Female Sexual Desire

In this article, we will be talking about women’s sexual desire. That is really one of the main concerns that I deal with in my office. I have both men and women come feeling that they have too low sexual desire, and it’s I think, also with my colleagues, that it’s one of the major concerns people have when it comes to sexuality. The women who come to me are in their 20’s, 30’s, 40’s, 50’s, and 60’s – there’s not a specific time that’s specific for this concern, it can happen any time in life and as you will see in a little bit I will be going over a few of the reasons for why someone might have low sexual desire. There are quite a few of them.

First of all, one thing that I always like to share with my clients when they come to the office – and by the way, I see heterosexual couples, I see homosexual couples – I take 90 minutes for my intake session because I really want them to feel comfortable. I’m providing a safe environment where we can discuss anything that bothers them, but I need a lot of time to really find out what their specific situation is like. And one of the things, when it comes to desire, that I share with them is this picture. It is an illustration about sexual frequency of people in the United States. This was a study that was done in the mid-90’s by the University of Chicago, and they interviewed several thousand men and women throughout the country, and so this really represents what people do sexually within the whole United States. And I think what’s important here to notice is the specific question to them was “how frequently have you been sexual over the past year?” And some people, this group right here – the blue column is the men and the red is the women – this group of people said not at all – they have not had sex at all. And this group over here said 4 or more times a week. And there were three relative – not the same size, but let’s take this one in the middle – said a few times per month, and this one said a few times per year, and here we have two to three times per week. So what I’d like from this chart is to see how wide the range is – and I usually don’t use the term “normal” but in this situation I’m going to use it – the normal range of sexual frequency is extremely wide, going all the way from not at all – and some people are perfectly happy not having sex ever in their lives, and I consider that as normal in many cases – and then some people like to have intercourse and sex more than four times a week, sometimes several times a day. And again that might be normal, but it can also cause problems at some stage if it interferes with their life. That’s something I will not talk about today – I will today focus on this group of people who maybe have low desire for sex. And again I’m saying maybe because some of these people might be perfectly happy without ever having sex. But for you to know that these groups are as they are, and the problem that happens is that if you have a couple, no matter if they are heterosexual or homosexual, if one of partners is in this group, wanting sex a few times per month, and the other one is in this group (wanting sex a few times a week), it causes problems. What I can do sometimes is help the couple find a compromise, and maybe instead of having sex more frequently try to put more quality into the event when it happens.

Also, another thing that I usually ask people – there are really two kinds of sexual desire. One is the desire to masturbate and to have sex by yourself, and sometimes that’s used for tension release. Some people who maybe have no interest in partner sex – the other desire for sex – may be perfectly fine pleasing themselves. So I’m always inquiring “do you only lack desire when it comes to partner sex, or do you also not enjoy solo sex.” These two things are important to ask.

Then I do also want to mention that it is very – and again I’m going to use the word “normal” – for all of us, we have ups and downs with our sexual desires, and that is just the way life goes. It changes all the time, and some people may have a period of low desire for a while. However, if it’s a persistent low desire, that changes the picture. If it’s always like that, then that’s when we’re talking about low sexual desire, or hypoactive sexual desire is another word that we use. And in those cases a lot of times I see that people don’t even have any sexual fantasies – they don’t think about sex at all. And that can then cause problems if someone is in a relationship. Again if that person is single, then they may never be bothered by it – but it’s usually when the person is in a relationship that there can be problems. Also some people never seek help for this problem, even if they are part of a couple and it is causing problems.

Another thing that I do mention, I do a lot of education with my clients, is I want them to know about the different models for human sexual response. And this is really the very traditional model. It started back in the 60’s and 70’s. Masters and Johnson, and then Helen Singer Kaplan edited desire. What they determined was that it all starts with desire. Then comes the arousal phase, and arousal really means increased blood flow. In the man it means an erection, in women it means lubrication, engorgement of the genitals, and then the person may or may not have an orgasm and have the resolution phase afterwards. So I just wanted you to see this traditional model, how I was certainly trained about sexuality – that it all starts with desire, then comes the arousal, orgasm, and so on.

