Chronic pain can change how you see your body, connect with a partner, and experience sex, but it doesn’t mean intimacy is over.

Licensed sex therapist and clinical sexologist Dr. Deborah Caust joins Holly and Megan to explain how pain, stress, body image, medication, and caregiver dynamics can affect sexual desire and response. They discuss how the nervous system influences arousal, why touch may help reduce pain, and how couples can move beyond an all-or-nothing view of sex.

You’ll learn practical ways to reconnect with your body, communicate with a partner, explore touch without pressure, and redefine intimacy around what feels possible now. Whether you’re partnered or single, this conversation offers a realistic starting point for rebuilding pleasure, trust, and connection while living with chronic pain.

Guest: Dr. Deborah Caust, Ph.D.

Dr. Caust holds a Doctorate in Sexology from the Institute for Advanced Study of Human Sexuality and a Master's in Counseling from San Francisco State University, specializing in marriage, family, and child counseling. She is a licensed psychotherapist and works with clients through her private practice. She is board-certified by the American College of Sexologists, a Diplomate of the American Board of Sexology, and a Fellow of the American Academy of Clinical Sexologists. Dr. Caust has also taught human sexuality courses at several California universities, and served as President of the Northern California Chapter of the Society for the Scientific Study of Sexuality. She is a member of the California Association for Marriage, Family Therapists and the author of the Q/A column “SexSense.”

Deborah Caust, website

I am so happy that we are diving into the topic of sex today. Yes, sex here on the Unpacking Pain podcast, because it's necessary. We're talking about all these aspects of life that are impacted by chronic pain.

You know, we lose touch with ourselves in lots of ways, and one of the things that inevitably can be impacted is our relationship to either our partner or even to ourselves with regard to sensuality and. And our sex life.

It's just one of the tough things that just can fall by the wayside when our bodies have, quote, unquote, failed us, you know, in other areas. So we have brought on a really interesting and wonderful licensed sex therapist today. She is a clinical sexologist, board certified.

She practices in San Francisco. Her name is Dr. Deborah Caust. She's phenomenal. She's been practicing for 45 years now, which means that she has seen it all.

And I think this is really about getting into the areas and the topics that can seem uncomfortable but really need to come to light.

So we're going to hear from Dr. Caust, who is a specialist in treating all kinds of sexual concerns, relationship issues, they can be individual issues, the things that are putting a wedge between us and the sexual satisfaction that we want to experience, which, God knows, for so many of us, living in chronic pain is a tough one. So without further ado, I'm gonna jump us into the conversation. We're so glad you're here. You don't wanna miss this chat.

Welcome to Unpacking Pain, a podcast dedicated to understanding the complexities of chronic pain, what causes it, how it affects our lives, and what we can do about it.

Join doctor of physical therapy and pain science researcher, Dr. Megan Steele, and me, Holly Osborne, a chronic pain sufferer, as together we explore the biological, psychological, and social aspects of chronic pain and create community and understanding in the process.

All right, welcome back to Unpacking Pain. I'm so excited we're going to dive into this topic of session because you know what?

Not everything around chronic pain has to be down and difficult, although so much of it is. And that's what we're. We're here to, you know, look at the hard stuff, no pun intended, and the easy stuff.

And so today, we're going to really delve into a topic that should be talked about more around pain, and that is sex in our sex lives. And not just sex sex, but also sensuality. So, Dr. Megan, you're up for this, right?

Absolutely.

I mean, so many aspects of chronic pain contribute to changes in our daily lives, our daily function and that has to include our relationships and intimacy. So I'm really excited.

Thank you so much for having me. I'm really excited to be here and talk about sex and sensuality.

Fantastic.

Well, I think one of the first things really that we want to dive into is that this is not the disruption of our sex life is not just happening to people in chronic pain. And so I don't want anyone who's listening to feel like, gosh, here's another thing that I have to acknowledge is going wrong.

For me, this is something that can happen to any of us at any time in our lives, right, that we sort of lose touch with ourselves sexually or lose touch with our partner.

