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Carli Blau, PhD candidate - Endometriosis and Sexual Functioning

Carli Blau, PhD candidate - Endometriosis and Sexual Functioning

Carli Blau, PhD candidate - Endometriosis and Sexual Functioning

Patient Awareness Day 2019: HEALTHY MIND & HAPPY PELVIS
Living Your Best Life With Endo
March 10, 2019 (8am - 5pm)
Einhorn Auditorium, Lenox Hill Hospital, New York City
https://www.endofound.org/patientday/2019

Thank you so much. Good morning, or good afternoon. This daylight savings time has really taken me through a loop. I'm also a new mom. One thing I wanted to tell every single person in this room is that ... Well, one, I get nervous speaking so I'm fine. Two, if there's anybody in here who has ever questioned your ability to have a child with endometriosis, my daughter is home sleeping today. Last year at this time, I was just approaching an embryo transfer. The Endo Ball was the day I had my transfer and on March 21st I found out I was pregnant, so don't lose hope and just keep fighting. If you need support, I'm here.

Let's get started. Today, I want to talk to you about endometriosis and sexual functioning. Is there ... Hold on. How do I get to the next slide? The clicker. Of course. The clicker. I'm blaming the mom thing.

Okay. Today, my goals for this presentation are for you to understand how endometriosis affects sexual functioning both physically and psychologically. A lot of times, we don't realize how something that is so biological can impact our mind and the way that we think and what we think and how we behave. I want to bring light to that. We're also going to learn about how endometriosis affects intimacy and your relationships and how sex therapy, which is what I do, can help patients with endometriosis.

Excuse me. Okay, now I sound normal.

Endometriosis can cause physical discomfort and sexual dysfunction. Now, I want to just say my fonts got messed up. This was not how it was supposed to look so just bear with me. Some of the sexual dysfunctions, and I'm going to explain what they all are to you, that you can experience as a result of endometriosis are dyspareunia, chronic pelvic pain, vaginismus, vulvodynia, and lack of vestibular lubrication. Now, I want to be clear. It's not that necessarily endometriosis causes these sexual dysfunctions. However, the way that endometriosis tends to take over our bodies physiologically ends up resulting in our bodies experiencing these sexual dysfunctions.

Has anyone in here ever heard of dyspareunia? Okay. Raise your hands high, I can't see. Okay, great. A lot of people. Dyspareunia is actually one of the most common symptoms that are reported with women with endometriosis. Interestingly, a lot of of men who don't know what dyspareunia is, they'll go to their doctor and be like, "Hey, my wife, my partner is experiencing deep pain and pelvic pain. What could this be?" Then men are also learning about what dyspareunia is.

What is dyspareunia? It's defined as a vaginal and vulvar pain that's experienced during or after sexual intercourse and it's four times more likely in women with endometriosis when compared to women without endo. 60-80%, 80%, that's a huge percentage of women, who receive surgery for endometriosis also exhibit dyspareunia as one of the leading symptoms for why they go through surgery. Sorry my voice is so weird.

Okay. These are some of the things that I want to talk about, identifying dyspareunia and understanding what it is and how you know if you're experiencing it. Right. This area that's highlighted in red, that part of the vagina is actually called the vulva, and there can be vulvar pain that's experienced as a result of endometriosis. Then, there can also be vaginal pain that's anything by the opening of the vagina and anything inwards in the body. Some things that can help you identify whether or not you or someone you know is experiencing dyspareunia is that they might have painful intercourse. It can happen at any time and any time of sexual intercourse, foreplay, all the different types of foreplay, and oral sex and a bunch of different other things that you could experiment with. It happens at different stages of life, also. This is not subject to just a woman who is young or someone who is in the middle of their life, or I like to say that we're all young, it's just a matter of how you define it.

Then, the duration. Just as the frequency depends on the cause, it also is the length of time for each episode. You could experience pain for a few seconds, so just at penetration. You could experience pain during the entire time that you're having sex. It's very important that, when you seek out medical help and you want to speak to a doctor or you might be informing someone about this or telling someone about it, that you inform them of all the different ways that this could present because so often we feel like we're boxes that get checked off. It's like, if you don't fit all the boxes, all of a sudden it doesn't apply to you. That's not actually how it is. It can apply to all of us.

