Over the years, experts in sexual health have struggled to define sexual desire. Often they resort to primarily physiological indices, such as vaginal lubrication or genital swelling caused by increased blood flow; psychological indices, such as the perception of wanting to make love; or a combination of the two.
Rather than attempting to generalize something so unique and personal as sexual desire, we encourage you to define this state for yourself. By creating your own measures, you can determine whether or not you are personally satisfied with your sex drive.
When we look at women who have reached sexual maturity since the sexual revolution of the 1970s, we find that as a group, they have embraced a less restrictive view of their sexuality. This freedom has allowed them to experience great sex and great sex lives. They have known lust; they are comfortable with a strong libido. They know their bodies and have confidence in their ability to satisfy themselves.
At the same time, women in this age group—between 20 and 50—inevitably encounter countless physical and emotional hurdles (marriage, career, and childbirth, to name a few). They may notice a decline in their passion and sexual desire during these transitions. Though it is unfortunate, it is common—almost universal.
Some women who lose libido don’t particularly miss it. They seem to live without sex quite contentedly. For the vast majority, however, a decline in sex drive takes a tremendous physical and emotional toll. These women speak of feeling deficient, ashamed, sad, angry, anxious, or unfulfilled. Or they may vacillate among all of these emotions.
After years of enjoying an exciting and fulfilling sex life, a woman may mourn the loss of what was an integral part of herself and her relationship with her partner. Sometimes this loss leaves her feeling confused and overwhelmed. At other times, she is so detached and distant from her sexual self that she becomes convinced she no longer cares about her lack of desire. But, clearly, she does.
Margaret sat in her dark kitchen, crying into the phone. Her closest friend, Linda, listened silently on the other end, unable to help. “When Frank and I were first together, I was turned on just by looking at him,” Margaret recalled. “His smile and sincerity were so sexy to me. I enjoyed just being around him, and I loved turning him on. It made me feel so good when he wanted to make love to me.
“But when I look at him now, after being married for 8 years, I never think of making love to him. I miss the closeness and the connection we used to share, but I just can’t seem to muster the will to want him. I know it sounds terrible, but I’d rather be left alone. I don’t want to have sex, but Linda, I’m so afraid that Frank is going to have an affair!”
A decline in sexual desire is just one type of sexual disorder that affects women. Until recently, such problems went largely ignored in medical and research circles. They devoted the lion’s share of their attention to sexual dysfunction in men, developing and refining treatment protocols for common male conditions like premature ejaculation and erectile dysfunction.
We are happy to report that this double standard is finally changing, as physicians and scientists have begun investigating female sexual dysfunction. We applaud this change, which is bringing to light the prevalence and severity of female sexual concerns.
Female sexual dysfunction can manifest itself in a variety of ways. The most common problems, as identified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (or DSM-IV-TR), generally fall into one of four major categories: sexual pain disorders, orgasmic disorders, sexual arousal disorders, and sexual desire disorders. All significantly affect not only women’s sexuality but also their relationships and overall life satisfaction.
Although we will review the four categories of sexual dysfunction below, the rest of the book will focus exclusively on low libido. We want to note, too, that other types of sexual problems—such as substance-induced sexual dysfunction and sexual dysfunction caused by a medical condition—can occur in women. But these conditions are much less common than the ones highlighted here.
Sexual pain disorders. Until recently, sexual pain disorders were largely unstudied and misunderstood. Yet they affect approximately 7 percent of women, according to an extensive study of the prevalence of sexual dysfunction in the United States, published in the Journal of the American Medical Association (JAMA) in 1999. They’ve been linked to a variety of causes, both physical (such as vaginal infections and hormonal imbalances) and psychological (relationship problems).
Dyspareunia, or pain during intercourse, can result from poor lubrication—perhaps because of lack of foreplay or diminished blood flow to the vagina. Poor lubrication also can stem from a deficiency of estrogen, which causes a condition known as atrophic vulvovaginitis (thinning affecting both the vulva and vagina). Certain factors can raise a woman’s risk of atrophic vulvovaginitis. The most common cause of atrophic vulvovaginitis in premenopausal women is oral contraceptive pills. Surgical removal of the ovaries (oophorectomy) and the decline in estrogen associated with perimenopause and menopause can also cause atrophic vulvovaginitis.