But, you know, I think what we need to do is tap into the expertise and wisdom of practitioners like Dr. Caust to say, hey, I might need a little guidance here to get back.

So, you know, I think one of the reasons that this felt very necessary was hearing from others who are living in chronic pain and saying, when I look in the mirror, I see a body that's not really working, and I see a body that hurts, and I'm tired and I may even have some scars or I may not feel great about taking my clothes off. And that can be true of someone who's living in chronic pain or not.

But as we focus here in unpacking pain on that lived experience, you know, that's a tough one. Dr. Caust, what would be a starting point when someone's looking in the mirror?

And let's just take that one part of it where they say, I don't recognize myself anymore. My body's changed.

You know, in this case we're talking about, you know, because it's been hurt, you know, maybe had surgeries, things aren't functioning properly. But that could also involve weight gain. It could involve, you know, some loss of muscle.

It could involve just not seeing ourselves as sexy because we've been in a sling or in a cast or any of that. So it's a long winded preamble. Forgive me, to ask you about, you know, what happens when someone's relationship to their body changes.

You know, that is such a good question, because in some way, it is true for all of us. It especially can be true for women who've had their image of themselves challenged from the time that they reach puberty.

But especially when you pass menopause and other things, you do take a look at yourself and you go, what's going on? And of course, pains creep up and pain isn't pretty the way that we feel about our bodies and ourselves related to our partners.

And the idea of being sexual, it just feels like it goes so hand in glove. It just feels like such an important question to ask. And so how do you begin again?

I think you begin again by trying to redefine what's attractive and what's not attractive and look at ways to take good care of yourself. You know, I was thinking as you were talking, you know, as you get older, when you're in chronic pain, you start skipping the gym.

You start, you stop, you start to skip all those things, things that are those secondary things that make us make you feel beautiful about yourself. You don't think about buying something sexy to wear when you hurt. So I think you sort of have to start again with.

Well, there is a mirror exercise that I have given clients where you look in the mirror and you start at the top of your head and you go all the way down. And whatever you criticize, you have to think of something positive about that area. So you begin to gently shift, you know, the negativity.

Also telling people that they cannot talk to about their bodies in a negative way and starting to do some of the things that make us feel good about ourselves, like taking a warm bath with something that smells good, using candles, wearing things that make us feel good about ourselves, even to bed.

That's really interesting.

There's a body of research in the pain community with people with chronic pain that shows us that over time they start to kind of disassociate or disconnect from that body part and that area. And if you have them draw like a self portrait, they almost omit. Almost always omit that part.

Or they would draw something that would kind of COVID it up. Do you find that that exercise, that mirror exercise helps, or drawing a self portrait with those types of things can be helpful in those situations.

That's, I think, very interesting.

I hadn't ever heard about it, except that when we talk to women who have pelvic pain, sometimes we'll have them look at themselves in a mirror and draw what they see that reclaim what their body looks like and look for the flower, see the orchid, see what's beautiful. I'm thinking as I'm talking. Have I asked any man to do that?

Yeah, I was wondering about the male side of it too.

Well, men don't have pelvic pain per se. I guess you might have lower back pain pain, but you're not having necessarily genital pain the way that a woman.

Might with not as much frequency. Certainly Men do have quite a bit of pelvic pain. It's very underfunded. It's very under researched. It's very difficult to find participants.

I know of someone in the Bay Area that's doing research on men with pelvic pain. But, yeah, they don't have it, as far as we know, to quite the same extent that women do.

And backing up. I'm curious too, like in your work and in your research, Dr. Kaust, are you seeing that women.

I mean, I know this is gonna be a Captain Obvious question, but I wanna unpack it a little. That women look in the mirror and make a judgment about themselves more harshly than men, especially when it comes to being desirable sexually.

Like, do men have the same propensity to see themselves in the mirror and think, I'm just not, you know, I'm not ready for prime time. Like, I'm just not ready for sex where, like, women will see something wrong with themselves and think that translates into I'm not desirable.

