowing that we ever possessed that baggage. My go-to example in my own life is the day I was at the library. I was about 11 years old and I must've seen the word vagina in a book because on the drive home with my mom, I said, Hey mom, what's a vagina? And I do not remember what she said, but I remember the enormous flash of emotion that just shot through her body, the embarrassment and the shame and sort of horror and disgust. And I was like, I still don't know what this vagina thing is, but I do know how to feel about this vagina thing.

When I got home and looked it up in the medical encyclopedia in our house, I then knew what it was and I knew from my mother how I was supposed to feel about it.

So, I'm sure people hearing my story about like a child touching her own genitals have a flash of emotion and a contradictory story. A therapist who came to one of my trainings pulled me aside afterwards and said, I have to tell you the story about my child. When she was two years old, she was on the bouncy ball, the hippity hot ball, and she said, ‘mommy, this feels really good.’ And mom says, ‘honey, that's your clitoris.’ And the child two years old says, ‘my clitoris is my favorite.’ There are some people who are hearing that story and they're like, yes! And there are other people hearing that story who are like, ugh.

I might not even be able to explain what it is about the idea of a little girl learning to love her own clitoris that makes them feel worried or disgusted or ashamed or angry, and that has a name that's called a moral dumbfounding when you don't know what's wrong about it, but something inside you just tells you that it's not right. And that's the old stuff that is exactly the stuff to notice happening in your body and process it and try on the idea of viewing your child's relationship with their genitals in the same way you view their relationship with their feet and their elbows and their face. Like you want them to cherish their own body.

What if their relationship with their genitals is basically the same as their relationship with all their other parts? Yeah, there are cultural rules they have to follow. And there might be hygiene rules. I have a sex educator friend who tells her daughters we don't touch our vulvas at the dinner table. That's fair. And if you're going to touch those parts, you do those at home in your own room. That's fair. You don't have to introduce the idea of shame and disgust and hiding the emotion that goes with it. It doesn't have to be like shutting the person down and teaching them to dislike their own body.

If we teach our children not to be ashamed, then it gives them this sort of like protection. It's like an inoculation against the cultural shame that they are going to be exposed to.

Aviva: I think too, and not to say that that awareness is protection against micro and macro aggressions and assault against women, but I think for me at least, my sense of it is that when we feel more confident in our bodies, we're more aligned with our bodies. We actually trust our inner radar for safety a little bit more too.

Emily Nagoski: It's a preventive intervention to teach people to love their own bodies. Body self-criticism, body shame is a very powerful predictor, not just of sexual dysfunction and sexual pain, but also unwanted pregnancy, unintended pregnancy and sexually transmitted infection. Not using condoms and protection. Because, of course, if you feel shut off from your body, if you feel like your body doesn't deserve to be healthy, if you feel like all you want is to make sure this person is willing to engage with you sexually so that you can feel loved and appreciated and you don't want to offer any more reasons for them not to engage with you, like asking to use a condom, then you're not going to ask for that. You truly are protecting your kids when you're teaching them to turn toward their own body with kindness and compassion and trust.

A thing we teach girls in particular is to believe other people's opinions about their bodies more than they believe their own internal experience. This is a really powerful lesson. In Burnout Amelia and I call it human giver syndrome, where we teach women and girls that what you get taught is that you have a moral obligation to be pretty happy, yet calm, generous, and above all attentive to the needs of others. So if your internal experience is inconvenient or distressing to the people around you, you start wearing the mask, you start dismissing and ignoring your own internal experience because everyone around you needs you not to feel that way. And so you just don't feel that way.

Aviva: Yeah, I call it helper syndrome. And there's some really interesting data too when we talk about this syndrome, from sociologic studies that look at what's now called emotional labor. This work that women do to tend to the emotional needs of everyone else. It can be at a board meeting; you could be the CEO of a company and you could still be doing it to the other people, predominantly the men in the room. It's really a hidden cause of exhaustion that I think a lot of us don't realize we're carrying.

Emily Nagoski: Oh, absolutely. Yeah. We have the responsibility to put the smile on our faces and go ‘thank you for that feedback. I understand where you're coming from and let me apologize for myself too.’ ‘And, let me know if you've already heard this before, and this is probably a stupid idea, but I just want to…,’ and you do all this apologizing.

