Most women are well aware of the close connection between their moods and their libidos. Though feeling happy doesn’t guarantee a healthy sex drive, feeling depressed, anxious, or stressed certainly can take away from one.
In recent years, our country has seen an enormous increase in cases of clinical depression, anxiety disorders, and chronic stress. According to the latest estimates, a woman’s lifetime risk for depression ranges from 10 to 25 percent—though some researchers think those numbers may be too conservative. Anxiety disorders are even more common, as is chronic stress. Some 43 percent of adults experience stress-related health problems.
As the incidence of emotional disorders like these continues to rise, the incidence of libido trouble will rise as well. In fact, a significant number of women with low libido meet the diagnostic criteria for some form of depression or anxiety.
You don’t need to be diagnosed with an emotional disorder to notice the sexual effects of your distress. Even mild melancholy or irritability can dampen sexual desire. You’ll be not only less receptive to sex but also less responsive to sexual stimuli—things like your partner’s touch or an erotic movie scene. Simply put, if you’re feeling good, you’re more likely to perceive a sexual stimulus in a positive light. If you’re feeling bad, you probably won’t be turned on.
When a woman comes to the Sexual Wellness Center for help with her libido, we conduct a thorough assessment of her mood and emotional well-being. Perhaps you’ve started this process on your own by taking the self-test on page 24.
Now you need to ask yourself: Are you getting what you want from life? This is not about being happy all the time or about existing in a state of perpetual bliss. Generally, though, you know whether you feel content and fulfilled. If you don’t, it may help explain why you’re not all that interested in sex right now.
Perhaps your reply comes with disclaimers or modifiers, such as “Yes, but… ” or “I will when… ” Or maybe it’s an outright “No.” Either way, it hints at some level of emotional discomfort or dissatisfaction that may be sapping your sex drive.
Like most women, you may choose to set aside your emotional health in order to focus on the demands of family, home, and career. But this can backfire in the long run because of the potential negative impact on sex drive, among other things. Why, then, do so many women ignore their true feelings?
Busy lifestyles bear at least some of the blame. Sorting through even mild emotional upheaval takes time and energy, two commodities that are in extremely short supply these days. So many other things demand attention that tending to emotional health typically drops to the bottom of a woman’s to-do list. She may continue to function quite productively, even with the strain. But until she confronts and corrects it, she won’t truly be well, and she won’t fully recover her sex drive.
What’s more, many women have been raised with the notion that they should be able to keep their emotional house in order with relative ease. Our clients at the Sexual Wellness Center repeatedly say that they feel weak when they ask for help with emotional issues. This perception is unfortunate, because it leaves women feeling stuck and alone, too ashamed to talk even to trusted family members or friends about their problems.
In fact, just acknowledging our emotional distress to ourselves can be difficult. As it moves to the forefront of our thoughts and lingers there, it can seem particularly troubling, perhaps threatening. Fortunately, once we take steps to address our troubles, we begin to feel better almost immediately. So why not seize this opportunity to explore your emotional health? Your low libido may be an indicator of a problem that needs healing.
We’ve chosen to focus on a few of the more common emotional disorders known to affect sexual desire and response. For the most part, they require professional intervention and care. So if you think you may have one of these conditions, please see your doctor as soon as possible.
Clinical depression is one of several categories of mood disorders recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), published by the American Psychiatric Association. Interestingly, not all mood disorders negatively affect libido. Those that are part of the bipolar spectrum, also called manic-depression, can have the opposite effect. Their symptoms include extreme euphoria and/or irritability, coupled with high energy and a diminished need for sleep.
Bipolar disorders are serious illnesses that require specialized psychiatric care. Because they’re more likely to enhance sex drive than inhibit it, they will not be explored further here. The categories of depression that generally deplete libido, however, include major depressive disorder, dysthymia, and depression with postpartum onset, commonly referred to as postpartum depression.
When a woman is depressed, her energy declines, as does her interest in activities she once enjoyed. No wonder she doesn’t want to make love to her partner. Even mild depression may lead to low libido. And when the depression subsides, the sexual effects may linger.