Men will see something, quote, unquote, wrong with themselves. And it doesn't seem to make a difference, bit of dang difference in how much they think they deserve to get it on and how attractive they are.

So would you be able to speak to that? Like the difference, men and women and you know, how we're affected by this?

I think your perception is correct. And isn't it interesting that that has always been true and is still true even today when you.

When they do studies on what men and women find attractive in the opposite gender.

And of course, we're using a very heterosexual model, men would point to beauty and women would point to brains or sense of humor before they point to how attractive the person is. It is if you think anthropologically, no matter what our age, no matter what is going on. And I think this would be true for chronic pain sufferers.

They're looking for people to make babies with, even when we're not making babies. So they want somebody who looks attractive because it's perceived as healthy. Right. It's a model of healthiness.

And that can also be combined with this idea of chronic pain making you unhealthy and making you not look attractive. And you may look exactly the same to a partner as a female, but. But your chronic pain makes you feel differently.

And men just don't seem to have the same concerns, not around chronic pain. They might. It's not that.

I never see men who are worried about the way they look, who lose weight because they want to look more attractive and do other things. But it's not as prevalent as with women. We are really hard on ourselves.

Yep, that's true. And I also Learned earlier from Dr. Megan that. Oh, okay. You'll have to keep me honest here. This is like, little quiz time. Dr. Megan.

The percentage of chronic pain sufferers who.

Are women, somewhere around 70%. Okay.

I was gonna say 60. I was like, okay.

Most presents around midlife when things are changing, hormones are changing, life circumstances are changing, et cetera. I'm sure you see that in your practice.

Yes and no.

Because when we talk about vaginismus, which is a painful conditioning that you would probably know very well, where there is this clenching of the outer third of the vagina, or dyspareunia, which is painful sex, both in women.

I see probably more younger women who are. Who are coming to see me while I'm on the topic.

I've had women who've come to see me with these conditions and never been able to have penetration, and they're now married, and it's 10 years down the road, and you have to sort of slowly work with them.

I also see those conditions, of course, around menopause, as estrogen levels drop and you start to experience change changes inside the vaginal barrel. And also I have a client in her 80s who is having painful intercourse now. And actually, it's been coming.

And each one of those groups needs a very different kind of treatment.

Yeah.

I mean, it's just. It's like. It's so individualized. It's just a lot like living with chronic pain. Right. It's so different for everyone. But I think the.

The curious thing that. What I'm so curious about is how pain can get in the way of sexual thoughts. Right. It's like a. Especially for women. I won't.

I certainly can't speak for. For all women. And this is.

There are always exceptions, but I think that in order for us to really be in the mood and for us to achieve some modicum of pleasure from you, this. The sex act or whatever, you know, we're doing, like, sometimes our. Just. Our head has to be screwed on. Right.

You know, it's like, oh, my God, I was thinking of all these things and thought about how he kind of insulted my best friend yesterday. And there's laundry on the floor and, oh, my God, is that a cracker I'm feeling underneath my back? Damn it.

This bed is never clean, you know, and that happens. And then you throw chronic pain into the mix, and it just seems to, like, come in like a Big eraser and just go.

Let's just take that part of your life out of the equation, because you gotta have too much going right up in the headspace in order to. Is that a myth, Dr. Kaust, or is there something we can work with to say, ladies, it you don't have to stay up in your heads the whole time?

Well, you are exactly right. And this gets into an area of where we talk about the automatic systems in the body.

I don't know if you've talked about the parasympathetic versus the sympathetic, but I'm going to take a moment to get into that. And that is that when we feel any kind of threat, our body has an automatic response to fight or flee or freeze.

And that system releases neurotransmitters that shut down the ability to respond sexually. So our body does not know the difference between, oh, my God, I'm in real danger, and oh, my God, did I do the laundry?

Or oh, my God, I hurt, I have pain. All of those systems will shut the body down and keep it from responding sexually. So you can't lubricate and you can't get an erection.