I think for what the idea that you have and you know it's actually not that sort of like helping other people regulate their emotions that's the problem. It's the imbalance. It's the problem that women are carrying the entire burden of helping the men in the room cope with their uncomfortable feelings, making sure they don't make anyone feel threatened, which is so easy to do when you're a woman, like anything you do that's remotely competent is going to make somebody feel threatened. So you have to do this apologizing and what matters is that the other people feel entitled to your apology and your smile and your calmness and your self-regulation. When Fiona Hill was testifying to Congress about this, she talked straight up. Unfortunately when women are angry, they're often dismissed as just being overemotional when actually they have a serious concern and so they don't get heard.

I don't want us to live in a world where everybody feels like they just get to like spit out their emotions as weapons against other people. I want us to live in a world where everybody feels responsible for tending to the wellbeing of everyone else because if you've had a long, hard day and you get home, if you come home to a house full of other givers of fellow givers, they're going to notice that you're exhausted and they're not going to say, well, but what's for dinner? They're going to say, you go take a nap and then have a shower. We'll make the stew after your shower and nap. You come down, we will have dinner and a glass of wine and we will talk about our feelings and it's going to be awesome when we are all cared for, when all the people around us turn with kindness and compassion toward our difficult feelings in the same way that we feel obliged to care for other people. That's where peace comes from, not from everybody feeling entitled to be as cruel and vicious as masculinity says men are supposed to be.

Aviva: Well, I also think that, and maybe this is my upbringing as a New Yorker, but I think that there's a certain release to being able to fully express rage, to be able to fully express sadness, to fully express grief. And if that means yelling and screaming for two minutes, it doesn't mean you have to do it at someone or in a way that makes them wrong or bad or small or hurts them. But I do believe that we need to discharge these emotions. I also just read a study on women in very difficult marriages. There's been a lot of research over the years looking at the increased health risk of women who are in difficult marriages. This particular study was fascinating because it says that it's not just being in a difficult situation, it's actually being in a difficult situation and not expressing yourself, not raising your voice, not using your voice.

Emily Nagoski: It's being trapped. That's the problem – being stuck. Exactly.

Aviva: Unable to change. And that kind of comes back to autonomy that you talked about earlier, right? I mean, one of the biggest health measures is the ability to have autonomy.

Emily Nagoski: Yes. Our definition of wellness is actually that wellness is not a state of mind. It is not a state of being. It's a state of action. It is the freedom for your body to move through the cycles and oscillations that are inherent in living in a mammalian body. That's the cycle of stress into stress, back to relaxation, back to stress, back to relaxation. It's not living in a state of living in eternal bliss. It's when you get stressed out, which you're going to get, knowing how and having the opportunity to let your body go all the way through that so it can transition hormonally, literally physiologically transition out of the stress response and into the relaxation response. But also from attentive effort into rest, back to attentive effort, back to a rest. We’re not supposed to live in a state of perfect peace and rest. We're not supposed to sleep all the time but we are supposed to sleep.

Aviva: I talk about it like a piece of elastic – for elastic to maintain resiliency it has to be able to stretch and then rebound to its resting state.

Emily Nagoski: That dynamic process is what normal looks like and it's the same with connection. Connection is complicated to talk about, but basically the way Amelia and I have been able to wrap our brains around the research is to recognize that humans, yes, we are a massively social species. Jonathan Haidt calls us 90% chimp, 10% bee – we are basically a hive species. We are built to oscillate into deep connection and back into autonomy and independence or even isolation back to connection and back to autonomy.

Aviva: It's interesting, it really explains why being a new mom can be so exhausting, especially when people are doing attachment parenting, right? You don't get that autonomy part of it unless you really cultivate it.

I want to switch gears again a little bit. It was the thread where we were talking about women being emotional. Listeners might not know the term hysterical was actually used to define women's emotions as a disease and was rooted in our uterus. This idea that when we express emotions, one of the ways that's described is as being hormonal. So we've got a lot of cultural baggage where we blame our hormones for things. And one of the areas I'd love to talk with you about briefly at least is what I was saying in air quotes earlier – female sexual dysfunction – because, for one, women who are going through whatever their own sexual challenges at the time, may be diagnosed with something called female sexual dysfunction.

