The Holistic Intersection Between Psychiatry and Sex Therapy with Dr. Elisabeth Gordon

Sexual health is often treated like an extra part of healthcare, something private, something felt embarrassed, ⁓ optional, or just only relevant when there’s a crisis. But sexuality isn’t separate from mental health. Physical health, identity, relationships, pain, hormones, trauma, medication, culture, or nervous system regulation. And when patients don’t feel safe bringing it up,

important clues get missed. Today’s conversation is about changing that. We’re talking with Dr. Elisabeth Gordon, an integrative sexual health psychiatrist and sex therapist, about how sexual concerns can be understood through a whole person lens. Mind, body, story, relationship, physiology, and nervous system. We’ll explore how to reduce shame, how to ask better questions, what clinicians often miss, and what listeners can begin practicing right away to feel more connected to their bodies, their needs, and their right to seek support.

Welcome back everyone. Welcome back to the vocal pelvic floor. I am super stoked to welcome Dr. Elisabeth Gordon to the show today. Welcome.

Dr. Elisabeth Gordon, MD, CST (01:19)

I’m so glad to be here. Thank you for having me.

Dr. Ginger Garner PT, DPT (01:22)

⁓ this is going to be the best conversation because you have such a unique lens on this. so, dear listener, let me tell you a little bit about Dr. Gordon. She is a board certified psychiatrist and certified sex therapist who specializes in sexual health, which is already like a one to amazing, ⁓ you know, like knockout thing. She has a New York City based private practice, and she’s also an educator, speaker, researcher and writer.

dedicated to de-stigmatizing and improving sexual health and increasing the understanding of how sexual health is bi-directionally correlated with all health. And so therefore must be supported to ensure our quality of life. Dr. Gordon has written several expert opinions and research papers regarding the need for increased sexual health education. She’s taught at multiple academic institutions in the US and internationally.

and is a frequent commenter on sexual health topics in several internationally recognized publications, including ones you may recognize, CNN, New York Times, The Atlantic. She can also be found through her website, and we will share all of those details in the show notes. ⁓ But let’s get started. So welcome.

Dr. Elisabeth Gordon, MD, CST (02:38)

Thank you.

Dr. Ginger Garner PT, DPT (02:40)

What I love about ⁓ what you’re doing is that it’s at an intersection that as a pelvic health therapist, people come in and sit down and you won’t be surprised by this, but I don’t know, maybe listener, you will. People still separate pelvic health from sexual health. Like they’ll come in and say, have pelvic pain, but then maybe, you know, 10 minutes into their visit, they’re like, well, this is probably irrelevant, but I also have painful sex.

Right? So there’s this amazing disconnect and we want to, you know, patch that up and say, hey, they’re not disconnected. It’s at that intersection of what patients need so desperately, psychiatry, sexual medicine, therapy, relationship context, identity and the body. And they’re just told, okay, here’s one. They’re just told their sexual concerns are, it’s just stress. It’s just aging. It’s just hormones, right?

It’s just trauma, it’s just relationship issues, and it is like way more layered than that. So when you say integrative sexual health, like tell us what that means and what do you wish more clinicians understood about it?

Dr. Elisabeth Gordon, MD, CST (03:50)

So for me, that means ⁓ with my background as a physician, but also in psychiatry with psychology, understanding therapy, being a certified sex therapist, it really is the entire picture from micro to macro. And I think that that is something that is not considered often enough in health, but is truly not brought to sexual health, which is, as you said, often sidelined.

So for me, it is the understanding and the consideration of literally the micro of what are the genetic proclivities? What am I noticing? What different chemicals might be involved, whether that’s neurotransmitters or stressful experiences up through physiology, anatomy, through the experiences of the individual, their education, their family background, their cultural background, perhaps the religious background.

And then the relationship with others, both their history of the relationships, what was their family relationships like, but also their history of more romantic relationships, friend relationships, ⁓ as well as their current ones. So that it really is trying to look at the entire picture and understand the individual within all of these contexts.

Dr. Ginger Garner PT, DPT (05:11)

I love that. It’s what we are all, we all talk about this in healthcare, like the biopsychosocial model of like addressing every piece of that person, not just, you know, the diagnosis code, but it is often talked about ⁓ in more esoteric way. And then when you look inside clinics and hospitals and where things are being practiced, it’s like, where is that integrated model that we all learn about, right?

So why then do you think sexual health still gets treated as like separate from mental health and everything else? How is this still getting left out?

Dr. Elisabeth Gordon, MD, CST (05:55)

I think it’s still getting left out really because of the stigma, that that’s the major cause of why it’s getting left out. To be a little bit more, to parse through that a little bit more, I think that what we have is a distinct lack of sexual health education. And that is particularly true here in the US. There are definitely other countries where that is particularly true too, but here we have a very big lack.

And what we’re missing is both comprehensive sexual health education, which is the education that begins in infancy, early, early childhood and builds in an iterative fashion and a layered fashion to provide good understanding of what sexual health is. And to be very clear, that is not teaching toddlers about intercourse. The same way that you don’t teach toddlers about calculus, but you teach them how to count their fingers and toes and they eventually get there.

That’s what comprehensive sexual health education is. And since we don’t have that, we have people going into health professions without having a background or an understanding, and they are human. So they also understand the stigma. They carry the stigma. And then we very clearly have a dearth of sexual health education within health education. So I am intimately familiar both with the medical, but I’ve been working on a project looking at more of the psychological.

Dr. Ginger Garner PT, DPT (06:53)

Yeah, yeah.

Dr. Elisabeth Gordon, MD, CST (07:21)

side and there is so very little education on this topic. And so when I was noticing this, I wrote a couple of papers looking at what is the history, what is going on, what is the current state and how can we fix this. And the current recommendations out of the last international consultation on sexual medicine are to increase this, ⁓ but also to put it in

in small amounts across the education because it is so related to everything else that happens. So rather like the push for humanities education in the 90s and early 2000s in health education or at least humanistic education if not full humanities, I think that this needs to be the push now so that we have an understanding that whatever affects the physical is going to affect the sexual.

whatever affects the mental is going to affect the sexual and in turn whatever affects the sexual is going to affect the mental and even the physical. So that we have very clear evidence that is supporting this. ⁓ I don’t know how much research is being done anymore right now but we definitely had increasing evidence and we need to just

I think get over ourselves and understand this is just simply another facet of health. It is a human experience and it is a human right to be sexually helped.