In order to do that, you need to shift into the parasympathetic part of that automatic or autonomic nervous system that predominates when you are relaxed or you're sleeping. And from there, you're able to reach your sexual capability. How do you do that? You have to be relaxed.

So anything a couple does or anything you do to yourself that relaxes you, like cuddling and soft touch and you know, really taking your time to get into a sexual experience will start to put you in that part of your system. And it turns out that the touching in and of itself enables you to release other hormones and neurotransmitters that will block pain.

Oh, that's interesting.

Yeah. We talk a lot about threat detection in chronic pain on this podcast.

And I completely agree with you that if I'm in a state of fight or flight, my body is doing the things that are necessary to keep me alive and to keep me safe. And I'm not thinking about. You know, I love the analogy of, like, a lion enters the living room, right?

A lion enters the living room and your spouse gives you the eye or your partner, and you're going, are you kidding me? Do you see this lion?

Right?

And he sees a pile of laundry and is like, what's the problem?

But, yeah, I think what you're talking about, Dr. Kaus, is that type of touch that activates the C. Tactile fibers in our bodies. Can you talk a little bit more about that? Just kind of all the positive things that happen when we touch people in that soft caressing type of way.

Well, you lower your cortisol, you release endorphins, which are opiate, like substances that block pain. You release dopamine and oxytocin. All these things lower stress and cause you to feel closer and more relaxed. And even a very soft touch will work.

But vibration works. Turns out vibration is on the same neural pathway as pain.

So you can reduce pain just by, you know, think of a mother rubbing a child's knee or having your arm rubbed before a shot, those things you release enkephalins that lower pain.

Oh, yeah, yeah. So the mother rubbing their child's back is oftentimes equated to activation of those C. Tactile fibers.

And we think a lot about the vibratory sense as. As being one of our sensory activating one of the four sensory types of nerves.

And a lot of times that that will out compete those pain fibers that are deeper, that are sharper, that are more sensitized. So like you say, it can not only decrease pain, but also kind of shift you into that place of safety.

Is it almost like, are those hormones strong enough to actually, I mean, it's like when someone takes a painkiller and it hijacks that pain system. Are these hormones strong enough? Dr. Deborah, Dr. Megan.

Like, is this kind of what we're saying is that when you get those feel good chemicals going in the body, that the body has the ability to almost kind of override and sort of forget about the pain for a bit. Are those hormones strong enough?

As far as I know, yes. But you brought up an area of medication, and sometimes the medication can make it difficult for you to respond.

You have to figure it's like antidepressants sometimes can block your ability to respond. So you would need to time that medication and you would need to ask your doctor about it.

All I meant was just the same way that taking like a Percocet can dull your pain for a while.

Yeah. Yes.

Are the chemicals that naturally occur within us? Are they, can they be just as powerful?

Like you can get a break from your pain while you're having sex because you have so many great naturally occurring hormones coursing through your body that it could almost act like a natural painkiller?

It does act like a natural painkiller. Yes.

Okay.

Oh, go ahead. Sorry.

One of the things that is very interesting is when we look at people who are engaging in pain for pleasure, who are into sm, is that we don't realize that the more aroused they are, the less pain they're actually feeling. They're feeling intense tactile stimulation, but they're not feeling pain.

That's how effective it is, because they're getting closer and closer and closer to orgasm.

So is there like a. I mean, maybe all of us living in chronic pain are really missing a trick here. Maybe we need to be having sex, like, way, way more often. What do you think, Dr. Megan?

I will say that anytime a study comes out that shows that, like, sex improves headache or sex improves chronic migraines and things like that, the media grabs it and says, look at this, everyone. We should all just be having sex all the time. But to Dr. Kaus's point, I, you know, I have to be able to get there. Right? I have to be able to.

I think that's really the crux, and where a lot of people struggle is I cannot shift out of threat detection mode, sympathetic nervous system mode, to even kind of get my head around the idea of this is going to help my pain.

Why don't we talk about how you do that? Yeah. Again, you need to sort of redefine what sex is, what sex looks like to be, what is what can work now. And.