Many women who struggle with low libido can identify a specific depressive episode that seems to have triggered the onset of their symptoms. But this isn’t always the case. At the Sexual Wellness Center, we routinely see clients who have no idea that they are depressed. If depression sneaks up slowly, the mood changes may not be all that obvious.
If you have a family history of depression, you are at greater risk for developing the illness yourself. But it needn’t take over your life. The sooner you receive proper professional care, the better your chances are for a complete recovery. Most people respond well to treatment involving psychotherapy, medication, or some combination of the two.
Have you heard of someone experiencing a “nervous breakdown”? That’s the common name for major depression.
The most severe cases of major depression may be accompanied by psychotic symptoms, including delusions (for example, believing that one’s food has been poisoned) and hallucinations (hearing voices in one’s head). Often people who attempt suicide meet the diagnostic criteria for severe major depression.
Of course, the illness can take a milder form. The symptoms are similar to those of severe depression, but they’re not as intense. People who have mild major depression tend to be fully functional and may display what seems like a normal mood. Even they may not suspect that they have a treatable disorder. For this reason, they may not seek or get proper treatment.
The symptoms of major depression can be short-term (2 weeks) or long-term (2 years or more). They include sadness and irritability, lack of interest in previously enjoyable activities, disturbed sleep and appetite, low energy, and diminished self-esteem. Some women with major depression experience physiological agitation or, alternatively, slowed body movements. Others report poor concentration and memory, as well as feelings of hopelessness, guilt, and worthlessness.
People with major depression tend to evaluate themselves and their lives in an unrealistically negative light while being unaware of their distorted thinking patterns. They readily blame themselves for issues that are beyond their control. Often they experience symptoms of anxiety, which range from excessive worry to panic attacks. Sometimes they are more aware of somatic symptoms, such as bodily aches and pains, than they are their mood disturbances.
In an attempt to self-medicate, women with depression may turn to alcohol or other “addictions,” such as food or shopping. Combining an addiction with depression not only complicates the symptom picture but also further diminishes sex drive. This is because the addictions themselves diminish sex drive. For example, women who overeat and gain weight as a result may become so self-conscious about their bodies that they avoid making love. Those who shop to boost their mood may find their relationships with their partners strained by financial problems. And because alcohol is a depressant, excessive alcohol consumption—more than two drinks a day—can leave a woman even less interested in sex. (We’ve talked about the effects of alcohol on libido in chapter 4.)
Phyllis, a 41-year-old Web page designer and graphic artist, is typical of many women with major depression.
Phyllis ran her own business with style and creativity. She was well-liked and full of energy and enthusiasm. None of her friends or professional contacts would have imagined that she was depressed. But her husband, Ian, knew otherwise.
Although Phyllis was a high-functioning artist by day, she was irritable and socially isolative at night. She would vacillate between remaining quiet and yelling at Ian for rather minor issues. She hadn’t initiated sex in months, and when Ian made advances to her, she was unresponsive. For his part, Ian was losing interest in making love because Phyllis was so rude.
Ian wanted to help Phyllis, but he didn’t know how. He hoped that if he stayed out of her way, she would return to her old self again. But she seemed to get even more irritable as the months went by. She didn’t like the person she had become, either.
Phyllis mentioned her moodiness and low libido to her doctor when she went for her annual gynecologic exam. She was referred to the Sexual Wellness Center, where she finally got the help she needed. Without intervention, her depression would have continued to strain her marriage and likely would have affected her professional life as well.
Dysthymia is milder but lasts longer than major depression. In fact, some people have dysthymia for most of their lives without ever realizing it. They become so accustomed to feeling a certain way that they don’t consider the possibility of feeling better.
The primary symptom of dysthymia is a depressed mood that persists for at least 2 years. To be diagnosed with the condition, a woman also must experience at least two of the following: disturbed sleep, fatigue, poor concentration or indecisiveness, lack of appetite or a tendency to overeat, low self-esteem, and a sense of hopelessness. Although low libido is not among the diagnostic criteria, it is quite common in women with dysthymia. Social withdrawal, irritability, and diminished activity or productivity are other suspected symptoms.