Then, the intensity. Women might feel a superficial burning sensation or like a throbbing pain. All these different things exist and we have to be knowledgeable about them so that we can all be included and also supported in our experience.

Okay. The types of dyspareunia, so there's superficial and then there's deep. Superficial dyspareunia is the pain that exists in and around the entrance of the vaginal opening, and then deep dyspareunia is defined as the pain that exists deep within the vagina upon penetration, including deep penetration. A lot of women who have endometriosis experienced endometriosis tissue behind the uterus and in front of the colon, and so what can happen is it's actually ... The space is called the uterosacral ligament. In that space, it can be ... It's a very common place for endometriosis to occur. When women have endometriosis in this location, any kind of deep penetration, whether it be in a same sex relationship or a male and female relationship, when there's penetration in the vagina, it can cause a lot of pain in this area.

I thought I saw a question. Sorry. That's why I paused.

Okay. The other physical sexual dysfunctions that can occur as a result of endometriosis are vaginismus. Has anyone ever heard of vaginismus? Okay. Less than dyspareunia. Painful ... What this is are painful spasmodic contractions of the vaginal walls in response to physical contact or pressure, especially in sexual intercourse or penetrative sexual activity. It just feels ... Everything gets really tight and it's super painful. It can be burning, it can be throbbing, it can be all different types of pain. That's something that's also quite common but I think that less people know about vaginismus, which is why it's really important that we know, especially all of these people that are in the room today. All of you are here to get educated and to learn. The way that we impact and empower others is to learn so we have more information to inform other people.

Then there's vulvodynia. There's generalized and then there's localized. Generalized vulvodynia is pain that's in different areas of the vulva and that can occur at different times. It might be consistent or it might be infrequent. It can also be by touch or pressure. That may or may not prompt it or make it worse. Then, there's localized vulvodynia, which is pain in one area of the vulva. It's often a burning sensation.

I've heard often a lot of women with endometriosis experience this vulvodynia, localized vulvodynia, may I say, and a lot of women go to the doctor and they're like, "Hey, when I receive oral sex, it burns," or, "When my partner puts something inside of me," and I say something because I don't like to generalize, "it might be super painful or it burns. I think I might have a UTI. I might have a urinary tract infection. Something's burning me." When we think burning in our vaginas, we tend to think that it might be burning sensation with pain or with urination and then we're automatically, "Oh, you have a urinary tract infection. I'll get you on antibiotics. You'll be fine." You take the antibiotics and you're not fine. Sometimes this can be localized vulvodynia.

Then, one thing that I want you to remember is that endometriosis tissue does not necessarily cause a sexual dysfunction itself, but the pain and inflammation and adhesions that are related to the endometriosis tissue are actually what help cause ... I don't want to say help but they do cause all these sexual dysfunctions that we see.

Okay. Now, this is something I'm really passionate about and I think is really cool in the sense of how our mind works. I don't think it's cool that it happens. Sexual functioning is affected by our endometriosis because our brain maps things. Kind of like we know that, if there's ... If the sky is gray, what does our brain say? It's probably going to rain, right? Your brain maps. When we see something or we experience something, it can know what's coming.

Okay. Dyspareunia actually leads to a bunch of other things, and then it becomes this mind map and this cycle in our brains where we begin to expect something as a result of what we're experiencing. For example, in the diagram on the left, we might experience dyspareunia, and then we have a fear of pain with intercourse because I don't know ... Unless it's consensual, unexpected pain during intercourse is not very enjoyable.

Then, if you experience the pain during intercourse, then all of a sudden you receive anxiety with or without the sexual response. All of a sudden, our vaginas may not lubricate the same, or when we get that tap in the middle of the night, you know that tap that's like, "Hey, babe. You in the mood?" That tap? All of a sudden, you're like, "No, no, I'm really tired. Sorry." It might not be that you're really tired, it might just be that, in your mind, you're thinking, "Okay, if I go ahead and do this right now, I'm going to be in pain. I don't want to be in pain so I'm not going to go ahead and do this," the this being sex.

