Dear Carol,

I have a friend who just got some pretty weird advice from her doctor -- at least, it sounds weird to me. She asked him about some sexual problems she was having. She has been feeling less sensation sexually, I think specifically vaginally, and she has noticed a loss of muscle tone there as well. When she asked the doctor's advice, what he told her was that she was too fat, and that's why she was feeling less sexually. I have NEVER heard anything like this, and I just wanted to check with you. She said this doctor also said something to her about some women needing "cervical manipulation" or something like that, in order to have an orgasm. What's with that? Does my friend need a new doctor? Oh, my friend has definitely gained weight -- she had brain surgery a while ago and has not been too active as she has been convalescing.
-- Weirded Out

Dear WO,

This is a perfect example of something I talk about all the time: medical doctors may or may not know what they're talking about when it comes to sex. A large survey several years ago showed that more Americans would consult their doctor with a sex question than any other knowledgeable authority -- so your friend has a lot of company in that she chose to ask her doc about her sexual changes. Unfortunately, many doctors don't know much about sex. It's not completely their fault -- many docs don't get much chance to learn about sexual functioning in medical school. Just last week I spoke to a man whose brother recently received his MD from Cornell -- not a bad school, right? -- and he got two and a half hours of sex lecture in the course of his training. By contrast, Good Vibrations staff get about 50 hours, plus continuing education updates. (Doctors need to get CE updates too, but if they're about sex, chances are fair the company that makes Viagra sponsors them.)

Yes, WO, you have touched upon an enormous pet peeve of mine -- and a very large social issue. Now let's turn to your friend's situation. Could being overweight affect vaginal tone and sensation? Well, possibly, but it's most likely not a simple, cause-and-effect relationship. The possibility does exist that her weight gain, if great enough, might put pressure on her internal organs. But I have a related guess that I think might be more relevant. If her weight gain is fairly recent and is related to her convalescence from surgery, two things may be going on: first, her vaginal tone loss may be the result of not being sexually active for a while. Specifically, her pubococcygeal muscles are out of shape, and her blood's not flowing as readily as it would if she had been more physically and sexually active. Lowered blood flow will affect her erotic sensitivity and the degree to which she can get turned on. Loss of tone in the pc muscles will make her orgasms feel weaker, if she is having orgasms at all.

Second, any life change that results in a person being much more sedentary -- especially the complete rest required by surgical convalescence -- may affect a person's libido and sexual feeling. This is, in large part, a circulatory system thing too, but is also related to the chemicals the body produces when active -- these can enhance one's sense of energy, liveliness, well-being and also sexuality. One of the common "lifestyle factors" that affects sexual functioning (besides diet, drugs, alcohol and smoking) is exercise. You no doubt know that some large-sized folks (your friend's doc would doubtless label them "overweight") are active and get a healthy amount of exercise, whereas others are overly sedentary. This may be at the heart of your friend's sexual changes, not specifically how much weight she gained while convalescing. Whatever else she does, she should figure out a healthy, do-able exercise regimen, and that should include pc muscle exercises -- regular, rhythmic tensing and releasing of her pc muscles. These might well affect vaginal sensation, and they will help her problems with vaginal tone.

Now then... did you say brain surgery? BRAIN SURGERY? In the small amount of sex ed your friend's doctor got, perhaps he was taught that the head bone was connected to the neck bone and the clit bone connected to the vagina bone -- but did he not learn that the most important element for sexual functioning resides between the ears? What kind of brain surgery did she have? In what part of the brain was the surgery done? Does she show any other side effects at all relating to the ability to experience pleasure? Any other neurological effect? Effects on her hormonal balance? All of these questions could be relevant to your friend's situation, and if her doctor didn't ask them, then yes, she certainly does need a new doctor.

As for the question of "cervical manipulation": now that we are so suspicious of this particular doctor's sexological credentials, it's tempting to call into question the knowledge base underlying this statement. The phrase itself is certainly more at home in a (possibly quacksterish) medical clinic than in bed. In fact, though, some women love cervical stimulation, and perhaps some of these might find the sensation orgasm-producing. Your friend's doctor may have had a patient, or even a partner, for whom that was true. But it is not -- repeat, NOT -- way up there with the most common ways women come to orgasm, and when I am faced with any woman who is concerned about loss or lack of sexual sensation, I always like to say a few words in favor of direct clitoral stimulation. Some women have really internalized the notion that they are "supposed" to feel the greater part of their sexual sensitivity vaginally and are distressed when they don't; your friend's doctor, as near as I can tell, is doing nothing to combat this, so I might as well recommend it.

In short, here's my prescription for your friend: exercise, masturbate, do pc reps, and -- while she's at it -- ask her doctor to tell her whether any of the medications he has prescribed since she became ill might affect libido or sexual functioning. Better yet, she can do this search herself on Medline. That's yet another wrinkle in the question of her altered sexual functioning. Please wish her luck, and tell her to do her first set of pc exercises today!