Belinda’s story illustrates the effects of dysthymia on a woman’s sexuality and on her quality of life.
Belinda had been bothered by a blue mood and low energy for years. She always felt like she could use a nap, even though she was getting adequate rest almost every night. Her husband, Randy, expressed his frustration with her indecisiveness. But the fact was, she seldom wanted to do much anyway. She seemed most content when eating—but this also caused considerable distress because of the resulting weight gain.
A fifth-grade special education teacher, Belinda enjoyed her work. But she had to admit, it wasn’t as satisfying as it used to be. The rest of her life seemed even less interesting, but she couldn’t think of any way to improve it.
Belinda acted happy in front of her family and friends. Meanwhile, she and Randy grew further apart. She knew he wanted to make love more often, but she just couldn’t muster any interest in sex. So he spent more and more time watching sports on TV, and she found escape in her fiction books, reading about women who had passionate relationships and exciting lives.
Belinda didn’t see any value in going to therapy. After all, she couldn’t erase her past, and she wasn’t expecting much from her future. It wasn’t until a colleague confided that she had gotten help for depression that Belinda reconsidered treatment for herself. She attended individual and group sessions for almost 2 years. During that time, she achieved a better understanding of herself, and she made positive changes in her life that ultimately resolved her dysthymia.
A specific form of depression unique to new moms, postpartum depression occurs within 4 weeks after childbirth. It is characterized by unstable moods, including spontaneous, seemingly unprovoked crying spells. Many women who develop postpartum depression also report symptoms of anxiety, such as panic attacks, racing thoughts, and obsessive worrying. They may feel that they aren’t able to bond with their babies, which causes further guilt and shame.
At its most severe, postpartum depression may trigger thoughts of suicide and/or harming the baby. This fuels even greater emotional turmoil, as women believe they should be happier than ever, having just brought a child into the world. Unfortunately, they may be too embarrassed to reach out for help, so they won’t get the treatment that could make a dramatic difference in their emotional state.
Annie, a 32-year-old first-time mom, described her postpartum depression in these terms.
“I was exhausted and overwhelmed. It seemed like I could no longer think clearly or make even basic decisions. I blamed my baby, resenting her for changing my life so dramatically. When she’d cry, I just wanted to run. Everyone around me acted like I was behaving normally, but inside I felt like I was going crazy. I doubted that I could function as a mother.”
Women who have a history of depression are at a greater risk for developing postpartum depression. For this reason, they should stay in contact with a mental health professional throughout their pregnancies. A psychiatrist or psychologist could recognize the symptoms early on and recommend interventions before full-blown depression gains a foothold.
The good news is, symptoms like Annie’s respond well to treatment. As with other forms of clinical depression, the sooner postpartum depression is diagnosed, the faster treatment can begin, and the more effective it will be.
These days, the standard treatment protocol for virtually all cases of clinical depression involves some type of antidepressant medication. In general, antidepressants work by elevating levels of certain neurotransmitters—usually serotonin, norepinephrine, and dopamine—which are chemical messengers in the brain. They influence many of the human body’s basic functions, not just mood.
Unfortunately, most antidepressants can diminish sex drive. Often, women who experience this side effect feel uncomfortable talking with their doctors about it. And the doctors may not mention it for fear they’ll embarrass their patients. Or they may be uncomfortable discussing sexual issues themselves.
Sex is an important component of healthy human function. Doctors and patients ought to be able to talk about the impact of any medication on sexual desire and performance. But more often than not, these conversations don’t take place.
According to research, the most common class of antidepressants—the selective serotonin reuptake inhibitors (SSRIs), which include Prozac (fluoxetine), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), Lexapro (escitalopram), and Zoloft (sertraline)—tends to produce the most unwanted sexual side effects. So does Effexor (venlafaxine), which has SSRI-like activity but falls into a different class. Although some people experience no sexual symptoms with these medications, approximately 40 to 70 percent of women who take SSRIs or Effexor report one or more of the following: low libido, inefficient or unsustainable arousal, vaginal and/or clitoral numbness, and difficulty achieving orgasm. These side effects can vary in intensity. Sometimes they spontaneously subside as a woman’s body adjusts to the medication.