Some women may experience pain during intercourse because of an underlying condition that causes tearing or scarring of the vulva or vagina. Examples of these include lichen sclerosus and erosive lichen planus.
Another sexual pain disorder, vestibulodynia (previously called vulvar vestibulitis), affects the vestibule—that is, the entrance of the vagina. In some women, the vestibule has such a proliferation of pain nerve endings that any kind of pressure—whether from a penis, a tampon, or even clothing—triggers severe pain.
Dyspareunia can also be caused when the muscles of the pelvic floor—the levator ani muscles—go into spasm. The old term for this condition was vaginismus, and it was thought that this condition was primarily a psychological issue because it was felt the women subconsciously tightened these muscles due to a fear of penetration. However, recently it has been shown that women with levator ani syndrome have tight muscles all of the time, not just upon penetration, and that it is more likely to be related to other physiological causes such as hip or low back pain or injury to the pudendal nerve. In our opinion, doctors too often attribute pain during intercourse to vaginismus, rather than pinpointing the true physiological cause.
Women frequently believe that pain during sex is caused by vaginal infections, either yeast or bacterial. And while yeast infections can cause short-term pain during sex, pain lasting more than 3 months is only infrequently caused by chronic infections. Although most women think that making the diagnosis of a yeast infection is Gynecology 101, it is not as easy as it seems. I learned during the 18 months I spent working in a yeast genetics lab that the diagnosis of yeast infection must be confirmed with a vaginal culture.
A thorough discussion of sexual pain disorders is beyond the scope of this book. If you experience pain during intercourse, we encourage you to consult a physician who specializes in sexual pain disorders for an accurate diagnosis. To find one in your area, start by checking the resources on page 312. In addition, my Web site, www.cvvd.org, has a thorough discussion of the causes of sexual pain. Lastly, my textbook Female Sexual Pain Disorders: Evaluation and Management (Wiley-Blackwell, 2009) is the only textbook devoted completely to dyspareunia and can be an excellent resource.
Orgasmic disorders. This type of sexual dysfunction affects approximately 25 percent of the female population in the United States at some point in their lives. These women either have never experienced an orgasm (primary anorgasmia) or seem to have lost their ability to do so (secondary anorgasmia). Unfortunately, they may be too ashamed to talk with their partners about their inability to climax, choosing to fake orgasms. This can lead to more-complicated problems over time, as secrets create distance between partners.
Like most sexual dysfunction in women, orgasmic disorders can have both physical and psychological causes. For example, certain classes of medications can impair a woman’s ability to climax. On the other hand, some women become so uncomfortable at the prospect of losing control during sex that they can’t achieve an orgasm.
Sexual arousal disorders. The term sexual arousal disorder may be confusing, as it seems to encompass low libido. In fact, it refers to an impaired physical response when making love.
A woman who has a sexual arousal disorder cannot attain or maintain sufficient genital lubrication for comfortable sexual intercourse. Her vagina remains dry despite receiving adequate genital stimulation. Sexual arousal disorders can result in painful intercourse, particularly if a couple chooses not to use additional lubrication such as K-Y Jelly.
According to the JAMA article cited above, sexual arousal disorders affect approximately 14 percent of women in the United States. The disorders may be more common among women at or past menopause, because the decline in hormones—especially estrogen—can compromise vaginal lubrication. Psychological problems, such as depression and anxiety, also can cause sexual arousal disorders.
Sexual desire disorders. This category of sexual dysfunction includes sexual aversion disorder and hypoactive sexual desire disorder. In sexual aversion disorder, a woman is so repulsed by sex that she avoids all sexual contact. Just the prospect of sex may trigger a response ranging from moderate anxiety to intense psychological distress. Many experts attribute sexual aversion disorder to some sort of psychological trauma, such as past sexual abuse.
Hypoactive sexual desire disorder (HSDD) is an elaborate name for low libido. The DSM-IV-TR defines HSDD as “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity.” A woman who has HSDD exhibits little motivation to seek sexual stimuli and little frustration at thwarted opportunities for sexual interaction.
HSDD is the most common sexual disorder in women, affecting an estimated 22 to 43 percent of the female population in this country. To receive a diagnosis of HSDD, a woman must experience significant distress or interpersonal difficulty because of her low libido. This is an important point, because if a woman doesn’t want sex but isn’t bothered by it, she is not considered diagnosable.
