Sexual health, intimacy, and pregnancy: A conversation with Bethany Warren LCSW, PMH-C
There is a lot of misinformation and confusion surrounding pregnancy and sexual health, and what to expect from ourselves and our intimate relationships after having a baby.
It's not always clear what's within the realm of "normal", and when it might be time to seek professional help.
From periods, changes in bodies, libido and intimacy, to sex during and after pregnancy, there seems to be a lack of quality information to draw from, and it's not always clear who you can talk talk about these subjects. And, if your medical provider doesn't bring it up, is it up to broach these subjects and ask your most personal of questions?
I loved this conversation with Heather Evans, my former editor, and a brilliant publishing consultant. She asked such insightful questions, and it was really fun to talk about these topics, and shine a light on intimacy and sexual health throughout the reproductive period. Thank you, Heather, for facilitating this conversation!
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It seems that now more than ever we are inundated with information on what to expect from our bodies, our sexual intimacy, our relationships, and our experience of newfound parenthood before and after giving birth.
Social media platforms, such as TikTok, can make sexual health advice accessible to those who otherwise may struggle to receive care, especially regarding birth control and safe sex. However, it also allows for the spreading of misinformation, the setting of unrealistic expectations, and increased pressure for couples when it comes to sexual intimacy after having a child.
This can feed into a new parent’s darkest fears. What is ‘normal’ for me to feel?
I spoke with Bethany Warren, LCSW, PMH-C, a perinatal psychotherapist with over 25 years of experience working in reproductive mental health, to answer some common questions about sexual health and intimacy before and after pregnancy.
Q: There is a lot of misinformation surrounding pregnancy that we have heard as old wives tales, the media, or even our own family. How might you dispel any myths around sexual health and pregnancy?
A: Real talk here: when was the last time you were taught helpful, empowering information about your body and your sexuality? For some of us, that may have last been when we were children during our sex ed classes., and obviously the information was significantly limited back then. You may have talked about these topics in your childbirth prep classes, such as learning about sexual health during pregnancy and what to expect with your changing body in the postpartum recovery period. Unfortunately, I often hear that some people may have received no information at all.
I find that a lot of women are still trying to educate themselves about their bodies, their anatomy, their libido and sex drive, and their sexuality. Particularly during times of great changes like their pregnancies and postpartum recoveries, they may find themselves filling in the gaps of information with great shame, internalized negative beliefs and self-blame, and myths and misinformation.
Luckily, we are living in an age where information is much more readily available. That being said, it’s important to be an informed consumer and question the source of information, and be cautious of any information that seems to be shame or fear-based, or coming from an all-or-nothing standpoint. For example, if you hear information such as “all women should feel…” this might cause us to pause, when there is such a range of experiences for all of us. If you hear anything that sounds like an old wives tale, or guidance from a loved one that you’re not quite sure if it’s accurate, it’s helpful to add it to your list of questions to ask during your next visit with your ObGyn or midwife.
Q: When will my periods start again after pregnancy?
A: This is a great example of another experience that can vary for women, and a number of factors can contribute to the spectrum of onset of postpartum menstruation, such as whether or not you are breastfeeding and if you have started hormonal birth control. For some, this may be as early as 4 to 6 weeks postpartum, and for some it may be over a year or more.
What is equally as important to point out is that for some women, the first period after having a baby can be emotionally challenging. If you find that you are feeling more emotionally raw during your first menstrual cycle after having a baby, you are not alone. In fact, for some people who develop Perinatal Mood and Anxiety Disorders (PMADs), their first symptoms don’t start during pregnancy or immediately after having a baby, but instead will start during times of hormonal changes, such as when their periods resume, when they restart hormonal birth control, or when they wean from breastfeeding. If your mood changes continue to worsen or are challenging to tolerate, you do not have to sit with these symptoms by yourself. You can benefit from seeing a mental health professional that specializes in perinatal mental health (working with the pregnancy and postpartum period).