Then, it can resolve in vaginismus developing because then our anxiety in our mind says to our vaginas, "Hey, you don't want to do this. It's going to hurt you if you do this." Then, all of a sudden ... Anybody who has ever been nervous, do you know how your body gets? Your body gets tense, right? You get tight, your muscles get tight, your body doesn't feel the same. That happens in your vagina. Your vagina gets tight, and it gets super tight to the point where it can be really uncomfortable to be penetrated. Then, we get back to dyspareunia, where sex is just incredibly painful, and the cycle goes on and on.

Women with endometriosis are also more likely to develop mental disorders like generalized anxiety, depression, low quality of sex life, low sexual satisfaction, diminished sexual desire, increased sexual dysfunction, and sexual anxiety. Now, as a therapist, I'm going to say I want to be careful with how we call these things mental disorders. Technically speaking, that's how it's supposed to be spoken about, but it's not to say that anybody who has ever experienced any of these things, because I've experienced a hell of a lot of those things on that list, have mental disorders. I want to be really careful about how we define these things.

Women experience consistent pain from sexual activity and then the pain stops them from engaging in further activity, which ultimately makes them not want to engage in sex due to fear. 66% of women with endometriosis actually fear having sex. Can you imagine what it's like to want to be intimate with your partner, to want your partner to make love to you and to feel comfortable and feel intimate with you, and for you to be afraid of that? The gravity of that is just huge.

Then there's these negative sexual schemas. This is also something I work on in sex therapy, which is where the consistent negative thoughts and feedback that our brain receives as a result of painful sexual functioning and pain that's experienced as a result of all your activity that's sexually related becomes a consistent pattern of negative sexual expectations. The fear experienced emotionally then shows further in reduced desire, the lack of lubrication, pelvic floor spasms and tightening, and then these expectations perpetuate further dysfunction and set up this vicious cycle.

Now, something that I do in sex therapy that I'm going to get to in a minute is that I'll work with women on how to disembody and to break down these cycles so that we stop expecting the pain and how to actually engage in sexual functioning with your partner in a way that may redevelop the positive connections in your mind to sex instead of continuing the negative connections that you have.

Medicine. With endometriosis, there are now all these new drugs and these medication protocols that we get put on to treat our endometriosis. We have anxiety medications, we have depression medications, and all these medications, they have side effects. A lot of the side effects results in low sexual functioning or low sexual desire or maybe you don't have a libido anymore and you just are not feeling it. It's important to understand that hormonal therapies, as well, that are used to treat endometriosis and other medications can increase your chances of low sexual desire, lessened arousal, painful sexual activity, and lack of vaginal lubrication. It's really important when you see a doctor and you're suspecting that you have endometriosis or that you do have endo and you're experiencing any of these things related to your sexual activity that you let your doctor know every medication you are taking, and you also let them know before you start taking medication if you're experiencing any of these situations with your sexual functioning or lessened desire so that we can have a baseline for treatment going forward.

Now, last year I got a kick out of this one, but one of the main things that comes as a side effect of endometriosis are GI issues. I don't know about you but there's nothing sexy about diarrhea. Okay, I could have done better than that. I also think that, when you have a stomachache and your belly hurts and you're nauseous and you don't feel well, there's ... You don't come home from dinner with your partner and you're looking at them and you're like, "Wow, you look really good tonight. This was really nice. I'm really enjoying myself and, technically speaking, I'd like to go home and just want to rip your clothes off," but then you get home and it's like you're in the bathroom the entire time. That's not the way that you want to start sex. That's not hot foreplay unless you're into that. Okay, I got a little bit of a laugh.