Physicians tend to prefer SSRIs over other classes of antidepressants, because the nonsexual side effects tend to be less severe. For example, SSRIs typically don’t cause as much constipation, drowsiness, and dry mouth as tricyclic antidepressants such as Tofranil (imipramine) and Anafranil (clomipramine). Tofranil works by raising serotonin and norepinephrine; Anafranil primarily targets norepinephrine.
Two other antidepressants, Cymbalta (duloxetine HCl) and Remeron (mirtazapine), are less likely than SSRIs to cause sexual side effects. But they can cause other side effects, ranging from constipation and skin rash to blurred vision, dizziness, and weight gain. Cymbalta inhibits the reabsorption of serotonin and norepinephrine; Remeron increases the activity of these neurotransmitters.
The good news is that women who take SSRIs may be able to get relief from some of the sexual side effects. Studies suggest that another antidepressant, Wellbutrin, actually may enhance sex drive. Even in subtherapeutic doses, it appears to counteract the sexual side effects of other medications, including other antidepressants. Some doctors have begun prescribing relatively small doses of Wellbutrin in combination with SSRIs with good results. Wellbutrin works by preventing the reabsorption of serotonin, norepinephrine, and dopamine in the brain.
Another possible solution to the sexual side effects of SSRIs is Viagra (sildenafil), the “little blue pill” commonly prescribed to men with erectile dysfunction. Preliminary research shows that some women who experience sexual side effects with prescription medications can get relief with Viagra. It works by causing blood vessels to dilate and fill with blood, which may enhance sexual arousal for women whose nervous systems are affected by medications. (See chapter 9 for more about Viagra and its effects on female libido.)
Sometimes, too, sexual side effects will subside with an adjustment in dosage or a switch to another medication. This is why open communication between physicians and patients is so important. Your doctor should be well aware of the potential side effects of any medication she prescribes. And if she stays abreast of the medical literature, she will be familiar with the latest options for reducing these side effects, as well as new medications that may be less troublesome.
Please keep in mind that you never should alter your dosage or discontinue a medication without consulting your doctor. This is especially true for certain antidepressants, which can cause withdrawal symptoms if stopped abruptly.
As a group, anxiety disorders are the most common mental illness in the United States. By some estimates, they affect more than 19 million American adults.
Anxiety disorders tend to be chronic, meaning they don’t go away spontaneously. In fact, if left untreated, they may become more debilitating over time.
A number of conditions qualify as anxiety disorders, from social anxiety and panic attacks to obsessive-compulsive disorder and agoraphobia (fear of certain places or situations). For all of these, the primary symptom is excessive anxiety. They may cause low libido as well, though it isn’t one of the diagnostic criteria for anxiety disorders. This is because anxiety tends to affect libido more circuitously, by altering general quality of life. In other words, a woman with an anxiety disorder may be less interested in sex simply because she’s putting her energy into coping with her emotional distress.
Of all the anxiety disorders, the two that most commonly deplete a woman’s sex drive are generalized anxiety disorder and posttraumatic stress disorder. We’ll explore each of these in turn.
An estimated 4 million American adults may suffer from generalized anxiety disorder (GAD). It is twice as common in women as in men, often occurring in tandem with another psychiatric diagnosis. For example, many people with GAD also have some form of depression or a history of substance abuse.
Generalized anxiety disorder is characterized by excessive anxiety and worry occurring over a period of at least 6 months. People with GAD often say that they’re unable to relax or control their thoughts. Their days seem filled with apprehension, from which they get little relief. Related symptoms may include difficulty sleeping, low energy, irritability, poor concentration, and general restlessness.
With generalized anxiety disorder, a woman may feel too on edge to make love. She can’t relax enough to enjoy the sexual interplay, and she may struggle to turn off her mind and tune in to the pleasurable physical sensations. Essentially, she brings her worries into the bedroom, so concentrating on sex becomes highly improbable.