Dr. Ginger Garner PT, DPT (08:55)

Yeah, yeah, it is something that is, ⁓ we have the shame that people feel in talking about it with their providers, ⁓ but then we have providers who aren’t even comfortable talking about it with their patients, are asking them the right questions or the depth really of questions, ⁓ especially when it comes, I think, to women’s health and women’s bodies.

the way I often describe it because doing ⁓ pelvic health PT, we do lots of internal work. All genders really can be uncomfortable with that aspect. I explain ⁓ pelvic health like one of my ⁓ colleagues like to talk about it as well, which is pelvic health is just orthopedics, but in the dark.

in terms of what we have to explore. So I explain it like a knee joint or a shoulder or anything else. It’s like, I got to look at that upper trapezius or I got to look at that jaw muscle, but it just happens to be inside a cavity in the dark. It is no difference. It’s just orthopedics. And I think if we can look at things structurally like that, it just breaks down some of the embarrassment or feeling ashamed or broken or any sexual concerns. So how do you approach that with,

say the listener is feeling shame, they’re feeling embarrassed, they’re feeling broken around sexual concerns. What do you want them to know right at the beginning of this conversation?

Dr. Elisabeth Gordon, MD, CST (10:32)

I want them to know that this is important and that there is help. It is not easy to get there necessarily, but there is help available and a good chance that if you, and I hate this term, but if you advocate for yourself, because I think you should not have to, but here we are, that you can get there. ⁓

Dr. Ginger Garner PT, DPT (10:55)

Yeah.

Dr. Elisabeth Gordon, MD, CST (11:01)

And I would want the listener to know that if you even think something is wrong, bring it up. We have clear, clear evidence that healthcare practitioners are not asking these questions. We also have clear evidence that patients want these questions to be asked and they want the healthcare practitioner to be the one to bring up the topic, but we’re not there yet. So if there is something going on, I actually have a whole series of things I recommend. I recommend that you write

Dr. Ginger Garner PT, DPT (11:19)

Yes.

Dr. Elisabeth Gordon, MD, CST (11:30)

down your questions. You try to think of all of the questions. Maybe you do some research online and say, is it this, is it that? Write it all down and then take that list with you. Because of the stigma, it can be hard to get it out. So it can be really helpful to have it all written down before and just read off your list. If you want, ⁓ if you’re comfortable, I do recommend sometimes bringing your

partner or bringing a friend with you because of the stigma, because of the emotionality that comes up, it can be hard to remember everything that’s said and or take notes when your healthcare practitioner is speaking. And then ⁓ don’t be afraid to advocate for yourself. Don’t be afraid to say, no, this doesn’t seem like that is it, or this doesn’t see, you know, what you recommended doesn’t seem like it’s working. And if your healthcare practitioner is at a loss, then

asked to be referred to a sexual health practitioner. There are places to find them. You can either ask. Unfortunately, even many healthcare practitioners don’t know where to find them. But there are societies here in North America. There is the North American, ⁓ sorry, the Sexual Medicine Society of North America. There is the International Society for the Study of Women’s Sexual Health.

They maintain lists of various practitioners who are good for both male and female, but they tend to lean more male and female respectively. And then for psychological issues around sexual health, there is a STAR, the Society for Sex Therapy and Research, and there’s a practitioner list there, and there is ASEP.

the American Academy of Sexuality Educators, Counselors and Therapists. So those are four good resources, not the only ones, but four good ones to help you find somebody. ⁓ And I will say that in the sexual health world and ⁓ even in the sex med world, both sex med, sex psych, people want to help everybody that’s out there. So even if you are not calling the exact right person, chances are they can say, hey, I’m not it.

But I recommend that you check XYZ or call this person. So that is at least a good place to start.

Dr. Ginger Garner PT, DPT (13:57)

Yeah, it is. And, you know, and I would also add that for people who are in smaller areas, and that could even mean urban areas can still not have practitioners. I had this discussion yesterday with a nurse practitioner and a nurse midwife that are in, you know, struggling with that. I would say that every pelvic health PT will know at least two or three of people off the lists that you just mentioned.

so that if your practitioner isn’t aware of these lists, but listener, you’re going to be. You have four resources now where you’re going to be aware of those lists that you can always ask your pelvic PT because they will be trauma-informed and sexual health-informed, but they’ll have those resources available. You know, a whole list of people that will be on those lists and can also point you in the right direction. this is really good. We’re just kicking it off with a big list of resources in the beginning, and that just helps.

⁓ break down what the listener, what we all may be feeling of just breaking that stigma and naming what gets silenced so often. So what do you see as ⁓ a physician, as a sex therapist? Like what are some of the most common sexual health concerns people carry silently for years before seeking help?

Dr. Elisabeth Gordon, MD, CST (15:17)

There are so many. So the one that does show up the most often in sexual health treatment is desire discrepancy. That’s pretty much far and away the most common complaint. It is the way I like to put it to people who show up with this, this is not actually an issue in and of itself. ⁓ Desire discrepancy is only a problem when it’s distressing because

If you are with a partner or partners, then it is highly likely that at some point you are going to want something they don’t want or they’re going to want something you don’t want at the same time in the same way. As I like to tell my patients, can you imagine if you entered into a relationship and we’re told, okay, well, from here on out, you’re only ever going to eat your meals with your partner and you’re going to have to want the same thing at the same time, the same cuisine, the same dishes. It’s not going to happen. So you learn to navigate that.