Endometriosis, how does it affect our relationships and intimacy? Whether you're single or partnered, endometriosis requires constant open communication about your body, your sexual functioning, and your needs. Endometriosis can affect your partners, too. It's important that while ... Sorry, but it's true. Whether you're in a same sex relationship or a male-female relationship, or however you define it, sex is affected by endometriosis. In a male and female relationship, it might be important to acknowledge that your fear of having sex and the constant rejection every time your partner wants to have sex with you and you consistently saying, "No, babe. I'm just not ... It hurts. I don't want ..." It doesn't invalidate your pain. It doesn't invalidate what you as a woman with endometriosis are experiencing, but it also doesn't invalidate what it's like for your partner, however they identify, to be rejected consistently.

That is something that we don't talk about enough but we have to keep in our minds because we want, as people, to be wanted, and we want to be wanted sexually. When we're constantly telling somebody that we're not in the mood or we don't want them, it's hard for us to keep getting wanted or be wanted. Male partners of women with endometriosis may also experience erectile dysfunction, performance anxiety, or loss of desire and interest in sexual activity.

Now, I do sex therapy. What is sex therapy? I do not watch people have sex. I do not help people have sex. I do not engage in any of that. What I do is it's strictly talk therapy in which I am clinically trained to discuss sex on a more intimate level where maybe sex is something that makes a lot of people uncomfortable to talk about. One of the things that I would do is discuss how sex changes throughout our life due to many different differences, many differences, partners, age, childbirth, medical diagnoses, and medicines.

Then, also, what I love to do is to redefine sex. I don't know about you but I'm going to disclose and tell you this, that, before I was diagnosed with endometriosis when I was 14, when I became sexually active, sex for me was something that was enjoyable and I loved it and it was fun and it was intimate and it was great. Then, once I experienced pain with sexual intercourse, it became something that I really dreaded and I wanted nothing to do with, and that's grief in itself.

Then, I learned how to redefine sex. All of a sudden, sex wasn't what I was engaging in before, sex now became something that I recreated. Was it going to be the same way that I had sex before? No, but when you have endometriosis and you learn where your endo is and you have a surgery to remove it and you go through treatment, you understand then maybe sex at a certain angle or in a certain position is not something you can do. Maybe it's better at a certain time of day than it is at another, a better time in your cycle. You learn all these pieces so that you can redefine sex so that it can be something that you can enjoy again, and that it doesn't have to take over your life as something that you can't enjoy or that's painfully related in your brain, but it's something actually can bring you pleasure, which is what it's supposed to do.

Some of my tips for the endo girl or for your partner who might be supporting you is to talk about your experience. Every single one of your stories is valid, every single one of your stories should be heard. I want to hear every single one of them, and that's what you're all here for today. Ask for help. Don't be afraid to ask for help, don't be afraid to say that you need help. I think that's one of the biggest lessons in my life that I've learned thus far, is that, no matter how strong you are, it can be really hard to ask for help.

Communicate what feels good and what doesn't. When it comes to sex, it is ... We tend to take things personally when we hear criticism in the bedroom but, if we can take ourselves out of that mindset and we think that this is not just about us but it's also about our partner and how our partner experiences something, we can take it less personally and we can communicate about what feels good and what doesn't so that we can give them pleasure and receive it.

Gentle massages and foreplay can be a really great way to redefine sex. Avoid sex when experiencing endometriosis symptoms so that you don't perpetuate the issue in your mind of sex relating to pain and being directly correlated with your endometriosis because that can lead to further resentment. Pelvic floor therapy has been incredible. I know that you're going to hear from some pelvic floor therapists today, or you may have already. It's amazing and changed my life for the better. Try different positions based on your physical needs. Use lubricant. Redefine sex to make it something that you can enjoy. Co-masturbation is also something that a lot of people never think about but it's something that can be used to both receive pleasure without feeling like you engaged in what you used to or any pleasure at all.

That's me on a good day. If you have any questions, you can visit my website at carliblau.com or feel free to email me or give me a call. For any of you who need support, I'm right there by your side. We're not alone in this. No one ever is, no matter how many times you feel alone. Thank you so much for your time today.

I think we might have time for a couple questions if anyone has questions.

Does anyone have questions? Mm-hmm (affirmative)? Sure.

One of the symptoms my wife had before her excision surgery was dyspareunia.

Yeah.