Unfortunately, these circumstances can trigger what’s known as response anxiety. It is quite common among women with GAD, and especially those with low libido. Response anxiety is not a psychiatric diagnosis per se but rather a description of the process by which a person becomes almost obsessed with her sexual response. That is, rather than being “in the moment,” allowing a free flow of emotions and physical sensations, she becomes a critical spectator in her own sexual experience. And the more she judges herself, the more her dissatisfaction and self-criticism perpetuate themselves. This sets up a vicious self-perpetuating cycle.
As with clinical depression, most cases of generalized anxiety disorder respond to treatment with medication, psychotherapy, or some combination of the two. For psychiatrists, the medications of choice are SSRIs and tricyclic antidepressants. As we mentioned earlier, these medications can cause sexual side effects, including low libido. This is why we often advise our clients with GAD to try relaxation techniques first. They may be enough to manage all but the most serious cases of GAD without pharmaceutical intervention. (For basic instruction in deep breathing, meditation, and other relaxation techniques, see chapter 11.)
Post-traumatic stress disorder (PTSD) is a psychological reaction to a traumatic experience or event. It has been getting more attention in the United States because of the upsurge in cases after the 2001 terrorist attacks. More than 5.2 million Americans between ages 18 and 54 may suffer from PTSD.
Traditionally, PTSD has been associated with exposure to extreme trauma, such as military combat, natural disaster, or criminal assault. Now we know that whether or not a situation is traumatic depends on a number of variables specific not just to the incident but also to the person. For example, a woman’s trauma history, her coping mechanisms, her social support network—all of these factors help shape her perception of a particular experience or event. This is why incidents that seem mildly stressful to some people may be quite devastating to others.
Stressful but normal life events such as a death in the family or loss of a job can be upsetting enough to trigger PTSD symptoms in certain women. The disorder also can result from cumulative exposure to low-grade trauma. These days, doctors will consider a diagnosis of PTSD when the aftermath of a trauma interferes with a person’s normal level of functioning.
While PTSD symptoms generally appear within 3 months of a traumatic incident, they can have a delayed onset, showing up months or even years later. They include flashbacks or nightmares about the incident; attempts to ignore thoughts or feelings about the incident; emotional and physical numbness, including detachment from others; and physical and emotional agitation, characterized by irritability, angry outbursts, and difficulty falling or staying asleep. Even if a woman’s symptoms don’t lead to full-blown PTSD, they still can have a negative impact on her libido.
Amy’s story serves as an example of how perceived trauma can continue to influence a woman’s sex life, even if the incident occurred long ago.
Amy, a 41-year-old medical technician, struggled with PTSD for most of her life. It began in childhood, when her mother developed cancer. At the time, Amy didn’t know why her mother spent less and less time at home or why she looked more and more sickly. Because Amy’s father worked late hours, she became accustomed to making her own dinner and putting herself to bed, even while still in grade school.
It wasn’t until her mother died that Amy learned the truth, wrapped in harsh words from a distant aunt who arrived to assist with funeral preparations. Amy remembers few details about her life back then. But she clearly recalls the extreme fear and grief that consumed her for many months following her mother’s death.
As an adult, Amy prefers to keep her life as predictable as possible. Anything that challenges her sense of control, including sexual desire, brings on anxiety that overwhelms her. Amy is often irritable. She sometimes wakes with nightmares, and she worries that something will happen to her husband.
In Amy’s story, you can see how perceived trauma affects the body as well as the mind. Researchers have made some interesting findings about the body’s response to trauma that help clarify our understanding of female libido.
People who react to trauma with physical hyperarousal—in other words, an adrenaline rush—may come to perceive any form of physical hyperarousal as traumatic. So instead of experiencing sexual arousal as pleasurable, they process it as traumatic and therefore avoid it. This occurs despite the attempted intervention of logic. So even if a woman tells herself that she is safe and not being threatened when her partner makes sexual advances, her body can override these conscious thoughts and react as if it’s being traumatized.
Physicians routinely prescribe medication for PTSD, but it’s intended more for symptom management than for primary treatment. Antidepressants such as Zoloft and other SSRIs can help, as can antianxiety medications. Often they’re recommended in combination with some form of psychotherapy.