And that means infusing, if you're in a relationship, infusing your relationship if you're not in a relationship, taking care of yourself to think about sex being woven into the fabric of your relationship. So it doesn't just happen when you're supposed to turn on. You're already primed.

And you're primed by being kind to each other and sweet to each other and paying compliments and being affectionate so that you're already beginning to get closer to what you need when you're being. When you're being sexual.

And from there, it's easier to move into something that's a little bit more sensual, so touching, without any goal, that you're supposed to go anywhere just to try to start to enervate some of those systems.

And this requires something slow and something gradual and maybe something planned so that you have an opportunity to shower and shave and get ready and et cetera. I have this thing with my husband where he'll say to me, are you hungry for dinner? And I'll go, what? No, I'm not hungry.

And he'll go, that's okay, sweetheart. And then he'll go, and he'll get like a chip with Fresh guacamole on it. And he doesn't say anything. He just puts it in front of me and he walks away.

And then I keep looking at it and then I take a bite and I'm not hungry, but I finish it. Cause it's so delicious. You know what happens next? I'm hungry.

You want more?

I want...

The juice is flowing.

Same concept applies that you want to have between you. This idea that we're not going to be sexual. We're just going to sit here and talk. We're going to sit here and share memories.

We're going to just have a little some moments together, and then we're just going to lie down and just cuddle and share our skin together. And if you're on your own, take that warm bath and start to do a little bit of touch in ways that is not designed to turn you on.

And there's an assignment that I give clients to have a romantic experience, experience with couples. And that is each person plans an experience that is romantic to them, and then the other person accompanies them as a gift.

And so you get to think about what is romantic to you, what is romantic now. Not what was romantic at the beginning or before you had chronic pain, but what is romantic now.

And just the thinking about it and then the doing of it makes people feel closer to their partner.

You know, what I love about this is that I think sometimes when sex becomes challenging, we think that it's like an all or nothing. It's like we're not having sex or we're having sex.

Right, right.

And to fix that, you know, I put in air quotes because there's nothing broken. Like you don't have to, you know, fix something that's broken.

But if you do want to move the needle on that, I think a lot of us, myself included, think that the cure for that is just to have sex. Just. Just do it.

And then this insurmountable thing, and then there's this pressure because it's like, well, if I, you know, stroke this, you know, stroke my partner's arm, they're going to get the message. And that's not really where I'm at right now. So I love the idea that you're kind of taking the stakes out of it. You're taking sex off the table.

Not permanently. Doesn't even have to be more than, you know, one exercise worth.

But knowing that we can reconnect and find that soft and resting and close place again without it having to mean sex, I think could do wonders for People. That's really interesting.

Well, I think it brings you closer, and being close is the precursor. And you often, you know, when you hurt, you don't want to be touched. You not only don't feel sexy, you don't want to be touched. Yeah.

So these are ways to get you sort of not only started, but in and of themselves, they are delight and a pleasure.

Yeah, Yeah.

I like what you say there with.

The chip and the guacamole. It's almost like I call it planting the seed with someone. It's sort of like we're not going to solve chronic pain on day one.

I'm not going to teach you everything there is to know about pain science. Otherwise, I'm just pain splaining to you. Instead, I'm planting a seed and I'm saying, you know, here's this. Take it or leave it.

And then the next session, it's like, oh, you know, I was thinking about what you said there, and that's interesting. Maybe we talk a little bit more about that. And, you know, you just kind of like baby steps, Right. We don't have to do anything.

We're just going to sit next to each other and hold hands or whatever, whatever it is for that day. I think that's a great strategy.

I love. I love what you're saying. I think that's exactly, exactly right. And there's more. So the first step would be to sort of reengage in this way.

It sort of resets the relationship. I mean, people don't realize that you're not trying to go back to what you had before. You're trying to go to someplace possibly better.

And I think especially, you know, you were talking before, Holly about being in middle life. You are.

You have so much more capacity to sort of embrace the whole experience than you did when you were just sort of, you know, hormonally driven when you were. When you're very young. But I think, you know, the chronic pain gives you a chance to really tap into and slow down.