After we begged for her to have her endometriosis excised, her dyspareunia went away, but for about five to six years afterwards, we both were worried that sex would continue to hurt.

Sure.

It takes a while, even when you respond to excision, it takes a while for the brain to heal. It's like the body heals faster than the brain on this matter.

Yeah. Beautifully said. Thank you. That speaks to what I was talking about in the sexual schemas, right? Our brain ... We might actually get rid of the tissue that's causing the pain but the brain doesn't forget the pain. You don't forget what heartbreak feels like. You're not going to forget what that feels like.

I'll get to you in one sec.

Hi. I'm single, going through all of this journey with endometriosis.

Absolutely.

What is your advice with speaking to, let's say, someone you're dating for a couple of months?

Sure.

I know, with my experience, it's ... I get two responses. I get the man that really doesn't want to talk about this and then there's the man that thinks he has super sperm.

Of course. Oh, baby, I'm going to get you pregnant. Don't you worry.

Right. Yeah, that.

Don't you worry.

How can you encourage them to just even take an interest?

Sure.

How do you introduce that conversation?

First and foremost, and I'm just going to say it because I speak what's on my kind, I think part of finding a partner when we have these difficult things that we go through, especially one of the things being endometriosis, is to find a partner who is willing to just listen. If someone's not willing to listen to you, I don't care whether it's endometriosis or whatever, if you're in a relationship and someone's not willing to listen, as my mother would say, who is right there, "Next."

Gotcha.

Like Ariana Grande on her new song but my mom came up with that first. I would say to ... If they're not willing to listen, I think that that's a flag. That's me being the therapist speaking, but ... Go ahead, Dr. [Such-kin 00:22:04].

Well, I just want to make a comment and question maybe.

Sure.

I can't see how vaginismus is related to endometriosis other than ... Not organic [crosstalk 00:22:17], the disease there.

Sure.

I think this is a misconception there. I see patients like that and it's difficult to tell them, anybody, you don't have endometriosis when they come to you for pain. In your practice, do you see a lot of vaginismus patients? Vaginismus, as you know, the pain during entrance, there's ... They cannot consummate. They cannot have intercourse at all.

Sure. It's really interesting. There's actually an increased level of diagnoses in certain religious communities in which sex is very much correlated with fear and there's a lot of fear around sex and a lot of minimal education around sex. I will say that that's one thing regard-

This is in New York City, right? Certain religious communities-

Absolutely. In New York City, in the five boroughs, all-

I totally agree.

All around here. I think, like I said, it's not a result of endometriosis, but I do think that, when someone is so tight all the time as a result of pain, I have seen some patients where they've experienced vaginismus.

Now, the other thing about these sexual dysfunctions is it's a matter of who are you seeing and who is diagnosing you. I am a therapist and I don't do the physical vaginal exam so I'm not technically going to diagnose somebody with vaginismus myself because I can't make that medical diagnosis. It's also interesting, and we've talked about this, but how we educate the medical community about these things so that they properly diagnose patients based on what they're really experiencing versus what they just think it is.

I think the most proximal question that couples' pain during sex, the pain with sex during deep contact, my most common question that [burks 00:24:03] with the way my mind operates is but do you have painful bowel movement? Because what causes painful sex in the cul-de-sac, that's where the vagina and bowel have a relationship, if that space is closed ... Before uterosacral ligament is another thing.

Sure.

If there is an association, that's a high warning sign that it's ... It's a sign that there is something seriously going on there, that they ...

Absolutely.

If those two symptoms overlap, that means a lot for us.

Mm-hmm (affirmative).

Yes, sir.

I would like to make one further comment on the [tammers 00:24:41] bowel movement pain comment. One of the things that I found very predictive of what I would find in surgery would be if a patient has painful bowel movements during their menstrual flow only or primarily, that woman would typically not have intestinal involvement or obliteration of the cul-de-sac. If a patient had painful bowel movements all month long, then her chance of having significant deep invasive disease with obliteration of the cul-de-sac was quite high.