Talk therapy has proved helpful for people with PTSD, but recent research shows promising results with techniques that involve the body as well as the mind. One such technique is eye movement desensitization and reprocessing (EMDR).
Developed by Francine Shapiro, Ph.D., a senior research fellow at the Mental Research Institute in Palo Alto, California, EMDR originally was intended for use by military combat veterans struggling to recover from the trauma of war. It pairs deliberate rapid eye movements with thoughts, feelings, and images associated with the traumatic incident.
EMDR is unique, in part because doctors can’t agree on why it works. But studies of the technique are yielding promising results. Therapists who use EMDR must receive proper training. You can find a qualified EMDR professional via the Web site www.emdr.com.
In and of itself, stress is not a psychiatric diagnosis. But that does not diminish its impact on our minds, bodies, and relationships. In particular, the subjective experience of physical or emotional stress can significantly affect sex drive.
Sometimes, stress actually enhances sexual desire and response. This tends to be true for women who use sex as a coping mechanism. For them, sexual interplay is a “timeout,” a means of release.
More often, however, stress interferes with a woman’s ability to relax and enjoy sexual contact. Staying in the moment takes more effort, as her thoughts easily turn to nonsexual matters—even the seemingly unimportant tasks of daily living. This is a problem, because sexual arousal requires ongoing, relatively uninterrupted attention to erotic stimuli. Otherwise, a touch that previously felt pleasurable can be unstimulating at best, intrusive or uncomfortable at worst. Sex becomes another demand, a responsibility or chore instead of the gratifying exchange it once was—and should be.
To complicate matters, women who are in a state of chronic stress may not care that sex has become a casualty of their highpressure existence. Quite simply, they are too preoccupied with other things to worry about their sex lives.
These days, you’d be hard-pressed to find anyone who considers herself to be completely stress-free. At the same time, tolerance for stress can vary greatly from one woman to the next. In fact, you can have different levels of tolerance at different stages in your life. What might seem overwhelmingly distressing when you’re in your early thirties becomes challenging and stimulating when you reach middle age.
Other factors may increase your vulnerability to stress at certain times. For example, a decline in physical health can make previously mundane tasks seem overwhelming. Your body can communicate what your mind may refuse to acknowledge: You have physical and emotional limits that you must respect in order for it to function optimally.
Incidentally, life events need not be negative to be stressful. Though things like physical illness and financial problems obviously cause tension and anxiety, positive events such as marriage, childbirth, a new home, or a new job also take a toll emotionally and physically. The trouble is, you may be less inclined to seek relief from stress when it arises from something positive. Likewise, you may receive less support from loved ones in these circumstances, because they may not understand why you’re feeling the way you are. For these reasons, positive stressors can be more difficult to cope with.
If you feel helpless to control the stress in your life, you will experience it more intensely. Identifying and focusing on how you can change your situation may ease your sense of helplessness during stressful times. But your ability to cope could be at the mercy of your genes. Research suggests that humans have an inherited resistance or susceptibility to the effects of stress.
Many women can point to a specific stressful event that seemed to trigger a decline in their sex drives. In such circumstances, low libido likely is a component of the body’s normal stress response. We become concerned when a woman’s desire for sex doesn’t bounce back even after the successful resolution of a stressful situation. Chronic low libido can cause stress as much as result from it. This is especially true in intimate relationships, where the longer low libido lingers, the more stressful it becomes for a woman and her partner.
So how can you protect your sexuality from the effects of stress? Research repeatedly demonstrates that perceived social support is one of the best stress-busters around. When you reveal your problems to others, you feel less alone, and you open yourself to nurturance. Both of these factors weaken the impact of stress in your life.
Maintaining good physical health enhances your ability to handle stress and improves your sex life. Studies have shown that adequate sleep, regular exercise, and minimal alcohol consumption can raise stress tolerance in most people. Sticking with a schedule that includes breaks for relaxation also promotes a sense of calm and control, even in the face of chaos. (For a refresher course on self-care for good health and a strong libido, see chapter 4.)