I want to tell you another exercise that I give clients, and in my head, this is key to whether you have chronic pain or you don't have chronic pain. But in getting things to where they need to be, and in and of itself, there's no goal here. It's just a pleasure. And it's called sensate focus.

It's a very famous exercise that I was taught by Masters of Masters and Johnson at school. And it is where we. We have.

It's a touching exercise designed to teach sensuality so one person is considered the giver, the other person is the receiver and the giver touches the receiver for themselves. So they're staying in their own body looking for what is a pleasure, whether it means it's very soft.

So you may be, you know, I'll have clients sometimes do this on their hands because you know, in the session and then they go home and they do it on their bodies, whether it, what feels soft, what feels nice, what is interesting. And they're just gently stroking the body with small strokes to look for what feels good. Good.

And now we are shifting people into reducing pain and also creating a little bit of pleasure from the parasympathetic part of the system.

Because especially if, if you're in pain and you're being touched and there's nothing for you to do, your mind is able to focus in on what that touch feels like. Now it isn't actually for the pleasure of the person receiving, just turns out that it is a pleasure for the person receiving that kind of touch.

They are relaxing into it. The person doing it doesn't have any goal except for to look at what feels good.

And I always start with people doing it with their clothes on, just what's exposed. I have them get down to their underclothes so that, and I say you cannot touch breast, genitals or the butt.

So again you're getting back in touch with the other parts of the body. And then eventually they get to touching the whole body, not just focusing on those erogenous zones, but the whole body.

And in doing this, we are starting to turn the body on without our mind going elsewhere. The trick is to keep your mind under the touch and you can practice that on yourself. How does it feel to touch my hand?

How does my hand feel when being touched?

Okay, it's a two way street.

One thing that's really interesting about that, this is the first time I've heard of this type of exercise, is that oftentimes when our partner is touching us, we may be thinking, oh, that's not quite it. And that takes us out of the moment and into our head.

But if I know that my partner is touching me for his pleasure, I get to sit back and kind of watch the movie. And frankly, when you see someone else getting turned on, that's a turn on. I don't have to do any of the work and either think about.

Because a lot of women struggle with people pleasing when it comes to sex. We don't want to say a little to the left or please not so Hard or not so fast or whatever it is. And believe it or not, that gets in the way of like.

Like, there's a huge stat on this. Like a third of women are having bad sex specifically because they're people pleasers.

And so it's interesting how it kind of flips it to the other person is like, hey, you're not trying to get me off here. Like, let's just see what. Where you go with this. Is there. Is that part of kind of the psychological sort of theater or what's.

Of what's happening there?

Exactly, yes. Because, you know, whatever your partner's doing, they like it.

Yeah.

So you can just let go. And now all of a sudden, your body is automatically getting in touch with what feels good to them because they're not worrying about their partner.

Yeah. So I love your point about that. You know, women are people pleasers. Men are people pleasers too, it turns out.

And so the exercise is effective for both partners.

That makes sense. I have a question about shifting gears just a little bit.

And this is something also that Dr. Megan could maybe lend some perspective on from who she sees in her clinic as well, from a physical therapy standpoint.

What about the dynamic in a couple for whom where the chronic pain is present, there becomes a little bit of a caretaker and cared for dynamic, or maybe not a little bit, maybe a lot.

Yeah.

Do you see couples falling into kind of their roles shift over time, and then those roles are not really lending themselves to sexy time? So we see that pain all the time. So what. How do you help couples get out of a groove where they've taken on a different role with each other?

And what can come with that is this shifting of roles where it's like, I don't necessarily see you as a sexual partner. I see you as somebody or something I need to take care of. And. Or the receiver of the care may start to feel guilty.

It's like, I'm putting a burden on this person. That can start to change the sort of, you know, intangible dynamic, you know, that.

That sizzle, that thing between two people when you're taking care of someone. What happens in that kind of situation?

Is there a way that couples can get out of the roles that they've fallen into and get themselves out of that role that's not sexy?