But if you have this expectation that sex really happens between partners, that’s the most important place for it to happen. And I’m not in any way denigrating that that’s an important place for it to happen. But there’s an idea that then it needs to just happen naturally and you will always want it and it becomes distressing often because you don’t know how to negotiate around that. So that is the most common complaint. As far as things that people carry for years,

⁓ I find that people fairly quickly, male body people fairly quickly will come in with complaints about erectile difficulties or premature ejaculation because they find that uncomfortable. Sometimes it takes them time, especially if there is a significant or pure component of a psychogenic etiology, meaning it is psychologically ⁓

it stems from a psychological component, then it can take a while. ⁓ And actually, even when people come in, I come in to me with these complaints, if they have not been through the physical rigmarole, been tested, then I want them to be tested first to make sure that we’re not missing something that is physiological. ⁓ But if it is psychological, they often have been through rounds of, well, you just need to try this

PDE5 inhibitor. ⁓ you can try this penis pump. I mean, I’ve even heard for men, though less often ⁓ than I’ve heard for women or male bodied and female bodied. just try a glass of wine. You’ll be, you’ll be fine. And so that can, can take a while, but that often comes in fairly quickly. Pelvic pain often takes a while. That often is something that particularly female bodied people live with for a very long time.

Dr. Ginger Garner PT, DPT (17:55)

Yeah.

Dr. Elisabeth Gordon, MD, CST (18:13)

and way too often believe that that’s just the way it is and that’s what’s involved in sex and you need to engage anyway because your partner, particularly if you’re female bodied and with a male-bodied partner, needs sex and that is not true. So that is one that can often take a long time. Other things that take a while to get into the office and I would urge anybody listening if this is you to not let that time pass

Dr. Ginger Garner PT, DPT (18:17)

Right?

Yeah.

Dr. Elisabeth Gordon, MD, CST (18:42)

would be ⁓ things such as being uncomfortable with your erotic preferences, being worried that they maybe aren’t normal, or understanding that you have these preferences but not being certain how to engage in a community or find others to engage with, or being uncomfortable at the thought of doing so. Because often kink, which is simply

not what is mainstream sexual engagement for your community at that time, kink is often shamed. It’s othered. It is othered by definition. It is the bend in the road. And or another one that can come up is when individuals are really worried about their reaction to their partner, but it can take a while.

Dr. Ginger Garner PT, DPT (19:36)

That’s heavy. And then there’s cultural and medical messages that keep people from asking for support around desire, arousal, pain, orgasm, orientation, identity, or relational sexual concerns. So can you talk a little bit about what those cultural and our medical messages can be that keep people from seeking support?

Dr. Elisabeth Gordon, MD, CST (20:00)

Yes, we start with the cultural message that sexuality is shameful, the stigma around sexuality or sexuality is truly private and something you do on your own outside of the mainstream. And no, I’m not arguing that people go out in the middle of the street and engage sexually, but I am saying that we need to be more open with it, between even with ourselves, with our partners and be able to talk about it more, at least with our healthcare practitioners.

So that stigma message can get in the way. It can be reinforced too. It can be reinforced either by friends or by the healthcare environment with dismissing of, no, that’s not a problem or ⁓ you’ll just get over that or you’ll figure it out or again, have a glass of wine. But other components to the cultural messaging, because sexuality,

and sexual health is not just about sexual engagement, but as you mentioned, all of those components, it’s about your sex and your body’s representation of your sex, which is the genetic makeup that you have. It is about gender, who you feel yourself to be. It is about your erotic preferences. What do you like to do in bed, so to speak? It’s about your orientation. Who do you like to do it with?

And it’s about how you are able to function and how you’re able to relate and how you’re able to communicate. So we have a lot of room for many things to impact it. And culturally, what we see here in the US is the highly ⁓ dichotomized gender construct where men are mainly men and women are soft, sweet women.

can really impact what people think should be happening in sex. So we already mentioned how pain can often go ⁓ un-brought up or just people can exist with pain. And I do want to put out that I said that it is often female-bodied people, but in some ways there is even more of a stigma around sexual pain in male-bodied people because they should just suck it up. They should be manly. They should, of course, want sex no matter what.

Dr. Ginger Garner PT, DPT (22:24)

Mm-hmm.

Dr. Elisabeth Gordon, MD, CST (22:27)

And that should take preference and priority. So these can really impact the way people see themselves as sexual beings with an understanding perhaps that if you’re a female body, you should be passive, you should receive, you should be providing sex for your partner who needs it, particularly if they’re male or identified as men. And for…

male-bodied individuals, it can be that they feel inadequate because they’re not wanting it all the time. That they maybe if there’s lower desire, there’s even then a female body partner, then it is more shameful. So there’s ways that our gender stereotypes can impact culturally.

Then we have the various messages of family of education or lack thereof that this is not something you talk about and because of this messaging of not talk or this is something that’s shameful there’s no practice talking about it and It takes a bit of practice when something is stigmatized And it’s something that I have argued within Health professional culture to medical

Dr. Ginger Garner PT, DPT (23:20)

Yeah.

Dr. Elisabeth Gordon, MD, CST (23:44)

education particularly that I’ve heard people push back and say, well, you know, but it’s just so hard. And as I say to health professionals, and you would understand this, it’s also hard to learn to put your hand in the middle of somebody’s body. That is quite stigmatized in our society too. That is not something that you do on a daily basis or grow up doing, but you learn how to do it because you need to to support somebody’s health.

and you learn how to do it and be comfortable with it and you learn how to do it in (hopefully), a very sensitive and very kind and supportive manner to be able to support health. So these are other cultural components, this lack of education or the stigma. This is a way that it can really impact how people approach sex and how they talk about it and the lack of communication.

Dr. Ginger Garner PT, DPT (24:36)

Yeah, it is something that creates a fear, I think, for individuals going in. They have a fear of being dismissed already. They may have never been dismissed before because they’ve never talked about it, but I think a lot of people may get to the cusp of talking about it, you know, from being in this space as long as I have, as long as you have. You can…

You can feel, you know, when someone feels awkward or afraid of being dismissed. So how can listeners begin to talk about sexual health with a provider when they feel that way, when it feels weird, when it feels awkward, when they feel afraid of being dismissed?

Dr. Elisabeth Gordon, MD, CST (25:19)

I really recommend again, that write it down because between you and the paper there is no stigma and if you can write down what you’re thinking then you have something to hold on to. Then I recommend for basically everybody I see that if you’re trying to talk about it and you’re feeling awkward you can say that you can say that you can say this isn’t so comfortable for me.