But the history of this condition, if you will, is one of the classic examples of what we call the manufacture of illness. There was a pharmaceutical, next there was a condition, and next that pharmaceutical could be applied to that condition. And wham, it was in the Diagnostical and Statistical Manual of Mental Disorders (DSM) as something we can label women with. There's so much to unpack around women's sexual health, and this is what you do so tremendously in your book.

Talk to me about female sexual dysfunction. A lot of women think that when they're having a sexual challenges in their life, whether that be response issues, challenge experiencing orgasm, desire, libido, whatever we want to call that, it's their hormones. But statistically that's actually a pretty small amount of the time. Very rare. What's going on? Let's talk about cultural context, what women's experiences are, and also what is that point in your work with women where you say, okay, maybe something is physiologic and let's explore this. How do you define that?

Emily Nagoski: I will start at the end. When I think it’s physiologic and that there might be something going on there is when there's pain – if you're experiencing pain, talk to a great sex, positive medical provider. It is unfortunate that a lot of women go to medical providers with sexual pain and their pain is dismissed. They're told that that's normal. They're told just have a glass of wine…

Aviva:  …use more lube for foreplay. I know I've had so many patients come to me with this, these stories that having been dismissed.

Emily Nagoski: And the thing is there are evidence-based treat based treatments for a lot of different sexual pain disorders if they can find a provider who's willing to take their pain seriously. So if there's pain, look for a physiological cause or at least a psychophysiological cause. I believe that physical therapy is the future of sexual pain treatment a lot of the time for people with vulvas.

Aviva: I couldn't agree with you more. I think pelvic floor physical therapy isn't absolutely brilliant.

Emily Nagoski: Yeah, that's the place that people are ultimately going to end up when they're looking for treatment around sexual pain that isn't just vaginal dryness in which case. So tearing if you're menopausal, that's the thing that happens when estrogen levels get low. Use more lube and talk with a medical provider about a hormonal intervention. When it's desire, I have not found any particular evidence that there's any hormonal anything that is usefully predictive of sexual desire situations.

Aviva: Sometimes I find that low thyroid, if someone just really tired in general, that can be associated and then sometimes I find that if somebody is really just burnt out and exhausted, so maybe there is a cortisol piece to that. Do you?

Emily Nagoski: Yeah, but if you fix the tired, there's a lot of ways to fix tired. And there's a lot of causes of tired and there's an interaction like where do we identify the causality? Is it their actual thyroid? Is it the situation that is burning out their hormones? Is it the combination of working a full-time job in raising two small children and being married to a partner who doesn't feel responsible for taking care of the second shift.

When I was reading the sleep research, the sleep researchers use this phrase, the third shift. The first shift is your paycheck job. The second shift is the housework and childcare that keeps a family together. And the third shift is the time at night when we're all supposed to be asleep, but we are not all equally sleeping. Women are just expected to disrupt their own sleep.

I hope people are all aware by now of how essential sleep is to our basic wellbeing. You want to talk about like hormonal impact. What happens to your cortisol level when you're getting poor sleep? What happens to your adrenaline levels when you're getting poor sleep? Depression, anxiety, which women experience at twice the rates of men, are causally linked to sleep disruptions. So do we want to tie the cause to the hormone situation that happens as a result of the disrupted sleep or are we going to identify the culture that prevents women from having access to the sleep their body requires, the relationship where their partner is not showing up for them to get adequate sleep. I don't know where we want to diagnose, but they're all the same story.

When I talk about like diagnosis, I like to situate the diagnosis in a place where direct intervention is going to create positive change and very often, especially for women in like long-term, maybe monogamous, not always, but sometimes monogamous relationships. The difficulty is not in them, especially like if things were great before but it's been 10 years and things are not great now. It's almost never the case that something is wrong with an individual's body. It is nearly always the case that there's something that changed in the context in which their body is trying to operate.

Aviva: Exactly. A lot of women to say to me, look, the partner I married 30 years ago does not look physically appealing to me anymore. And they're really struggling with that, right? They're like, yeah, this isn't turning me on anymore. What do I do? And it's like reframing. I find I work with a lot of women around reframing expectations, being okay with fantasy. When I say reframing expectations, if it's like what their partner looks like, what is it that we buy into when somebody looks one way but then maybe has less hair or a different body shape. Or the stressors in their life of caring for an older kid who may be having emotional challenges in college or as an adult or caring for older parents. There's so much that affects our context.