Mm-hmm (affirmative). Just to answer in your name ... Or, I'm not going to ask you your name because I don't want you to have to say it out loud as respect. Tanya. Thank you. Okay. Thank you for sharing. Tanya, to answer your question, I would say that, if someone's not willing to listen to you, thank you, next.

If someone is willing to listen, the biggest thing that I can suggest is education. First and foremost, before educating, to let somebody know, and this is what the difference between being a therapist and being a sex therapist is. When you hear about something that you've never heard ... Anybody ever tell you something and you've never heard that before and the first thing you do is you're like, "Hm. Okay, that's weird?" You have that reaction, and then you sit and think about it. Part of being a sex therapist is that you go through training where you're exposed to all these things that someone might come to you and say, including what's sex with endometriosises like and a lot of other things on the spectrum. Then, we have to process as sex therapists what that makes us feel so that, when someone comes to us with that experience, we can actually give them space to talk about it.

Giving your partner space to understand that hearing this or hearing that I'm experiencing pain during sex is not about you, it doesn't mean that you're doing something wrong or that I'm criticizing you, it just simply means that I need to talk to you about this.

Go for it.

This subject is getting exciting.

Sorry.

Well, there are more questions around this. I don't know, maybe I missed it, but do you ask the question during pain with orgasm? For example, we get a lot of questions about pain during orgasm.

Interesting. Hm.

Pain after sex, the next day, this continuation or arousal.

Yeah. Sure.

These questions, we do like to ask all the time, actually, during those interviews.

Sure.

Do you [crosstalk 00:26:58]?

I haven't actually heard a lot about that. I think what I ... It's interesting because I do have patients with endometriosis but it's not the bulk of my patients, to be quite honest with you, so I can't give you a very clear response, and I don't want to speak out of turn or not having the correct population to speak to that. What I can say is I could see how uterine contractions that are result of orgasm can cause increased pain with sex and orgasm if there is endometriosis tissue around the uterus. That I can see happening quite frequently, and I think that that's something that might not be spoken about. That brings a lot of light to me.

For us, yeah, it is uterine contraction with orgasm and then pain after sex, the next day or after the process, is significance of pelvic inflammation or peritoneal disease that may continue in combination [crosstalk 00:27:51].

Sure.

Not all the time.

Sure. Some people would say, or even myself, it used to be that, if I engaged in sexual intercourse, the day afterwards, I had terrible period cramps, or right afterwards I'd get really violently sick, have to go to the bathroom, there'd be vomiting and diarrhea. I couldn't understand why sex was not only making me hurt but also making me physically ill.

There is a person in the back who would like to ask a question. I just wanted to give you the moment to do that.

My question was basically, whereas when you're speaking on a sexual level, after a person does have sex and later on the baby and stuff comes, how does endometriosis play a part with post-partum?

Sure. With post-partum? Great question. It depends on also ... There's a lot of different variables. That question is an amazing question. Put me on the spot. Go you. I would say that a lot of different things play a role in that. Post-partum, which is where I am now, also ... The redefining sex is a huge piece. Understanding that the body biologically changes as a result of hormones, a lack of estrogen, lack of lubrication. Estrogen is something that feeds endometriosis so we tend to give endometriosis patients post-partum, right after a woman has a child, we like to get a woman back on birth control or back on some kind of estrogen suppressant to be able to monitor what's feeding the endometriosis, but that can also cause a lack of lubrication. There are different ways and protocols that a doctor can walk you through that.

I also think that, after having a baby, there's a lot of other stressors that occur. Lack of time, the child is crying. It's hard to feel sexy or to feel intimate or spontaneous when, all of a sudden, there's a doody diaper that you forgot on your nightstand or there's a child that's screaming because it's so hungry and you just want to be in the mood or right now is when you're feeling frisky but you can't follow through with those things.

It's hard for me to answer that in one solid answer because I do think that everybody's relationship, every parenting style, every child requires a different amount of attention, and everybody's case of endometriosis is different from one another. I think that that's something where that's my favorite kind of patient, to come in and let's explore what the variables are in your life and how can we actually work with what you've got to get ... Like I always say, we're always dealt one deck of cards. If we could be dealt the deck of cards we want, poker wouldn't exist. You get dealt the deck of cards, that's what you're dealt with. Now how do you learn to play the game? How do you learn to play the game so that ultimately you can win? That's something that I like to help my patients deal with.