Dr. Ginger Garner PT, DPT (25:21)

Yeah.

Dr. Elisabeth Gordon, MD, CST (25:47)

but this is important and you can remind yourself by saying that that it’s important. So I’m going to try to say it anyway and please understand that it might not be so smooth. And then if you have it written down you can refer to your notes. Things that I teach when I am teaching courses on sexual health are ways to get used to it. Simply stand in front of the mirror and keep seeing those words that you’re tripping over. So I often

If I’m teaching residents, we’ll have them go home and stand in front of the mirror and say, penis, scrotum, vulva, vagina, and tell them to say it 50 times each, just standing there watching themselves say it until it just becomes another word. So another way to help could be taking that piece of paper that you’ve written down and read it multiple times out loud until they are just words.

That won’t completely solve the issue, and I’m not saying that internally you might not feel some discomfort, but it can help get the important words out in a way that will allow you to get the help that you need.

Dr. Ginger Garner PT, DPT (26:56)

You just like read my mind with that, because that was my next question. I was like, what exact words could someone use? And you named it. Name the weirdness, name that it’s awkward, name that it feels hard and you’re going to trip over it and then read your questions. That’s just so good. And it really segues into what I was going to talk about next, which is mind-body awareness and that sense of empowerment. I think from your perspective,

How does the nervous system shape sexual experience from desire to arousal, feeling safe, huge thing, pleasure, shutdown or avoidance, all of those things that circulate around sexual experience?

Dr. Elisabeth Gordon, MD, CST (27:41)

I talk about this all the time. I talk about this every day, almost with every one of my patients, ⁓ maybe not every patient every day, but I do talk about it a lot. And I like to frame it, again, an iterative process, but the first time I go through it, I like to frame it really simply. And that is that we basically operate on two nervous systems. One is the somatic system, that’s the sensing system. I see that it’s a nice day out.

can feel where my water is. And that happens internally too, with interoception. And that could be, oh, I know that I’m thirsty because I sense my mouth is dry, or I know I’m hungry because I feel my stomach get tight. And we have that understanding, we can respond to it. But there is another part of the nervous system, and that is the autonomic system. And that sets the tone. How are we going to operate? What state are we going to operate in?

And this one is so important for everything, for health overall, physical health, mental health, but also it’s so important for sexual health because it really breaks down to two components. It breaks down to the sympathetic component, which I like to call the lion’s going to eat you. And the parasympathetic component, which I call the watch the movie on that streaming service and chill component.

And I mean that in both senses because when you are in the parasympathetic state or when you have more parasympathetic tone, because it’s not a light switch, it’s not one or the other, that is the restful state. And that is when you have physiologically more blood flow going to the internal organs, including digesting, including the gut for digesting and including reproductive organs.

And it’s because when you are calm and you’re safe, that’s the time you can stop and eat as opposed to when you’re more parasympathetic tone, which again, that lion is going to get you is not when you’re going to stop and eat. So if you were a furry little critter, you would come down out of the trees. You’re basically you and your tribe are evolving, making it to the plains. And there you are eating your nice, ripe figs. And all of sudden you hear that noise behind you and the

Primordial lion is there, yeah, I can’t stop and say, I’m sorry, I just want to finish my figs. Instead, you need to be able to react. And those reactions, essentially the five components of that sympathetic activation are fight, flight, freeze, fawn, and friend. And we can see particularly with those first two, to be able to fight, to be able to run that flight, you need to divert your energy to your limbs.

And that is a great place to keep yourself safe. But when you’re not safe, the other thing you don’t want to do is say, I’m sorry, you know, I was thinking about having a hot date with my honey later. Can you just wait a little bit, lion until, you know, I’m done with that because then we were going to have some cute little furry offspring and we’re really trying to evolve out to those planes. That’s not going to wait. So you need to attend immediately to the danger that’s in front of you. Now, here we are in modern life. And what is the

quote unquote, lion has evolved to be a variety of other dangers that we perceive. So we now know that the parasympathetic system is the one that can support healthy, reproductive energy and functioning. That translates to the parasympathetic and that restful state is where you need to be to truly be able to have deep desire and support good arousal and

get the arousal up to that point that is almost orgasm. And so when you were more in that sympathetic state, when you’re more anxious, it’s gonna be harder to access that desire. It’s gonna be harder to support that arousal. And if you are not supporting that arousal, then it’s harder to reach orgasm. It’s harder to be satisfied with the engagement that you’re having. So this whole body state is of essential importance.

Now you probably understand, and I’m thinking probably many of your listeners understand, that that sympathetic state, that anxious, chronically stressed state that we’ve seen to have railroaded ourselves into in our modern lives is not just that burst and you run away, but you switch over to this chronic stress state, which does a number on the body. And so it really can impact

the body in the cardiovascular system, it can impact mood, can impact digestion, partly for those reasons that we talked about when you’re constantly shunting blood out to the periphery and you also need a lot of sugar in that blood to be able to access it by the muscles very quickly to fight or run away, that can do a number on the body. And if you’re not surrounding the gut with all of that blood and calm to digest, that’s going to do a number on digestion.

and then they start feeding into each other.

Dr. Ginger Garner PT, DPT (32:54)

Yeah. And I think that brings up a really important next level awareness. you touched on this already when you said interoception and that translated into that somatic experience of understanding if for the listener, proprioception is where your body is in space, where your joint is in space. When you reach up, you know you’re reaching up.

Interoception is how you’re feeling on the inside, which we can translate into body awareness. And so that’s something that you touched on is the role that body awareness plays in healing sexual distress of starting with that starting point of interoception of how do I feel? And I don’t think that in our, ⁓ we’re constantly bombarded with information. We’re constantly bombarded with different tigers, you know, different

predators, whether it is a boss or a difficult relationship or the traffic or just the constant noise, it’s really hard to then slow down. We don’t get the opportunity to do that, which makes intentionality so much more important. But how do you address that role of body awareness and helping people come back to that in order to heal sexual distress?