No, it isn't sexy. And you have to have this sense of equality in order for both partners to be able to participate.

And so I think letting couples know or asking them about whether they're doing it and Letting them know that this can happen and that this is working counter to what they're trying to achieve. They can talk about what they need to do in order to even up.

For example, if we design some kind of scaling system in which the person in pain can scale what's going on between, you know, 0 and 5 or scale the pleasure. So rather than saying ouch, they're saying that's a five on the scale. So that is so that we're not, we're not hearing those kinds of words.

It does start to create a language for them in order to.

So that the person who's worried about the other person's pain can let go and know that the person in pain is going to say something or use a hand gesture. In fact, anything in which you stay away from talking is a good idea because talking takes you out of your body and into your head.

If they have great communication and they know that they're going to speak up, the other person's going to speak up, then we can, we can dissolve those roles a little bit. We've got to leave those roles outside the bedroom door so that when they're together they are both able to participate.

Wouldn't that be cool if like we treated.

And not to suggest that sex always happens in the bedroom, but wherever it tends to happen for a couple or for you, if you are solo, a solo act, it would be interesting to almost create like a false sort of threshold, like a portal. Make that door a portal where it's like through this door. We don't say words like, you know, my. We don't say humoral, my humerus.

We don't say my prosthesis. We don't. Physical therapy, right? And it's like, yeah, yeah, yeah, we leave that behind and it's through this door.

That doesn't mean like this is the sex door. Like you walk through here and you gotta be like, uh huh, baby. But maybe that's where you choose to leave that behind. Or you agree with your spouse.

Hey, when we cross this threshold, I don't want you to ask me if I'm okay and I don't want you to ask me what I need. And I don't even want you to use my pet name, Bunny. You know, like, this is like off limits in this everywhere else.

In the house, in the car, across the street, Go for it. I don't know. What do you like, Dr. Megan? Have you had to like help patients recreate their, like the way they show back up at home?

Or have you seen this Dynamic like where they're carrying guilt around, Certainly, yeah.

And that's part of the social aspect of the biopsychosocial is how, you know, we're not born with knowing how to ask for what we need, which a lot of us, you know, sometimes can feel shame around. And sometimes when we ask for what we need, that creates shame in whoever we're asking.

And so, to Dr. Kaus's point, having that dialogue outside of the bedroom so that everyone goes in there with clear expectations and clear understandings, I think is a really important aspect of it. And another part of the social component of pain is sleep. And so I do talk about that. This is a magical door.

And there are only two things that happen in this room. One of them is that thing that's really fun from time to time or, you know, however often.

And the other thing is sleep, because our nervous systems and our brains are so good at associatively learning. And so if I've. I've assigned my bedroom, this is where I receive care. This is where I am healing.

That may also contribute to difficulty shifting to a. You know, this is. This is a place where the fun stuff happens. Would you agree with that, Dr. Kaus?

Absolutely. I think that's. That's really great. I talk to clients about the fact that they are creating a secret club with their own language, their own signals.

They can signal each other across the dinner table when there's other people present to connect and how we're going to be and where we're going to do it and what this is going to look like so that they can go in their own pace, in their own space.

I love that secret portal stuff. I'm going to add that one.

There's a friend of mine, and I swear this is not one of those stories that you tell that actually is about you, but you're saying a friend, friend, this, this genuine friend of mine who lives in Orange county, and she's very creative, problem solver.

And she was telling me that she and her husband had fallen into that caretaker role and that they were using a lot of words that she was using with her own child. And she's like, oh my gosh, the words that are coming out.

And she said, I didn't think my husband had heard me say sexy or sexual words for a long time. So she bought a pair of dice that apparently every facet of the die had a sex or a body part word on it.

And she busted those dye out one night when he comes into the bedroom and she's like, roll the dice. And she's like, boob, boob, wet boobs. And he's like, whoa,.

That'll shift things pretty quickly.

It was really funny.

Like, I was giving her credit for that because sometimes just need that thing to get you, you know, over the hump or that kind of just like, triggers you. But we've talked about some really interesting things today. Like, Dr. Kaust, I love that you introduced us to.