Emily Nagoski: The baseline way to begin thinking about the way sexual sexuality functions is with the dual control model. The mechanism in our brain that governs sexual response. There's the sexual accelerator or gas pedal that responds to all the sexy information and sends the turn on signal. And then there's this sexual brakes which notice all the kinds of reasons not to be turned on right now, and it sends the turn off signal. So arousal is a dual process of turning on the on's. It's a dual process of turning on the on’s but also of turning off the off’s. And when people are struggling around sexuality, sometimes it's because there's not enough stimulation to the accelerator, but it's much more common for the cause to be too much stimulation.

The thing is, all the things you were talking about can hit the brakes. Stress is maybe the most common factor that hits the brake because it's so common and so many of us think we're supposed to just be able to shut it off spontaneously and without effort instead of allowing our bodies to go through a process.

We think just because we've dealt with all of our stressors, all the causes of our stress, that means we've dealt with the stress in our bodies and that's just not true. Unfortunately, evolutionarily the things that deal with our stress have almost nothing to do with the things that help us deal with our stressors in our lives. So we have to do intentional things to let our bodies complete the stress response cycle so that can stop hitting the brakes so that our accelerators freed up to do what it wants to do.

And then there's the body image piece. There's the like culturally constructed, aspirational beauty ideal that shapes our perception of our own bodies and our partner's bodies. The whole point of a long-term relationship, which many people aspire to, till death do us part – which means that if you meet your partner in your 20s or 30s, those of us who are lucky enough to get old are going to watch our partners body’s change and they're going to watch our body’s change.

There's a wonderful book coming out in 2020 called Magnificent Sex by Peggy Kleinplatz and Dana Ménard in which they interviewed dozens of people who self-identify as having extraordinary sex lives. The average age at which they had their first extraordinary sexual experience, do you want to guess?

Aviva: I'm going to guess 58, 62, somewhere around there. I'm cheating cause I've read a lot of the literature.

Emily Nagoski:  Somewhere around 55, I'm so excited about this book, but one of the most important ideas I got when I read it was recognizing that things we classify as disability or health issues, which so often can interfere with sexual functioning, won't necessarily. It's just about how you frame those body changes and the issues you may have with your health or with pain.

So much so that people who have like CUPD, for example, and use oxygen masks don't even perceive that as being something that interferes with their sexual wellbeing. It's just part of who they are and they don't let it be a thing that hits the brakes. That's just the body they have and they access the pleasure that this body has access to.

Aviva: Shirley Chisholm had a quote which said something to the effect of we not only have to free ourselves from the stereotypes that our culture puts on us, but from the ones that we've come to believe. And it's really fascinating to me how many women, I think in a way kiboshed their own sexual experience with this internalized idea, which we have so many cultural visuals that reinforce, of like once you get to a certain age you're not sexual and every bit of this research that's coming out shows that 50 and above you start having the best sex of your life.

Interestingly, I work with a lot of women in their 20s who really have a tough time there. They're either not having sex as much as they would have expected or hoped for. It seems like there's a lot of digital devices getting in the way of connection and sex time. But sexual pain seems to be a really big factor for women, particularly young women, endometriosis, other causes of pelvic pain, and I know you talk a lot about that in your book too.

I really can't recommend your book. I get a lot of books and they end up on a kind of bottom shelf or given away. I think yours is just one of the revelations of books that have come out. I think for me, I first started becoming aware of my cycle, got that wonderful hand mirror, all of that when I was 15, which is when I got a copy of two books. One was Our Bodies, Ourselves of course. And another was a book. I don't think it's in print anymore, called A New View of a Woman's Body. It was just photographs of vulvas, clits. Picture after picture of woman after woman. At that time it would have been biologically born women, but all cultures, all ages. It's really magnificent.

Where was I going with that? I had such a wonderful kind of very early in my life, entree into sexual health, and I became a midwife so young, I'm still so surprised sometimes at how uncomfortable women are looking at their bodies. I had an experience many years ago, this was around ‘97, ‘98. I had a woman who had grown up in a very religious, kind of restrictive background, very body negative, particularly around women's bodies and she was pregnant.

She went into labor and when she went into labor, she called me on the phone. She was planning a home birth. She was out of her mind with discomfort and anxiety and fear. So I went over and I checked on her. I did a public exam at that time just to feel how her cervix was dilated because the way she was acting, I thought, maybe she's actually just a lot farther along than I think she is and maybe that's what's really going on here. And she was not dilated yet.