Dr. Elisabeth Gordon, MD, CST (34:14)

So I think that that is built into sex therapy. And that is with what we call sensate focus. That is the codified way that we go through a series of exercise to help people become more rooted in their body. But there is an element of mindfulness to that. And that was very much innately understood by many sex therapists. But now, ⁓ my dear,

friend and colleague, Laurie Brodo, has done extensive research on this and proven that particularly for pelvic pain, it is extremely helpful to really boost that mindfulness component and that that can really be helpful to help people re-enter their body and to help…

I’d like to say heal because it’s self healing some of the components of those various sexual dysfunctions or difficulties. ⁓ That is not to say that there aren’t other components that might need to be brought in, but that mindfulness really does help direct energy. And it’s both ⁓ in a physical way where if you can tell what is happening with your body, and I’m sure many listeners have heard if you are exercising, if you focus on the muscle you’re exercising.

that you can really work it a little bit more strongly, you can add a little bit more oomph to that workout for that muscle, it’s the same with sex. If you know what’s going on where in your body, you can really heighten the feeling that you’re having there. And another thing that I like to talk about a lot when I’m working with my patients is there isn’t actually a difference between physical and psychological.

that what you feel for emotions is simply another set of electrical interactions in the brain that set off a cascade of chemicals that we interpret as an emotion, but that has an effect throughout the body as well. And when you are feeling something in your body, if it is good, that can help boost that psychological mood. And if it is not good, that can help bring it all down. So they’re very, very

intertwined. And so when you are able to be mindful, you can be mindful both of where you feel an emotion and or where you feel something that is going on physically in your body. And we teach that through a stepwise process, either with partner or on your own. And it’s a set of exercises. And essentially what we’re doing is teaching a form of meditation, but a

Dr. Ginger Garner PT, DPT (37:04)

Yeah.

Dr. Elisabeth Gordon, MD, CST (37:04)

form of meditation

that truly supports parasympathetic state and truly supports sexual function.

Dr. Ginger Garner PT, DPT (37:15)

mindfulness is so important on so many levels. And so I hope that to the listener, you are inspired to pick that up and then know that there’s a specific way of doing that ⁓ in sex therapy, which is fantastic. So my next couple of questions are ones is related to like differentiating between two different feelings. And I think they can be difficult ones. And then the other one is like performance based stuff. So let me start with this one.

How can you help someone tell the difference between the, I’m not interested in sex versus my body doesn’t feel safe, present or resourced enough for sexual connection?

Dr. Elisabeth Gordon, MD, CST (37:57)

That is a tricky one and that can take a little bit of time, but it can be learned. So when I am working with individuals who have lower desire or fear they do, because I always say we cannot diagnose low desire until we make sure that everything else is okay. If you still have low desire after everything else physiologically and psychologically is okay, then we’ll diagnose low desire. That’s okay.

But since desire is so subject to all of the other states feelings and if you have say for instance physical pain, it would make sense not to have desire. So when I’m working with that, I like and even if it’s not, if it’s really a question of how do you tell, how do you tell if you’re there, I really like to have people focus on pleasure and learn what their own physical pleasure is, learn what their own psychological pleasure is.

and then also start to become aware of how they feel when they are stressed. And this is in conjunction with explaining, educating people that desire is not actually just an on and off switch either. We have this idea that desire is something that comes over you or your partner is there and you see them and you want to get it on. Or you’re walking down the street and you see something and

And maybe you don’t even see something and you just think, ⁓ I’m just so horny right now. I really want to have sex. That is one kind of desire. We call that spontaneous desire. That word gets lost. And we use that word to differentiate it from what is called reactive desire. Reactive desire is, yeah, I wasn’t really thinking about it. But now that you mention it, I am open to it.

And when you are open to it and begin to engage, either the engagement sparks desire and or the engagement sparks arousal, which then sparks the desire. So it can be desire to arousal or arousal to desire. How do you tell the difference between those? Well, if you find yourself thinking, yeah, I could engage and I know that it will be better between my partner and I, or I’ll sleep better or

If it’s a cold winter day, I’ll be warmer after I have a good orgasm. That is being open to it. But if you find that you really cannot get your mind there to even consider if your mind is racing, if your mind is off and running, and if it feels like a burden, then not only is that that state of no, that’s that component that you ask, how can you tell when you’re not there?

but it’s really important that we empower people to be able to say no when they are there. Because if you say yes, when your body’s really not there, you can begin a cycle of not enjoying it ⁓ and or resenting, engaging, which then carries into the next time, well, I didn’t enjoy it last time. Am I gonna enjoy it this time? I don’t know, I really couldn’t calm down last time. Am I gonna calm down this time? And that very act of thinking about

what is going to happen, if it’s going to happen, is essentially worry. You’re looking forward and trying to predict what is going to happen. And that is that sympathetic activator, because you’re worried that the outcome isn’t going to be what you want. And you have completely undermined your own capacity to really support that parasympathetic tone and get back into arousal and desire. So it becomes a vicious cycle.

Dr. Ginger Garner PT, DPT (41:37)

Yeah. So I think it brings up, I mean, this is a great segue to the next, that second part of the question, which is then how do you help people move away from like performance based sexuality more towards curiosity and sensation and agency? Cause I think that’s where a lot of the angst comes from.

Dr. Elisabeth Gordon, MD, CST (41:59)

So that word comes up a lot, perform, performance. And I hate that word. I think that word has no place in average sexual interactions. If this is a burlesque show or if this is a live or filmed form of pornography, great, that is a performance. But when you are engaging,

Dr. Ginger Garner PT, DPT (42:14)

Yeah.

Dr. Elisabeth Gordon, MD, CST (42:26)

there needs to be presence and there needs to be a focus on what are you feeling and enjoying. And hopefully your partner is also focused on what they’re feeling and enjoying. And you can trust that you can follow your pleasure and trust that your partner will follow their pleasure. And if it’s not pleasure, that you’ll let each other know. And that is not that your partner or you are doing something wrong. It’s simply, it’s not right for your partner at that moment. So that is much more present and rooted

but that word performance comes up a lot. In fact, I recently had a reach out from a company and since their tagline is about performance, I was like, don’t know. I don’t know that I can work with this. Because to perform means that there is some form of expected steps, some form of script, some form of behavioral interaction that is part of that performance. And when you have a script,

Dr. Ginger Garner PT, DPT (43:07)

Yeah.