But there’s another model that I want to share with you that I find very important, and it’s called the Female Model of Sex Response. It was Dr. Rosemary Basson in Canada, she discovered by talking to hundreds and thousands of her clients that this original, traditional model just didn’t always fit. And I’m not saying that it’s wrong – I think both of these models are valid – but this model seems to work better for most women. And what it is, instead of starting out wanting to have sex and having desire for sex, a woman may start out wanting to feel close and committed to her partner. And you may not be able to read this, but I’m going to read it to you. This box up here says “wanting to feel close and committed, wanting to show love and affection” or wanting to be attractive and attracted to your partner. And when the person is in this mode, maybe she has absolutely no interest in having sex at this point, but she wants to be close to her partner. She then seeks, or at least is receptive to sexual stimulation. So let’s say she’s tired, it’s late at night, they both are tired, and she doesn’t want to have sex but she wants to feel close to her husband or her partner or her girlfriend, and so they start snuggling, kissing, maybe her nipples are being fondled, so she might find herself getting sexually aroused. And this then leads to sexual desire in many cases. And the cycle completes with physical and emotional satisfaction, and then the cycle keeps going. But the very important thing that I want to point out here is that the arousal comes before the desire – very different than in the traditional model, where we all assume the desire has to be there otherwise nothing else is going to happen, but what really happens, and this is true for so many women, and this is really how most women react, is that a lot of times the desire just has to be triggered. It may not be there from the get go, but you can maybe get there by allowing yourself to get aroused and then the desire kicks in.

Another thing that this model helps me with is sometimes when I have my couples in front of me I show them this cycle and some people say “well I’m not even there – I don’t even feel close, or want to feel close to my partner.” So that’s something that we can then work on. Another person might say “yeah, fine, I want to be close to him or her, but I don’t get aroused.” So then that’s something else to talk about. It’s a way for us to identify where the problem might be and what we need to work on.

I want to say, before I talk about the different reasons why someone may have low sexual desire, I want to say one more slightly general thing about men and women, and that is that for women, they have different reasons for having sex. For women, love leads to sex – it starts with love and they want to feel loved by their partner, and that’s why they agree to have sex. For men it’s the other way around – they want to have sex and that then leads to love. I know this is a generalization, but it’s fairly true in general. The other thing that’s different between men and women is that women want sex when they feel reassured, when they feel good about themselves, when they feel good about their bodies, when they feel good about everything. That’s when they like to have sex. Men, on the other hand, sometimes they want sex when they need to feel reassured. Maybe he had a bad day at work, something happened that upsets him – a lot of men react by wanting sex in this situation, and it’s usually the last thing a woman would want. And I just want to clarify these two things, these differences, because sometimes people are not really aware of those.

Before I go into details about what the reasons can be for low sexual desire, I do want to mention that some life circumstances can affect sexual desire. These are usually just temporary events that blow over, and then everything might be fine after that. An example is marriage conflict, if there is a severe conflict in the marriage that can certainly affect sex and the sex life. And once the conflict is resolved everything might be fine again. Divorce, retirement, unemployment or job loss, can certainly affect one’s mood and desire for sex. Being unhappy about a career – again sometimes it’s something that’s temporary but it can affect someone’s mood and desire for sex. Having young children – I see a lot of young couples in my office because it’s just a lot of times, for many couples, it’s a big stress simply to have children, and that whole adjustment, and the mother usually is just exhausted and tired and there’s not much room and energy for being sexual with each other. I’m not saying that this is true for all couples, but it happens for many couples. And then another scenario is if someone is trying to have children and is dealing with infertility, then that can also affect desire.

Now when I have a couple in my office, I like to kind of separate the different factors, and I look at individual factors, something that might be related to the one person who has low desire, and then also relationship factors. And I was making this list for this presentation and it kept getting longer and longer, about the individual factors for you to see. I’m not going to go through all of them, but I’m going to read out some of the most important individual factors that can affect sexual desires.

The first one is hormonal issues. I many times like to see a recent hormone profile for the person, maybe they’ve been to their physician or nurse practitioner and had their hormones tested, because if someone has very very low desire, it’s usually helpful to see what your hormone levels are like – what is your thyroid function like, what is your testosterone level like, and those things can be helpful because if they are very very low, below baseline or the normal range, then it might sometimes help to replace some of those hormones. And I’ll be talking a little bit about this at the end. Medication side effects – very important. I brought this book here, this book is called Sexual Pharmacology, and all this book is about is different drugs and how they affect sexuality. So many drugs have sexual side effects, and some of them, the more typical ones, would be anti-depressants – many of the SSRIs have sexual side effects, reducing the libido, desire. And then also some women who are on birth control, they find that their sexual desire is decreased. And in all of these cases it’s always important if this is happening to you, don’t be shy to mention this to your health practitioner – go ahead and tell him or her that your sexual desire is reduced, and sometimes simply by changing medication or changing the dosage this might help. But you need to talk to your physician or your nurse practitioner or whoever prescribes the medication for you about that.