Or at least for me, it was the first time thinking about outer course. There's intercourse and then there's outer course. And, you know, you. You've really some cool things to think about. What would you. As.

As we get ready to kind of wrap up our time here, what. What would you like to leave listeners with?

You know, if someone's listening to us right now and they're a chronic pain sufferer and they're saying, oh, I, you know, I don't think. I can't remember the last time I've had good sex, and I don't know where to start.

What do you think is one thing they could maybe do that would feel really low risk, you know, but maybe high reward within the next week or to.

If they're in a relationship, I think one thing they could do is lay down facing their partner. Yeah, there's something about face to face on your sides, you know, general genitals in proximity of each other that starts something. Yeah. So that.

That is sort of one thing that they could do. But I think that they have to start talking to their partner and bring this.

The topic up and begin to joyously embrace the idea that just because they're in chronic pain doesn't mean their sex life is over. They just have to find a new path.

Thank you for saying that. Yeah, I think people needed to hear that. It reminds me of how Dr. Megan says, you know, we're.

We're neuroplastic, and we can always change our bodies. We can always change our pain. Now I'm stealing our final Lyme that we like to. But it just seemed like such a good moment to draw that parallel.

And what I love is that I think you've demystified Dr. Kaust this idea that sex is this huge Everest that we have to climb.

And I think part of the problem is the fricking media and social media makes us think that it's like immediate hair tossing back, orgasmic, and just the greatest sex. And that we're both arriving at the same time, as Sabrina Carpenter likes to say. And that's what makes it feel like climbing Mount Everest.

But what Dr. Kaust is reminding us is just so doable. Start with a conversation. Make it something smile worthy. This is not paying a tax bill that you can't afford.

This is not, you know, talking to your oncologist. This is, you know, we got to try to, you know, hold on to the things that can be sweet and fun and, you know, I think. I think that's really special.

Now, how about if they're solo and they don't have a partner to lie across from? How about that one? What could someone do within the next week or two?

Well, I'd like them to get back in touch with their body, and they can start with taking that warm bath and stroking their body and refamiliarize themselves with taking care of themselves. Masturbation. It's a lot easier to find a partner when you already feel sexual yourself.

Ooh.

Could that also apply to someone in a relationship where, if they can, like, would they. Would you ever advise someone sort of start on themselves a little bit?

It's like, hey, get back into sexual groove with the masturbation, and then you'll be even more ready for your partner.

Yes, absolutely. Okay.

All right.

Okay, so listen up, everyone. You have an assignment, and it's a good one. For one, it's a great homework assignment. Dr. Megan, what do you think?

I mean, is this something you could see bringing up in your clinic ever?

Absolutely. You know, relationships and how chronic pain affects our lives and aspects of our relationships are necessary to talk about. It's a component of the.

The whole person. And if this is something they're struggling with, then certainly I'll refer to someone like Dr. Kaust if there are, you know, deeper things.

And also when people learn how to shift out of that sympathetic threat detection, fight or flight response, a lot of things start to emerge as possibilities, and I think sex is definitely one of them.

Well, then I'm extra glad that we have this conversation today. Thank you, Dr. Kaust, for your wisdom, your expertise. Thank you as always, Dr. Megan.

And listen, if this proves to be a popular topic, we can always get, you know, sex is like an endless conversation, right? Like, you know, we can pick this back up again another time and keep delving. So in the meantime, I hope everyone can pick up on those exercises.

And hey, if you didn't need this conversation, extra good for you. Pass us your tips.

Yeah.

Big thanks and gratitude to you, Dr. Caust. We really appreciate it.

Thank you so much.

Yeah, thank you.

All right. And thanks so much for tuning in. We already said the last bit, so you know, just keep your head up and keep on trucking.

We are here for you and we look forward to seeing you on the next episode of Unpacking Pain.

Thank you so much for listening to this episode. We appreciate your tuning in and being part of the Unpacking Pain experience.

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