When deciding on treatment for a case of HSDD, most experts consider three core characteristics of the disorder. The first relates to onset—whether a woman has had low libido all her adult life or whether she has lost interest in sex over time. The second asks about occurrence—whether the woman experiences low libido all the time (generalized) or only in certain circumstances, such as when she’s with a particular partner (situational). The third involves cause—whether the disorder results from psychological factors alone or from a combination of physiological and psychological factors.
Note that virtually all cases of HSDD have a psychological component. Even when libido declines because of a physiological problem, such as a hormonal imbalance, it is likely to produce secondary psychological symptoms such as anxiety or impaired self-esteem.
As you might imagine, HSDD often occurs with other types of female sexual dysfunction. For example, if a woman experiences pain during intercourse, she may lose interest in making love. Or if she repeatedly tries and fails to have an orgasm, she might feel bad about herself and eventually avoid sex altogether.
When women come to our Sexual Wellness Center seeking help for low libido, they invariably ask the same question: “What’s wrong with me?” In our experience, a decline in sexual desire seldom has a single cause. The collection of factors that influences a woman’s sex drive is as unique as the woman herself.
This is why we believe so strongly in a holistic approach to treating low libido. If we were to focus on just the physiological or psychological components of sex drive, we likely would overlook other underlying issues that might prevent a woman from fully recovering her sexual desire.
As we explained in chapter 1, our approach involves creating a profile of a woman’s libido by assessing what we’ve identified as the four primary dimensions of sexual wellness—physical, emotional, intellectual, and spiritual. All of these dimensions contribute to a healthy libido and an active sex life.
For example, to desire sex, a woman must be in good physical health. Her hormones of desire (estrogen, testosterone, and dopa-mine) must be in balance. The skin and nerves of her vagina, clitoris, and nipples must be sensitive to arousal. She must know her body and her erogenous zones. She must be able to have sex without pain.
Beyond physical health, a woman must possess the emotional hardiness to acknowledge and experience the full range of feelings that come into play in an intimate relationship. They may be sexual or nonsexual, pleasurable and positive, or uncomfortable and negative. An emotionally healthy woman easily moves through her full range of feelings without fixating on one or avoiding another. She can be passionate, empowered, desired, vulnerable, open, and loved.
Intellectual health, our third dimension of sexual wellness, is not measured by level of education or IQ. It is much more complex than that. A woman who is intellectually healthy feels stimulated and useful in her life. She perceives herself as competent and appropriately challenged. This filters into all aspects of her life, including her sexuality. Her thoughts about sex, and her sexual expression, are positive and reaffirming.
A woman’s spiritual beliefs and needs play a powerfully influential role in her libido. In its broadest sense, spiritual health refers to a woman’s ability to find meaning and worth in herself and her life. Of course, this means something different to everyone. It is personal and specific to a woman’s unique psychology and belief system. It may or may not revolve around a relationship with God or a higher power.
Bringing spirituality into an intimate relationship enhances desire and the overall sexual experience. It allows for a sense of transcendence, as well as a deeper and more meaningful connection between a couple. The act of making love becomes richer and more desirable when physical pleasure is not the only component of what a woman gets for herself and shares with her partner.
Through the rest of the book, we will further explore each of these four dimensions and their respective effects on libido. In general, when they are optimized and in balance, a woman will find happiness and fulfillment in her life and in her intimate relationships. But if something disrupts this equilibrium, a woman’s sex drive will suffer.
Dawn knew she couldn’t say no again that night. It had been weeks—no, months—since she and her husband, Eric, had made love. She was all too familiar with the routine; they had fallen into it maybe 15 years before. First, Eric would go down on her for 3 minutes or so. Did he really enjoy that, or was he just doing it to get her wet? She had no idea. Then he would climb on top of her and thrust for about 2 minutes. Eric would come, and then Dawn could sleep.
Should she take a risk and suggest they try something different for a change? She briefly recalled how exciting sex was in the first years of their marriage. “Oh, who really cares,” she thought. “I’ll just plan what I need to pick up from the grocery store tomorrow.”
Just as internal issues rooted in the four dimensions of sexual wellness— things like hormonal imbalance, repressed anger, and poor selfesteem— can undermine libido, so can external factors. Chief among these is the relationship dynamics between a woman and her partner.