Through our conversation together, through having known her through the pregnancy, something struck me as this sort of intuition. One of the big things that was a clue for me was toward the end of the pregnancy she was really clear. She didn't want to see the baby coming out and she didn't want her husband to see her naked. And she told me that they'd been married for like 9 years at this point and he had never seen her fully, fully naked. There's a certain amount of ability to be comfortable with our sexuality and open up that does really facilitate a home birth for most women. And so at this point I was like, I'm going to give you this hand mirror. I'm going to go on the other room. And it was like the equivalent of giving someone who's exhausted stress and been in labor for days an epidural and their body just opens up. It was like that. The transformation of just looking at her vulva getting comfortable with such a switch.

She came out of the room, she's said ‘I had no idea. It's really cool down there. It's really kind of beautiful.’ And I was like, yes. And she went on into labor full-on later that day and she had a beautiful home birth that night. What was really amazing was she gave birth with her husband sitting on the edge of the bed, her sitting in his lap with her legs spread open in front of a full length mirror. So I kept moving to the side so that she and he could see what was going on. It was transformative. I know that in your book you talk about the mirror exercise. Tell me what you think is the role for this in women's sexual health and sexual awareness.

Emily Nagoski: I can say for me, when I was 18 years old, I did not have the early start that you had, but I did have the fortune that at 18, I was being trained as a peer sex educator. I was given the homework assignment to go home and look at my own genitals, which I had never done. And remember that when I had asked what a vagina was, my mother had responded with horror and disgust. When I picked up that mirror, I felt like I was going to confront an enemy. I had never received an explicit educational anything that told me to feel disgusted or horrified by my genitals, but that was absolutely the message that I absorbed. And so I went and I looked and I instantly burst into tears because when I looked, I had the same experience – ‘Oh, it's just, it's just part of my body. It's really interesting. It's just normal and part of me and mine.’

And ever since then I go back to that moment as the touchstone that, no matter how much affective neuroscience I love to talk about, no matter how much I love endocrinology, ultimately the most important source of wisdom anyone has about their sexuality is their own body. If they can turn toward it with kindness and compassion and welcome it exactly as it is right now instead of trying to make it into something that they think it is supposed to be.

Your story actually reminds me of the ways that people who experience a Phantom Limb Syndrome – if they've had a limb removed, but they're still experiencing pain in that limb. If you put the intact opposite limb, so if your arm has been removed at the elbow, but you put your opposite arm in front of a mirror so your brain can see in the reflection what it would look like if you did have that hand, instantly the pain goes away. If we can just let our brains see what's happening down there. There's this really powerful complex relationship between our emotions and our experience of pain. Our brains sense that there is danger and if we can teach our brain that our genitals are not dangerous and we don't need to be afraid of them, it goes a long way in helping us to access pleasure and to reduce pain and shame and distress.

Aviva: It's so beautiful. I mean there's so much research that shows us, and of course women who have experienced trauma know this in their bodies fully, the connection between what has happened to us, but also the connection between cultural microaggression – how we think, how we think about our bodies, how we think about our cycles, how we think about menopause actually shapes our physiology. It's astonishing.

Emily Nagoski: When I talk about that research, it's complicated because on the one hand it is absolutely true that our emotional framework for an idea shapes how it impacts our body. And that sounds a little bit like if you're experiencing pain, it's because you have the wrong beliefs.

Aviva: I don't want it to sound like blame either because it can really quickly get into that as well. And it's absolutely not that either. It's really just basic pain physiology.

Emily Nagoski: Yes, it is. I am counting on medical providers and sex educators like me and therapists getting better and better at being able to talk about the relationship between our beliefs and attitudes and the way our physiology functions. It makes perfect sense that if we believe that our body is dangerous and disgusting, that emotion is not just like an idea. It exists in our bodies physiologically. There are hormonal and chemical changes that happen inside us because emotions are body processes, they exist physically in your body. Emotions, they're real. And I don't just mean we can't dismiss them. I mean they physically happen in your body. So it makes perfect sense that if you're in one emotional state, that is to say one physiological state, that's going to change the way your brain perceives a sensation. We know too that to be true, like with tickling, we can all accept that if you're in like a sexy turned on playful state with somebody you really love and trust and they tickle you, that can feel great. But if that exact same person tries to tickle you when you're in the middle of an argument and you're really pissed off, that same sensation from that same person is just going to make you want to punch him in the face. There's nothing wrong there, but the context changed, your chemical state changesd. So of course your perception of that sensation changed.