The next factor I’ve listed here is body image concerns. If a woman doesn’t feel good about her body, it might be really hard for her to share her body with someone else, and enjoy sexual intimacy with another person if she’s very self-conscious about it, how she looks.

Aging-related concerns – it’s kind of in the same category of affecting your whole body image, and so on. And I will be talking about aging-related concerns in a separate video.

Depression is a big factor – most people who are depressed don’t have any interest in sex.

Sexual trauma – you can see how these factors are very very different, but they all can have a tremendous effect on sexual desire. If someone was molested in the past or maybe has experienced rape, or some other negative sexual experience – it doesn’t have to be rape, it can be really anything that was experienced as being negative, it can have profound effects on someone’s desire, and you can deal with that in separate sessions, you need to focus on the sexual trauma.

Another factor is fear of pregnancy – some people don’t realize that they are really afraid of getting pregnant, and maybe they’re not using any birth control, or they’re not quite sure that they’re fully protected, and that might inhibit someone’s desire.

I’ve already mentioned childbirth – I want to mention that some working mothers, not everyone who is breastfeeding is lacking desire, but it’s certainly the case for some women that when they nurse, their hormone levels drop, and that sometimes causes women to have less desire for the time being. But again, I do want to emphasize that many, many women who nurse have absolutely no problems with desire.

Another one is fear of loss of control. If you feel like, when you are being sexual, that you might lose control, either of yourself or maybe within the relationship, it can affect someone’s desire to engage in sex.

Fear of rejection or abandonment – if you are afraid of getting too close to your partner by having sex, maybe afraid that he or she is going to reject you, that fear can interfere with your desire for sex. On the other hand, fear of dependency – if you are afraid of getting too close, and being too dependent, for some people this also can affect their desire.

Religious orthodoxy – things like sex is sinful, some people have had these experiences maybe in the past, where they were taught that sex is sinful and so on, and that can certainly follow people throughout their lives and can affect desire.

Let me list a few other ones – I’m not going to read all of them out. “Widower’s Syndrome” – if someone lost their spouse, that can take a long time to get over and it can sometimes be hard for them to move on and feel sexual desire again. Sexual orientation issues – if someone is not quite sure about his or her sexual orientation and doesn’t really want to think about it and deal with it, it’s almost easier not to go there and not to engage in any sexual activity. And the same is true for people who may be questioning their gender identity – that can also affect sexual desire. Let me just mention the last two here – I’m not going to go through all of them. One of them is other sexual problems, such as pain. I see a lot of women, usually young women, who have pain during intercourse. And of course that can really affect sexual desire, because who wants to have sex when it hurts? And a lot of times pain can be addressed and it can be helped. So be sure to mention that to your health provider, and if he or she can’t help you, be sure to look for someone else who can – there are many, many professionals out there who can help with pain during intercourse.

Finally, chronic conditions, like multiple sclerosis for instance, can affect sexual desire – not just the fact that someone has a chronic condition, but in this case with multiple sclerosis the sexual desire can also be affected by the disease itself, and not just the fact that there is a chronic condition.

Let me just mention a few of the relationship factors – I mentioned most of the factors that can be causes for low sexual desire for the person, and let’s look at relationship factors.

Lack of attraction to a partner can be very important, I always ask this. And this is something that I usually ask it when the individual comes in by himself or herself, are you attracted to your partner. And if it turns out that the person is not attracted, then maybe that explains at least part of. It’s usually not just one answer – I call it the puzzle pieces. It’s like a big picture that’s made up of little puzzle pieces and they all fit together and make up this one big picture. And it’s a matter of identifying these puzzle pieces.

Another puzzle piece might be anger in the relationship and other conflicts. Another one is partner’s poor sexual skills. If someone is not very fun to be with sexually, maybe doesn’t really know how to stimulate you, it might not be as enjoyable and you might not have as much desire for sex. And of course once we identify these puzzle pieces you deal with each in its own way – I deal with a couple where this is the case, where the person has poor sexual skills in a completely different way than dealing with a couple where maybe the partner was previously raped. In the case of the partner with poor sexual skills, I would help them maybe learn more about sexual skills and discuss that with them and give them some ideas of what they can do.

The last couple of factors that I’ll mention here are fear of closeness and intimacy, and then finally the person with the lowest sex drive is really in control in their relationship about how often the couple has sex. So sometimes it is a control issue between the couple, that the person with the lower sex drive controls how often they have sex, and maybe needs to have this kind of control.