Through our interaction with clients at the Sexual Wellness Center, we’ve seen firsthand how a decline in sexual desire can be a direct and natural consequence of the challenges inherent in an intimate relationship. Because a woman’s libido is so incredibly sensitive, it responds to a wide range of these challenges—some obvious, others quite subtle. As long as they are ignored or unresolved, libido is a likely casualty.
When a woman loses interest in sex, she may begin to doubt the “rightness” of her romantic partnership or marriage. It is not unusual for women to wonder whether they still love their partners, especially if their experience of making love has deteriorated over time. They may feel that sex is not worth the effort or is just plain bad.
Indeed, women with low libido often describe their sex lives as monotonous, uninteresting, or unstimulating. Worse, they feel bored, angry, and alienated from their partners because of bad sex. At the same time, they feel they can’t do anything about it. They worry that opening up about their dissatisfaction will hurt their partners, or they’re convinced that their partners wouldn’t want to try to change anyway.
Most couples consider sex to be an important part of re-lating—though this isn’t true for everyone. We know partners who dismiss sex as an unimportant or unnecessary aspect of their bond with one another. They are comfortable with making love very rarely, or even not at all. They prefer a certain amount of space in their relationships. If they love each other, they find less personal, nonphysical ways to share intimacy and feel connected.
These couples are the exception rather than the rule. Most of us believe that in a reasonably solid relationship, wanting to make love is a natural and expected outgrowth of our connection with our partners. And if we don’t get that urge to have sex, we are left feeling demoralized, distressed, and somehow defective. Our lack of desire becomes an albatross around our necks. It is a dark secret that slowly and insidiously taints our perception of ourselves and weakens our relationships with our partners.
For women, the insecurities that arise from not wanting sex with a partner become worse with the experience of feeling turned on by other men. Fantasizing about someone other than a partner can lead a woman to wonder whether her body is telling her that she is no longer in love, or that she and her partner have lost their ability to connect meaningfully. Though this may be true, more than likely her low libido means something altogether different. In fact, her body could be telling her that she and her partner share a tremendous capacity for intimacy that they haven’t fully explored— perhaps because they fear being so close to another person, as much as they desire it.
It is easy to blame your partner if you are not enjoying sex. You may even be able to identify why your partner turns you off, or at least why your partner no longer sparks your sex drive. The truth is, it is more fruitful to look within yourself to understand your lack of desire. This is because any change in your self-understanding and behavior will have an impact on your partner, ultimately influencing the dynamic between the two of you. Besides, giving someone else the responsibility for your satisfaction is never a good idea.
This doesn’t mean that your criticisms of your partner are not valid. They very likely get to the heart of the relationship issues that the two of you need to address. However, if you put your goals in someone else’s hands, you probably will never reach them. Nowhere is this more apparent than in the bedroom.
While we’re on the subject of relationship dynamics and libido, we want to mention that one partner’s struggle with sexual dysfunction can weaken the other’s sex drive. For example, if a man struggles with premature ejaculation or erectile dysfunction, sex can become more emotionally stressful and less physically pleasurable for both partners. As a result, the woman may lose interest in making love.
All this talk about sexual desire begs the question: What makes sex desirable? In other words, exactly what is good sex? Although every woman must answer this for herself, we can identify certain elements that seem to be essential for a pleasurable sexual experience. But first, let’s look at what isn’t good sex.
Unfortunately, our society promotes the misguided view that good sex is primarily dependent on superficial variables such as a woman’s body type and weight. Of course, this “cultural wisdom” couldn’t be further from the truth. Whether or not a woman experiences good sex has little to do with the size of her waist. But like any message we are repeatedly exposed to, we come to believe it over time. In this way, it inhibits a healthy libido—and good sex! It is so destructive because it encourages women to feel ashamed when their bodies aren’t perfect (whose is?), and it allows the truth about good sex to remain ignored and unexplored.
Our society also buys into the notion that good sex always involves intercourse and orgasm by both partners, preferably at the same time. This approach to sexuality is restrictive and unrealistic. The most-rewarding sexual experiences are much more rich, diverse, and creative. They grow from powerful connections of hearts and minds. Unfortunately, few of us seize the opportunity to explore the sexual possibilities. It’s no wonder so many women lose interest in sex.
Truly good sex, however, begins with a willingness to be open and vulnerable, to give pleasure freely and receive it fully. It also depends on both partners’ commitment to shared intimacy, both physical and emotional. Relying on just one form of intimacy without the other is like trying to enjoy a movie without popcorn. It’s pleasant enough, but it isn’t quite as satisfying.