Aviva: Speaking of wanting to punch someone in the face, I think that Jada Pinkett Smith wanted to punch TI in the face, pretty much. You talk about hymen truths in your book. It's funny, until I read your book, I hadn't thought about that. I had never had a woman or a mom or a young woman who I was doing a first pelvic on – nobody's ever actually asked me, is her hymen intact? Is my hymen intact? So I learned something very new when I read that in your book. And then there it was in the media recently. What happened?

Emily Nagoski: I actually had not thought about the hymen at all until I was teaching my class at Smith College. My first class is always the anatomy class. I show a bunch of pictures and a student raised their hand and asked about the hymen in particular – how to break a hymen if you're having sex with a partner who doesn't have a penis, how do you break a hymen? And I was like, why does this matter so much to people? Why is this a question people are being really persistent in asking? It sort of confronted me with the idea that people really care a lot about the hymen. They have a lot of questions. And so it sent me down this rabbit hole and it turned out everything I had ever been taught about the hymen was wrong.

It does not change size just because a vagina has been penetrated. Some people are born without hymens. Some people who've given birth, their hymens are still intact. If a hymen does break, you know it's tissue. What does tissue do when it gets damaged? It heals, right? Of course it does. It makes so much sense. It doesn't make any sense to imagine that it just breaks, except that that's what we get taught. It's this beautiful example of the difference between the biological reality of our bodies and the cultural script that we're handed. Here is this fold of tissue that has no particular biological function much, and it's given so much cultural importance that a person's life can literally depend on the size and shape of this fold of tissue at the mouth of the vagina.

Aviva: Absolutely. In many cultures, people can be literally killed. And this is sort of this cult of virginity and this double standard because nobody thinks about that with toys.

Emily Nagoski: Yes, literally. And virginity checks, even though as we now know the size and shape of a person's hymen does not give us any information about whether that vagina has been penetrated,  And there's like a geek nerd part of me that's like, that's not even an accurate measure of the thing you're trying to measure. That's an invalid test.

Aviva: So, if there were three myths that you could say, all right, there are three myths I really want to dispel for women, what would those be?

Emily Nagoski: First, that there is not necessarily a relationship between what your genitals are doing and how turned on you feel. This is called arousal non-concordance. When there is not a match between what your genitals are doing, like how much blood is flowing to your genitals or how wet your genitals are getting, when there's a mismatch between that and how you feel, how you feel is what's true and right. So, if your genitals are responding and you're like ‘it is meh,’ you are right that it is ‘meh.’ Just because you don't want and like what's happening, it doesn't matter what your genitals are doing.

This is a phenomenon we are all very able to understand when it is any physiological experience other than sex. If it is a person bites into an apple and it turns out there's a worm in there but their mouth waters, nobody's going to say, well, your mouth watered. You just don't want to admit how much you liked that worm. We all understand that how a person feels trumps what their genitals are doing, what their physiology…

Aviva: …back to paying attention and trusting and honoring what our body's telling us.

Emily Nagoski: Given the helper syndrome, the human giver script, women in particular are prone to believing other people's opinions about their bodies more than they believe what their own internal experience is telling them. It doesn't matter what your physiology is doing, you can trust what your internal experience is saying.

Two, I would say sexual desire. The script we’re handed about sexual desire is that it's supposed to just appear out of the blue spontaneously. Erika Moen, the cartoonist who illustrated Come As You Are, draws spontaneous desire as a lightning to the genitals. You just want it. And that's absolutely one of the healthy, normal ways to experience sexual desire. But it’s actually very common to experience this other way called responsive desire. Spontaneous desire emerges in anticipation of pleasure. Responsive desire emerges in response to pleasure. So instead of just being kaboom out of the blue, it's like you and your long-term partner are – Saturday at three o'clock, you, me, and the red underwear? Let's do this thing. And you send the kids to the [inaudible]. You lock the doors and you turn off the phones and you put your body in the bed. All right, let's go. Your skin touches your partner's skin and your body wakes up and goes, all right, I really like this. I really like this person. That's responsive desire and it is very typical of healthy, normal sex in long-term relationships. Couples who sustain a strong sexual connection over the long term are not necessarily couples who constantly can't wait to get their hands on each other. They're really good friends who prioritize sex. They decide that it matters for their relationship, that they spend time just doing this slightly silly thing that humans do.