Dr. Elisabeth Gordon, MD, CST (43:24)

or at least the expectation that there are some words or engagement or behaviors that must be involved, then again, you are not as rooted in your body saying, am I liking this right now? You are busy, at least a part of you thinking, okay, well, what is the next step? Am I accomplishing this step? Where do I have to go next? Is my partner enjoying that I’m accomplishing this step? Did I do it right for my partner? Does my partner appreciate that I am performing this way?

And all of that, again, is not being rooted in your own body and your own pleasure, but being worried about whether you’re matching that script. And we have a term for that in sex therapy. We call that spectatoring. When you are outside your own body, evaluating your own behaviors, your own words, your own actions, or to put it succinctly, your own performance, and spectatoring truly undermines pleasure.

Dr. Ginger Garner PT, DPT (44:06)

Hmm.

Yeah, well said.

So when we look at like higher level diagnostics, so we’ve talked about this, know, body image and focusing on curiosity and sensation and agency, which leads to empowerment. We always come up against the inevitable thing, which is people come in to see you and they’re like, what’s wrong, right? So from a higher level diagnostic perspective, not that we can diagnose on a podcast, but helping listeners understand

you know, that sexual symptoms have many possible roots. ⁓ So someone comes in and they have low desire for painful sex or arousal difficulty or changes in orgasm. I see that a lot in pelvic health, especially perimenopause, know, to menopause and beyond, ⁓ avoidance or distress. What are some of the overarching kind of categories or things that you are actually looking for, for them to help them get to the root cause?

Dr. Elisabeth Gordon, MD, CST (45:24)

So this gets straight to the heart of the diagnostic interview for me. As a psychiatrist, I am not hands-on, but as a sex med, ⁓ swish fellow, as somebody who is very well versed in sex med and a physician with my background, then I’m always thinking about the physical and the psychological. And in medicine, even in psychiatry, we have a kind of hierarchy that we go through.

which is what can we rule out physically and then we’ll address the psychological because the physical can be the entire cause or can be impacting the psychological and also because the physical is often a little bit more time constrained to fix than many of the psychological components. So when I go through this, looking for, I’m asking questions and looking for answers that might suggest that there’s something wrong physically. If it’s pain, where’s the pain? When did it start?

⁓

Is it worse or better at certain times or with certain actions? If it is, for instance, erectile difficulties, then I want to know very much if the individual is having erections that they notice overnight or wakes up with erections, or if they’re having difficulty with their erections if they’re self-pleasuring versus when they are engaged with a partner. And if the answer to all of the first ones,

are yes, but it’s difficulty engaging with a partner, then I can fairly confidently say, okay, your plumbing’s working, the vasculature, your electrics are working, the nerves, and yet now we have something about this interaction that is really stymieing this ⁓ engagement. And so I want to go through and ask questions about when did it start, where did it start, what is the quality of the pain, what are the situations in

which it happens. And if I hear anything that makes me think either that there might be a physical component or even if I don’t hear that there’s a physical component, but there’s some holes that I’m feeling about what’s going on, I want somebody to get checked out physically. And I will refer them to somebody who is good at sex med, either a urologist or urogyne or a gynecologist who is good at this, who knows how to check.

for these ⁓ different components of sexual dysfunction. Once that is clear or we know what we’re dealing with on that side, then I will address the psychological components. And that includes how do you relate to what’s happening physically? How do you feel about it? How do you relate to yourself sexually? How do you feel about your own sexuality? How do you feel about your partner? How do you feel about sexual engagement? How do you feel about the way that you relate outside of sexual engagement?

So we go through these questions and maybe that can be helpful to the listener to understand that first you want to think about what is the symptom if it is physical and understand kind of when did it begin? What does it feel like? Are there places or times or situations that it’s better or worse? And then begin to sort of think about it in context.

Dr. Ginger Garner PT, DPT (48:47)

Yeah, that’s such an important distinction to make. think that this can be, this is what’s missing in our medical education as well in terms of where people go to first, right? If a clinician jumps too quickly to its psychological, which happens, I think a lot, yeah. Or it just being relationship stress, ⁓ then you miss a big part of things, which could be hormones, anatomy, ⁓ meds they might be on or other.

physiological issues, things that we look at all the time in pelvic health. ⁓ And then they might miss other things like meaning, safety, shame, relationship context, that kind of thing. So, yeah.

Dr. Elisabeth Gordon, MD, CST (49:29)

I really, if you don’t

mind, I’d love to echo what you’re saying. And it is true. So often sexual concerns are dismissed as psychological, which is absurd to me because again, all of the physical can affect sexuality, all of the mental. And what is also not necessarily known even by prescribers of these medications is that so many medications can affect sexual health, sexual engagement as well.

So there are so many reasons why there might be a physiological component, but conversely, once those are identified, there is almost no attention then paid to the psychological results of having had that. And sometimes, yes, if we treat the physical, then things are great and then sex is back to normal. But often it’s not. Often there is…

Dr. Ginger Garner PT, DPT (49:58)

Yes.

Dr. Elisabeth Gordon, MD, CST (50:22)

some question lingering, why did that happen? ⁓ why did my partner react like this when I wasn’t feeling well or I had this difficulty? Now are they going to be reacting differently? Or what do I think about my own sense of self and my own sexuality given that this is an issue and maybe it’s an issue that might stick with you. If it’s say a medication that’s working in other ways or a chronic health condition that’s been impacting. How do you handle that psychologically and that’s often

often missed as well.

Dr. Ginger Garner PT, DPT (50:54)

Yeah, it is. think I want to just echo that sentiment on ⁓ medications and sexual health of someone prescribing something, I’ll come in and we always look at all their meds and that hasn’t been considered. Are there some things you can just quickly identify off the top of your head? The most common, the more common ones, I think of medications that aren’t considered that should be in terms of sexual health.