Q: What are PMADs? What behaviours or signs should I be aware of that indicate I should seek help from a professional?
Perinatal Mood and Anxiety Disorders are any mood changes that start during pregnancy or the postpartum period, and persist. Meaning, these are not the typical, short lasting mood changes we see with the hormonal adjustment immediately after having a baby known as “The Baby Blues” that last around 2 weeks, and do not impair functioning. PMADs can include perinatal anxiety, depression, Obsessive Compulsive Disorder (OCD), Bipolar Disorder, Posttraumatic Stress Disorder, and Psychosis. These diagnoses can range in severity, can potentially impact your functioning, your relationships, and attachment with your baby, and most importantly, all of these mental health conditions respond to professional treatment. You do not have to suffer alone. I highly recommend that you seek a mental health clinician with training and expertise in perinatal mental health. No matter where you are in the world, a good place to start is Postpartum Support International, or postpartum.net
Q: I am concerned about having sex that is safe during and after my pregnancy. Is this something I can speak with my therapist about? Or should I speak to a different professional?
A: It’s completely understandable that you might be nervous about having sex during pregnancy. Not only is your body undergoing significant (and constant!) changes right now, but you also may be noticing changes in your libido, your energy, your emotions, and your relationship. You may have also gone through a lot just to get to this point. Perhaps you’ve been through infertility treatments, experienced prior pregnancy losses, or tried for a while before you successfully conceived. Maybe you’re feeling hypervigilant and focused on your body sensations, and unsure about what physical activities (including sex) are safe or unsafe. And let’s be honest, there’s a lot of information out there to wade through when it comes to being pregnant.
The bottom line is: please don’t hesitate to talk to your ObGyn or midwife about sex. If they don’t bring it up then it’s absolutely OK (and important!) to ask about it. You may be feeling some shame or embarrassment around this, yet if you don’t ask, then you won’t get the help and answers you need. I’ve found that some medical providers are great about broaching topics around sexual health, and others wait for their patients to initiate the conversation. And if you find that you’re not comfortable talking to your provider about these topics, or are not getting the answers or care that you need, then please consider transferring your care, if you’re able.
These can be vital and empowering conversations to have and nothing is taboo or off the table, I promise. You can address any concerns about your libido, body, and health, find out what’s within the range of “normal” body sensations and changes throughout your pregnancy and your postpartum recovery, your options for postpartum/postnatal birth control, and ask about STIs/STDs, just to name a few. It’s also helpful to ask them for indicators of when things are not normal. Especially if you have any pregnancy complications, this is a vital conversation to have. Together with your provider, they can also help you create a proactive plan for postpartum physical recovery, and to protect and strengthen your pelvic floor.
Physical and occupational therapists can be wonderful additional resources for this as well (both pre and postnatally), in strengthening, protecting and healing the pelvic floor. You can also loop in your mental health providers (therapist, psychiatrist, etc.) as well, if you’re experiencing any fears or anxieties about your body, your mental health, or concerns about your relationship.
Q: How long should I wait to have sex after I’ve had a baby?
A: This is such an important, yet surprisingly nuanced question. When you go for your postpartum/postnatal check with your provider, you will get the clearance when they think you have healed well enough to resume sexual intimacy with a partner. For some, that’s six weeks, for some, that might be longer, depending on physical recovery and healing after delivery. However, and this is really important, it is absolutely OK that you might not yet feel ready to resume sexual intimacy just because you’ve gotten the “go ahead” from your provider. In fact, I hear this more often than not in my practice.
Why might this be? First, you’ve just gone through one of the biggest life changes you will ever go through in having a baby and becoming a parent. Have you ever heard of the term Matrescence? Like how adolescence is a significant time of change between childhood and adulthood, Matrescence is used to describe this developmental stage of life in becoming a mother. This time period encompasses great emotional, physical, biological and changes. Your sleep has changed. Your world has changed. The way you’re interacting with your partner has absolutely changed. You both need each other in new ways, and that can be uncomfortable. You might feel over-touched and over-stimulated, and sexual intimacy might be the last thing on your mind.