Aviva: I think this is so important. You're emphasizing long-term relationships. I would add to that women who have young children because a lot of times you feel touched out and so your desire to initiate just isn't there. You can think you have low libido, but actually you're really just more in that responsive place. And similarly when you're in that sort of peri-menopausal but especially post-menopausal place, maybe you do have a little vaginal dryness. Maybe hot flashes woke you up 6 times the night before. Maybe you have a lot on your mind. Maybe there is that sort of body image stuff going on. I really talk with couples at that point, and I see this more in heterosexual couples – I see this less in women having sex with women – but in heterosexual couples I really need to explain to the male partner, ‘Hey, this is on you to maybe do some extra giving, nurturing, gift giving, making things sexy and special and reaching out because a lot of women will respond readily and pleasurably.

Emily Nagoski: Absolutely. This is the beautiful thing about responsive desire. If you can embrace it as this is a normal way that sexual desire functions in our relationship. You ask yourself the question that Peggy Kleinplatz, the sex researcher and therapist, asks her clients, which is what kind of sex is worth wanting. And then once you know the answer to that question, you can wonder how do we create that in our relationship?

Aviva: It's so beautiful. I think it's so liberating. We get such false ideas of sex, orgasm, pleasure, stimulation from pretty much every media source, every TV show, every movie. So to really look at this as conversation cultivation and a choice is really beautiful. Okay, third myth.

Emily Nagoski: That you have a moral obligation to conform to culturally constructed aspirational ideals for how you should look, how you should feel and how you should behave. If you violate your role as a human giver, yes, our culture is going to try to punish you for violating your moral obligation to be pretty, happy, calm, generous, and attentive to the needs of others. But if you can create what Amelia and I call the bubble of love, where you're surrounded in your family by people who welcome you precisely as you are – with your body, precisely as it is, with your emotional state precisely as it is – and can create space for that freedom to move through the process of living in a mammalian body. That is all you need. You don't have to perform for all those strangers who will judge you. You need to create for yourself a pocket of beautiful, protected love where you are welcomed and accepted precisely as you are right now.

Aviva: You wrote that you wrote Come As You Are because you're done living in a world where women are trained from birth to treat their bodies as the enemy, and you have created in your book this truly incredible bubble of love. I think that it's one of the most woman-body-human-sex-friendly and instructive books out there. And I did not have Emily on this show to promote her book. I don't do that and I'm not paid to do this. I really love this book and that's how I pick guests. So I really encourage everyone to read it, and own your body, own your pleasure.

Emily, you say you offer training for individuals and professionals. For folks who want to study with you beyond your book, let's say there are professionals, what can we do?

Emily Nagoski: Most of the time when I do trainings, especially at the professional level, there's a practice that invites me to come and work with a dozen or all of the medical providers in the practice or the therapists in the practice. And that's my favorite thing – to create like a day or two, like get together with your colleagues, cordon off some time when you're just going to spend time thinking about sex. It is a glorious moment of permission to learn about sexuality for a couple of days by setting aside all the other things you're going to do. So invite me. I love it.

Aviva: And everyone get Emily's book or books. Both of the books are wonderful.


Show Notes

  • How Emily Nagoski became a sex educator – and why.
  • The problem with heteronormative research.
  • What’s gotten better in sexual health in the past century and decades.
  • Why brain studies on orgasm are limited.
  • The need for women to stop apologizing.
  • Big changes for the better in sexual health in recent years: Sexual survivors speaking up – and experiencing pleasure.
  • There's more good news too around acceptance of trans folks and non-binary needs.
  • How many women own at least one vibrator.
  • What turns your sexual accelerator off, and your sexual break on.
  • What sex positivity means to Emily (hint: defining what it means to YOU).
  • Why putting down our own baggage is important four our kids’ sexual health.
  • Why we need to stop teaching girls that other people's opinions about their bodies is more important than their own internal experience.

Links Mentioned

Where to find Emily online: Website | Instagram

Buy a copy of Come as You Are: The Surprising New Science that Will Transform Your Sex Life

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