I hope that answers to some extent how you work through that. It's really ... It's very individual and personally based.

Okay. I think we have time for one more question and then we need to ... Go ahead.

This is a quick question.

Sure.

Well, not quick, but I would like to know your approach on this.

Sure.

Sometimes, womanhood can be defined or put into a box.

Absolutely.

What I've noticed in friends and people that I know who have dealing with endometriosis, that society, men, family, father, mother, daughter relationship, it puts pressure on women sometimes to think that, if they do not have a child, they are not a woman or not valid.

Yep. Oh, yeah. Just got the chills.

What is your approach when talking to women or talking to men or anybody that you want to help in having that conversation? I've been in instances where another woman has said to a woman, they're like, "When are you going to have a kid?" They don't understand how insensitive that question can be.

Absolutely.

Or a father to a daughter, "When are you going to have a baby? Because you're not a woman until-"

When are you giving me a grandchild?

Yeah, when are you doing this? I don't think they understand the pressure that that puts on a woman.

Of course.

What is your approach to that?

To the pressure and how to deal with it?

How to deal with it and how people can actually probably attack that issue better when talking to a woman.

Yeah. Yeah. I think, first and foremost, I want to say that I think the biggest assumption is that a woman who may not be able to achieve a natural pregnancy on her own can't be a mom. Part of my whole policy in being a therapist is I like the idea that we can mother ourselves and what that means. I think that before you can become a mom to anything else, whether it be a child or a pet or a partner or whatever, and I don't believe you should mother your partner but that's a whole 'nother story, I think the first step to really doing that is self-love and mothering the self. Once you mother the self and you can take care of yourself, that's really the only mother you need. That's one.

Two, I think every one of us, and mom, I love you, but every one of us could have something to say about our moms. I think the other step to that is really being the mother you wish you had. Now, I love my mother to death and she did an amazing job raising me and I'm so grateful but there are a lot of things that I would change, and I think one of those things would be changing what I would do as a mother to me and being the mom that I wished that I could have had in some respects. I hope you take it the right way. In some respects, some of the things that I wish I had like maybe more sex education at a younger age, because my mom didn't think she needed to be educating me at 12 about sex. She didn't think I'd be engaging at 13.

Those aspects, I think we can mother ourselves. Then, how can we combat that assumption that we all need to be freaking moms? I think really giving people the power to advocate for themselves and the confidence to believe if you don't want to be a mom, power to you, because you know what? You don't need to mother ... Like I said, you don't have to mother another life to be a mom. You don't. You can mother yourself. That's really all the mom you need to be. I really believe in that wholeheartedly.

There was a time where I didn't think I ... I wanted to be a mom since I came out of the womb. I've had baby dolls. I'd walk around at three years ... No, I was like six years old in my apartment building and I would tell the doorman, "I'm pregnant." He would be like, "Yeah, okay." That was my dream. Then, when I couldn't have ... When I was having trouble conceiving, it became a nightmare.

I think that really giving somebody the power and the ... Sometimes we need to support each other. Sometimes we need to stand behind someone and advocate for someone else. I guess my biggest answer to that is, if you're in a conversation and someone says to someone, "So when are you going to give me a grandchild?" or, "Are you guys thinking about having kids yet?" Instead of embarrassing the person in the moment or saying something to the person that they spoke to, it might be ... It's all about how you say it, not what you say. Maybe pull that person aside after that conversation and say, "Hey, not for nothing, I don't mean to ... I'm not trying to attack or be confrontational, but maybe just open your mind to thinking that sometimes somebody may not want to have a child. That doesn't make them any less of a woman."

I think it's a matter of how we can educate and empower and step in and really just inform people in a positive way instead of putting people down. Then, people get to actually look at the self and say, "Hm. Self, how can I change to be better?" I don't know if that answers it, but ...

Thank you.

You're welcome.

Thank you, Carli.

Thank you so much for your time.