Dr. Elisabeth Gordon, MD, CST (51:23)

Basically, all of what we call the psychotropics, the psychiatric medications for depression, for psychosis, for bipolar disorder, for addiction, ⁓ all have an impact. In fact, I have a nice handy little list that ⁓ I love to disseminate where we have the prettiest, okay-ish kinda, the meh, and the naughty list. And so that is, we know this, but it’s not taught.

Dr. Ginger Garner PT, DPT (51:48)

⁓

Dr. Elisabeth Gordon, MD, CST (51:52)

But as far as other medications, everything can affect. Even things like ⁓ diphenhydramine, your average allergy medications can affect your sexual health. It can make you drier. It may make it a little bit more difficult to have full arousal, to really engage with your ⁓ physical side of your sexuality. And in fact, when I get this question, I often say, it’s easier perhaps for me to…

provide a list of which medications don’t, absolutely do not have any potential impact. Because so many of them have impact directly, and then there’s an entire category of medications that may not have direct impact, but if they’re making you feel sleepy or they’re making you feel nauseated, then you’re not gonna wanna engage sexually either.

Dr. Ginger Garner PT, DPT (52:43)

Yeah, so true. So in terms of like…

someone listening, they’re disconnected from their body because that going back to that body awareness for a second and interoception, what’s just a simple awareness practice that they could try, that they could start out with to just get reconnected again?

Dr. Elisabeth Gordon, MD, CST (53:07)

I recommend starting with something that you like, whether that’s a piece of chocolate, something you enjoy eating, or you like to take a hot bath, or you like to go on a walk. What is something that you like that feels comforting and feels relaxing? And then begin to do that at least every other day, very slowly and very mindfully. And by that, as

sure you know, but I’ll explain in a little more detail, is pay attention to the sensations that you have around engaging in that activity. So if it’s going for a walk, it’s what does it feel like to pull your coat on? How does that fabric feel against your hands, against your skin? Is the doorknob hot or cold when you open the door?

What do you notice about the way the breeze hits you as you open the door? What do you smell as you open the door? What do you notice that’s different in the sound of outside versus inside that door? And if it’s food, you can add taste too. And I recommend that when your mind wanders, which it will because we are humans and we have this pesky cortex that keeps on chattering away at us, you simply

non-judgmentally notice that you’re having a thought and as soon as you notice you just tell yourself well that’s a thought but I’m focused here now and get back to the sensations and the more that you do that the more that you practice the easier it will become and the more that you practice and it becomes easier to focus on what you’re doing the more you will start to notice what you are sensing overall

Dr. Ginger Garner PT, DPT (55:02)

Do you have a ⁓ framework to help people? I think this is probably the most common thing that I hear a lot of in practice is naming what they want, actually being able to speak up about what they want. Do you have just a simple kind of first step to help people name what they want?

Dr. Elisabeth Gordon, MD, CST (55:25)

Yes. If you already know what you want, yay, I am applauding you. I often get people who don’t even know what they want. Yes. And so that mindfulness, that embodiment is one of the first steps that we have to do because you need to know how to monitor what is happening in your body to then be able to really pay attention to what

Dr. Ginger Garner PT, DPT (55:34)

what they want.

Dr. Elisabeth Gordon, MD, CST (55:54)

feels good and what feels great. And then you have the concept of what it is that you like. so once you have that understanding, there can be a lot of difficulty expressing this to a partner. Going back again to that stigma, going back again to that lack of education that did not teach you how to communicate this very basic and very necessary human right, because it is your right to have.

satisfying sexual engagement. And so I recommend that people start by understanding that when you are having pleasure, for most people, i.e. for most partners then, that pleasure is quite the turn-on for your partner. Your partner wants you to be having pleasure. Your partner…

will enjoy your pleasure and it will feed back to make them have more fun and feel more sexy, have more pleasure, be more aroused, have more desire. So within that framework, you have to understand that being able to say what you want can really help feed this positive cycle. And if your partner doesn’t want your pleasure, then that’s a whole nother issue. And we can talk about relational components later.

Dr. Ginger Garner PT, DPT (57:14)

Yeah.

Dr. Elisabeth Gordon, MD, CST (57:16)

But when

you have that framework, it can help. Then if you get stuck on it, I recommend a variety of very simple exercises. You can start by suggesting to your partner that maybe you want to branch out a little and maybe you each write a few things down and then you exchange lists. There are online ⁓ lists and some games that you can use where you check off either on the list, you each check off what you’re interested in and then it lets you know where there’s a match so that it won’t

Reveal where there isn’t a match if that makes you uncomfortable though I recommend working towards that because often people are open to trying things and that would be part of that negotiation I discussed early earlier or you can bring it up and say, know, I’m really interested in maybe reading some erotica with you or maybe we could watch some porn together and Get some porn that starts to touch on what your interests are

And when it comes up, you can say, actually, I think that I find that really hot. Is that something that we could bring into what we’re doing so that it’s not you directly bringing it up?

Dr. Ginger Garner PT, DPT (58:28)

Yeah, I like the indirect and the direct techniques because I think people often just jump to direct. I just have to say it. I just have to do it. I just have to be courageous enough or whatever. And so I like the fact that you address communication tools for the individual, but also for partners so they can talk about sex without like blame or pressure or anything like that. ⁓ And I think we’ve already hit on a big part of the importance of referrals. So that might be

psychiatry, sex therapy, ⁓ gynecology, urology, pelvic floor PT, urogons, ⁓ endocrinology, you know, but the interdisciplinary aspect of it, is very much, ⁓ you know, the phrase it takes a village is very applicable here. I think that one question I have for you, because you’ve got such, again, this unique lens and experience, ⁓ what…

Dr. Elisabeth Gordon, MD, CST (59:02)

for physical therapy.

Dr. Ginger Garner PT, DPT (59:26)

can clinicians from your perspective do? Like, how can they do less harm? I guess is getting the point. When they’re talking about sexual health, like, let’s do less harm here. What can they do?