This is not necessarily the case for everyone, but it’s quite common for couples to have different needs afterwards. The partner who did not give birth might be yearning for normalcy and connection, and sexual intimacy might be something they crave to feel “right” in their relationship again. And how quickly this can become a source of strain and conflict, if you are not wanting sex, much less to be touched, by your partner. It’s not all hopeless, however. This is something you can work on together, with a couples therapist, or by slowly rebuilding intimacy and connection without the expectation of sex.
Q: Is it strange to have a lower desire for sex during and after pregnancy?
A: It’s not at all strange. We’re all so different and have such different reactions and sensitives to hormones. You know how you have some friends who have really light, easy periods, and some who really struggle? Pregnancy is similar in that there is often a spectrum of experiences. Some people seem to respond fairly well to pregnancy hormones, and others may struggle at times. One of the ways that we see variations in hormonal sensitivity is having variations in sex drive. Some people may have a strong libido during or after pregnancy, whereas some may have a low (or varying) libido. This might also be related to feeling unwell physically or emotionally (meaning, of course you’re not going to have a significant sex drive if you’re also nauseated or vomiting, or have increased anxiety and worry). A loss of libido can be one of the symptoms of a Perinatal Mood and Anxiety Disorder (PMADs) that often goes overlooked and not talked about.
It’s also understandable that you might have some feelings about your changing body, which might impact your feelings of desirability. I also mentioned some of the changes your relationship may be going through as well, and the impacts this can have on intimacy and desire. Wherever you fall in this continuum of your desire for sex (or the lack thereof), it’s OK. However, I will say that if you find that you are experiencing a lower sex drive than normal AND it feels connected to a change/shift in your mood that is not normal for you, then you deserve support and can benefit from talking with a mental health clinician that is trained in working with pregnancy and postpartum, like we talked about above.
Q: What are your tips on building sexual intimacy with my partner after having a baby?
A: You know how when we climb a ladder, we do so one rung at a time, and we certainly don’t skip all the middle bits and jump straight to the top? It’s often quite similar when returning to sexual intimacy after having a baby. Many couples find that they need to go slow, and first rebuild connection and emotional intimacy after having a baby (i.e. climbing rung by rung, like an intimacy ladder). Because you may feel disconnected and distant from each other (in addition to still healing physically, and/or feeling exhausted and overtouched and overstimulated), finding time to connect may truly be all that you’re capable of right now. In my book, Healing From Reproductive Trauma, I have an entire chapter about the impact that parenting and healing has on relationships.
Some ideas for finding reconnection are to start small and be intentional. Perhaps you might first talk about what you both are missing in your relationship with each other and what you might be open to trying (such as time together on the couch after dinner, or having conversations that aren’t about the baby). It’s also important to practice touching each other again without any expectation of sex initially, so there can be reconnection and closeness without a lot of pressure. Maybe that looks like holding hands as you’re taking a walk in the evenings with your baby, or lightly touching their shoulder as you walk by them in the kitchen.
You are a team, and are leaning on each other in new ways right now, which can feel really weird. It can take practice and patience to rebuild a sense of comfort and intimacy with each other again, but it’s possible and you deserve a space to do this comfortably and at a pace that works for you both. Please remember, you don’t have to go at this alone. If you’re struggling with your mood and emotions, worrying about your changes in your relationship, having difficulty with communicating your needs, experiencing pain or discomfort physically, or just feeling off like something is wrong, then you deserve support from a trained professional.
If you found the information helpful in this article, you can purchase Bethany’s two books, The Pregnancy and Postpartum Mood Workbook and Healing from Reproductive Trauma which goes into these topics in beautiful depth. You can also find her on Instagram (@bethanywarrenlcsw) and at her website.
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