Brigitte and her husband, Adam, continue to enjoy good sex after 8 years of marriage. Here she describes one of their sexual encounters.
“I was exhausted after a long day at work. As I drove home, all I could think about was grabbing some leftovers from the fridge and crashing on the couch. But Adam was so sweet. He had made dinner for the two of us.
“After we finished eating, I just wanted to go upstairs and collapse into bed. But Adam followed me to our bedroom. When he embraced me and kissed me, I responded in spite of myself. His insistent, demanding touch changed my whole frame of mind. I wanted him, and I gave in to him. After he brought me to orgasm, I returned the favor. He knows my body and my turn-ons so well. And when he holds me after sex, I feel so safe and loved.”
If you’re like most people, you may be wondering whether to believe Brigitte’s story. After all, she and Adam have been together for nearly a decade; how can they still share such passion for each other? Perhaps a story of boring sex would be more believable. Why is Brigitte so responsive to her husband’s sexual advances?
Brigitte obviously enjoys making love to Adam. On this particular evening, she allowed herself to yield to his power over the situation, and his control over her body. It created the illusion of risk, which heightened the sense of passion for both of them. But Brigitte knew that she was safe and that Adam would never hurt her.
Brigitte doesn’t always submit to Adam. Sometimes they reverse roles, and he becomes more open and vulnerable to her wishes and desires. This adds an unpredictable quality to their lovemaking, and richness and depth to their erotic experience.
Just as an illusion of risk contributes to good sex, so, too, does an element of mystery. When partners uncover or reveal something “secret” while making love, it intensifies their sensations of stimulation and arousal. Brigitte and Adam achieve this by allowing themselves to feel physically and emotionally exposed during their intimate encounters. For example, Brigitte may keep her eyes open while she climaxes, so Adam can make loving eye contact with her at the height of passion. Or Adam might disclose a sexual fantasy that he was keeping to himself. Their options for sharing themselves on a most personal, intimate level are almost endless.
Because of the positive dynamics in their relationship, Brigitte and Adam are able to bring a sense of spirituality to their lovemaking. That is, their physical interaction creates a strong spiritual connection that sustains them as individuals and as a couple. They know they are loved, nurtured, and cared for on a deep, powerful, personal level.
Good sex, then, is a complex concoction of openness and secrecy, risk and control, personal satisfaction and mutual fulfillment. With too little of any one ingredient, sex is boring and not worth the effort. Too much of one, and sex turns threatening—prompting discomfort, anxiety, and shame. Above all, sustaining a healthy, balanced sex life requires mindful attention to the physical, emotional, intellectual, and spiritual dimensions of our selves, as well as our relationships with our partners. We may be entitled to good sex, but we must earn it through effort and commitment.
Most of us have experienced the pleasure of sexual desire. The fact is, many women with diminished sex drive simply have lost touch with what feels like good sex to them. Sex went from easy and enjoyable to a tangled mass of anxiety, frustration, and disappointment.
So many of our clients at the Sexual Wellness Center say that they want to get their libidos back. But when they describe the sex they’ve been having, we’re not surprised that they lost their libidos in the first place. Most healthy, mature women are not going to want mediocre or bad sex. Why would they?
Somehow, we come to believe that we should want sex with our partners, regardless of the quality of the lovemaking experience. This is an interesting notion, but it doesn’t necessarily translate well into other aspects of our lives. For example, would we expect to desire a massage with a mediocre masseuse? Would we expect to desire a dress made from fabric that irritates our skin? These examples seem absurd initially, but their point is clear: We want only what feels good.
Of course, what feels sexually enticing and exciting to one person can be completely unappealing to the next. A loving, committed relationship provides a safe and trusting environment where both partners can explore and express their sexual needs and preferences.
The goal of our practice, and this book, is to help regain what women know is inherently natural for them: a healthy sex drive. At the same time, they can use the challenge of low libido to foster a deeper understanding of themselves, their relationships, and their sexuality.
We encourage you to take advantage of your dissatisfaction with your libido, seizing a rare opportunity for self-growth and greater self-knowledge. Now is the time to identify and heal whatever is interfering with your ability to get what you want from your life, your relationships, and yourself. In this way, you can help revive your libido—and create a more satisfying sex life to boot.