Dr. Elisabeth Gordon, MD, CST (59:39)

So ⁓ I actually wrote a paper where I argue that not having sexual health education and thereby the end result of having clinicians who cannot address sexual health is really a violation of biomedical ethics. So I am so on board with improving this because exactly there can be harm and that may be unintentional harm, but harm in ways that violate the principles of biomedical ethics. So what can clinicians do?

they can start by remembering that there is sexual health and asking if there are any sexual concerns to open that door. Even if they are not, then they need to take when their patients come in and say something is going on quite seriously. I going back one step, I would really like them not only to be asking, but to be knowing it because so often it’s a medication that you’ve given or it’s a treatment that you’re providing or some form of

physical intervention that can really alter what’s happening. And you want to know what the state of sexual health was before you did that to know if there’s a change, whether it’s because of that intervention. But again, if we’re not there, then at least I would hope clinicians would take the patient seriously when they bring this topic up and at least know that there are sexual health.

Dr. Ginger Garner PT, DPT (1:00:48)

Yeah.

Dr. Elisabeth Gordon, MD, CST (1:01:06)

practices out there, support out there in, as you said, a variety of ways. And there are databases to find places to refer these patients if you don’t know what you’re doing and facilitate that referral. That’s all you really need to know. You need to know to ask, you need to know what you are doing that may be a problem, and you need to be able to take the patient seriously and know when to refer.

Dr. Ginger Garner PT, DPT (1:01:33)

Perfect. So for listeners, those are your green flags. That’s what your practitioner should be doing ⁓ when you come in. And if they’re not, that’s a good yellow to red flag ⁓ indication that you may need a different provider to listen to you.

So last question, this is kind of like a rapid fire and I’m sure you have multiple myths about sexual health that you would love to retire or have people just strike out of the vocabulary altogether. What’s one or two of those myths about sexual health that you’d like to see just please go away.

Dr. Elisabeth Gordon, MD, CST (1:02:11)

There are so many. You touched on one, performance. ⁓ There is also the myth that sexual health is just about sexual engagement and that ⁓ therefore it’s only fixing how you are interacting or which orifice, which part is going into, at which point with which amount of turgor. That is not the entirety of sexual health.

Dr. Ginger Garner PT, DPT (1:02:15)

Good.

Dr. Elisabeth Gordon, MD, CST (1:02:37)

Sexual health is everything about how you relate to yourself as a sexual being. Back again to that sex, gender, erotic preference, orientation, ⁓ as well as how you relate to your partner and the physical behaviors or interactions that you’re engaging in. And so we want people to be sexually healthy across the board. Another myth would be the myth of the hymen. I think this one so needs to die. The hymen is…

As you know, not a real thing that indicates whether somebody has had intercourse or not. It may or may not be there. It’s a piece of vestigial tissue. It’s usually gone in most female body people who have actually moved in their life, which is most female body people. And the idea that virginity, both with the hymen and as a before and after, especially when it’s referring to, this is another myth, sex is penis and vagina intercourse.

That one I’d like to get rid of too because for me sex is anything that you engage in for the purposes of erotic pleasure. It doesn’t need to have any penis involved or any vagina involved. It can be other body parts. It can be two of one or two of the other or more. But sex is not just penis and vagina intercourse and the myth of virginity that there is the hymen and then if you…

lose your hymen because of penis and vagina intercourse, you are no longer a virgin. This myth needs to go somewhere else too, because I think that all body parts are amazing and beautiful, but we do know that that idea of virginity is often attributed to female body people more than male body people. And there is nothing neat about having a penis and a vagina that is going to change you, whether you are

Dr. Ginger Garner PT, DPT (1:04:26)

Thank

Dr. Elisabeth Gordon, MD, CST (1:04:33)

male or female, in any meaningful physiological manner. You might feel different because this has been held up as the end all and be all, but I wish that we understood that it is how you engage along the way and that that is not the big end conclusion. And lastly, that the idea of penis and vagina sex being real sex, that you have foreplay, which is everything you do before, to get to the penis and vagina sex, to get to the orgasm, preferably mutual.

I think we need to get rid of this myth that there is a hierarchy. I like to use the term core play. I say core play is more play than foreplay. Core play is anything that you want to do in whatever order as long as you are having pleasure. And that’s what good sexual health is about.

Dr. Ginger Garner PT, DPT (1:05:23)

I that. All right, one more time for the listener. Because I was like reacting, I was like, I love that and they may have missed it. So say that one more time.

Dr. Elisabeth Gordon, MD, CST (1:05:30)

So as opposed to foreplay, which is the idea that you have all of these things that you engage in before you get to the main event, which is penis and vagina intercourse with an orgasm, possibly mutual at the same time, I really like the idea of core play. And as I say, core play is more play than foreplay. Core play includes penis and vagina intercourse if you want. It includes

ludes orgasm, but core play is the understanding that sexual engagement is a buffet of options. And as a buffet, not a seated and served dinner, you can choose whichever course you want to eat in whichever order. And you can go back for seconds of anything and skip some dishes entirely. That, as long as you are having a really good time, enjoying yourself, having pleasure is a very good foundation for sexual health.

Dr. Ginger Garner PT, DPT (1:06:25)

That is exactly the kind of conversation that we need more of. Elisabeth, thank you so much for coming on the show today. This has been grounded and compassionate and clinically nuanced. It is, know, an incredible, I love this last takeaway on core play. ⁓ These things that you discussed tell us so much about how our bodies are working, getting back in touch with our body, learning what

Dr. Elisabeth Gordon, MD, CST (1:06:28)

Yes.

Dr. Ginger Garner PT, DPT (1:06:54)

know, interoception, how we feel, means, and how much of a heavy, lovely impact that it can have, you know, on outcomes, ⁓ because everyone needs better support in this arena. And to everyone listening, you’re allowed to ask questions, you’re allowed to want clarity, you’re allowed to seek care that treats your sexual health as part of your whole health. It’s not an afterthought. Dr. Gordon, thank you so much for being here today.

Dr. Elisabeth Gordon, MD, CST (1:07:20)

Thank you so much for having me. This was an amazing conversation.