Let me just start finishing off here. I do want to say that when the couple comes in, or even just one person comes in, with a concern about low sexual desire, sometimes they’re very anxious about it and they really want to feel different, and it’s almost a negative cycle, because the more tense they get about wanting to have their desire back sometimes the harder it gets. So it can be really hard, and I think one of the things that helps is to sit down with the person or the couple and discuss these things, and just put everything out on the table and say “well, this is what the situation is like, and what can we do about it?” So the first thing is really to identify the different pieces of the puzzle, and you work on them – you pick them one by one, you start with the most important ones first and you deal with the other puzzle pieces as well. One thing that I find that I actually ask a lot of couples is “how do you get aroused?” Some people don’t know – I say well, do you get aroused by visual stimulation, do you enjoy reading novels, does smell turn you on – there are all kinds of ways that people can get involved, really using all senses. And sometimes people don’t really know how they get aroused, so I help them think about how they get aroused and I help them explore ways that they could get aroused. Within a couple two people may have very different ways of getting aroused and it can be very helpful to know that about each other, that maybe one person is not turned on by watching erotic videos but if the other one is then maybe that’s something they should start doing, and do some of the other things that the other person likes as well. I also ask people with low desire to try to notice when they lose arousal or desire – when is it in the sexual situation that they suddenly lose desire. It’s important to try and put a finger on that so that you can deal with it and figure out what you can do about it. And it can be completely depending on the couple when that happens, it varies from case to case. But I ask them to try to notice when they lose arousal and desire.

Finally, I’m asking a lot of the women to have low desire – because sometimes it turns out that they don’t allow themselves to get aroused, that for some reason they are holding back, and once we talk about that it might help them to realize that they really are holding back themselves and they don’t allow themselves to get aroused.

The one thing I also ask them is to try to tell me whether they ever have any sexual thoughts – I call them “sexual sparks” – throughout the day. And usually the person says no, I don’t have any of those, and I say “well, just think about it and when you come back next time let’s talk about it.” A lot of times what happens when they come back one or two weeks later is they say “yeah, I had a few of these thoughts.” And I say great – try to, next time you have them, don’t let them go go away but hold onto them. Don’t let these sparks fly out, hold onto them, hold them back in, think about them, try to dwell on them a little bit longer and try to build up on these sexual sparks within your body.

I’m getting to the end here – one thing that’s very, very common is the person who has lower sexual desire is sometimes very afraid of getting close and showing affection to the other partner, even though she might be needing to be close to her partner she doesn’t want to go there because she does not want him or her to take it as an invitation for making love. Even though she may only want a hug, she doesn’t want to go all the way so she never even gives this hug. So what I do in my office is I encourage people to hug each other, kiss each other without going all the way – just do it for the sake of being close, you don’t have to go all the way to having intercourse or even touching your genitals. Do hug each other and kiss each other. And I specifically in my office give my people homework exercises, I give them assignments to go home and do touching exercises, hugging exercises, kissing, without initially going all the way. And that sometimes really helps the low desire person catch up into simply being able to relax and enjoy intimacy with their partner without having to go all the way to intercourse.

Let me just, at the very last couple of things I want to say here – the question and request that I get from many individuals and couples is about medication. They want some kind of a quick fix, and really there is no quick fix with respect to low sexual desire right now. This is the beginning of 2005 – there’s a lot of research on the way right now, and a while back the testosterone patch was almost approved by the FDA. It’s not approved yet, they still want to do some more research. I think it’s going to be helpful, probably, to have testosterone as one of the options to treat low sexual desire, but it’s definitely not going to be working in all cases. It might work for women who have very low levels of hormone, but it will not work in other situations – remember the long list of factors. There simply are no quick fixes for these factors – taking hormones will not help. You need to deal with what’s going on in the relationship or in the person itself.

Finally, I do want to show a few of the books that I like. There are a lot of books out there – one of my favorite books is called “Reclaiming Desire,” and you will find the links on the website. It’s by Dr. Goldstein and Dr. Brandon. Another book that is wonderful is called “Rekindling Desire,” it’s by Barry McCarthy and his wife Emily McCarthy. And then also I like “The Sex-Starved Marriage” by Michele Weiner Davis, I recommend this book. And then finally for more of the professional people, it’s not that easy to read, but if you want to read up on this issue, “Hypoactive Sexual Desire” by Weeks and Gambescia.

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