Female Sexual Desire Disorder
By Dan Pollets, Ph.D.
A recent study which attempted to look at the benefit of giving women who are on anti-depressants Viagra so as to improve their low sexual desire and poor arousal gives pause to consider the very complicated issue of sexual desire disorder in women. Sexual desire disorder in women is in fact an extremely common condition. Studies report that having too little sexual desire is the sexual dysfunction most frequently seen among women, reported by 10 – 51% of women surveyed in various countries. Women reporting low sexual desire also report low levels of arousal and sexual excitement and infrequent orgasms. This all adds up to a lot of women feeling sexually dissatisfied with the experience.
Getting back to the Viagra study (see Journal of American Medical Association, 8/08), there were promising results in that the group that received Viagra (in comparison to the placebo control group) showed significant improvement in arousal and orgasm. However, there was no improvement in sexual desire. There does not currently exist a pill that can be taken that would have the effect of increasing a woman’s desire for sex. This finding begs the question of how to define sexual desire in women, how desire is experienced differently given gender, and what are other important factors that influence sexual desire in women. I hope to provide some clarity to these issues in this brief article.
Defining Desire Disorder Contextually:
It should be no surprise to women readers that if the standard of comparison regarding sexual desire is a man’s desire, most women would come up short. Spontaneous sexual desire is a rarity in women. Further, the desire for sex independent of a number of other considerations; for instance, biological, psychological and interpersonal (relational) is highly unusual in women. In fact, sexual desire is an infrequent reason for engaging in sex in women in established relationships. Women give many reasons for engaging in sex; for instance, the desire for emotional closeness, to please one’s partner, to communicate intimately - all independent of a purely biologic drive. This biological sex drive in men, in contrast, might manifest as sexual fantasizing, yearning and looking forward to sexual experience, and “spontaneously” thinking about sex.
What is important to note is that while studies find that a larger percentage of women report that they infrequently felt sexual desire, the majority reported that once engaged in sexual activity, they were capable or arousal (lubrication, engorgement, orgasm) and reports of discontent were less frequent. In other words, women can have low spontaneous desire but once engaged in the sexual experience can become aroused and actually enjoy the experience. This being true, the challenge then is how to overcome the initial hurdle so as to land in bed where good things can happen.
What are the implications of this research for the sexual relationship and relationship in general? A woman with low sexual desire can feel shame and feelings of inadequacy. Conflict can be ignited between partners as the result of infrequent sex and lack of female initiation. Men will complain that they “always” have to be the one that initiates and this get to be laborious. Men often fantasize, possibly fed by ample images and scenarios from readily available pornography of the always available, insatiable, and sex hungry and very carnal "hotee." This wish of men to have their long term partners initiate sex and thereby match up to their fantasy may be unrealistic and in conflict with female sexual physiology and psychology. The research demonstrates that women do not experience strong sexual desire independent of environmental and relational cues. They will not initiate based on inner biological drive but will respond to a set of circumstances that are associated with romance, pleasure and intimacy. Sorry men. However, the good news is that once conditions are favorable it appears that most women can become aroused and orgasm just fine. This fact calls for better attention in the sexual dance to “fore-fore play,” the relationship dynamics, lowering stress levels and increasing romance in order to generate the “heat” if you will. This argument has a familiar ring to it.
Factors Relevant to Female Sexual Desire:
Rosemary Basson (see Footnote 1) has written extensively about the topic of female sexual desire and here I am indebted to her work. If the search for one causative agent or pill that would create increased levels of sexual desire in woman is bound to fail, what are the specific conditions or factors the research has deemed relevant to or correlated with increasing a woman’s sexual desire or interest in sex. What would be treatment implications?
The research suggests that a woman’s accessibility to sexual experience is particularly dependent on the context of a given sexual interaction which includes the quality of intimacy and feeling about the relationship she is having with her partner. Other important factors which interact include the woman’s psychological and medical health, sexual and cultural contexts. Let me briefly describe these relevant factors.
The overall sense of emotional closeness, capacity to trust, and ability to communicate and be validated in this communication is highly related to a woman’s availability and openness to become sexual. The adage that men seek out sex in order to feel close while women must feel close in order to become sexual might have some truth in it. It is therefore impossible to accurately assess low sexual desire in a woman without attending to the quality of relationship and level of emotional intimacy. The delight in an exquisite dinning experience takes into consideration the setting, the service, the presentation of the food (appearance) as well as the actual taste. It also helps the overall enjoyment of the evening to find your dinning partner attractive and a good conversationalist. So men, ramp up your romance and seduction skills and you might ignite more “fire.”
The less a woman struggles with issues such as low self esteem, poor body image, depression, anxiety, and history of sexual/physical/emotional abuse the greater the possibility that sex will be sought and enjoyed. Depression is strongly associated with reduced sexual function. Unfortunately and ironically, anti-depressants prescribed to treat depression, especially SSRIs (Zoloft, Prozac, Paxil, etc.) typically have side effects which reduce sexual desire and arousal. This is why the Viagra study mentioned has some promising implications. Viagra could be the counterweight to the sexual side effects.
In terms of sexual history, women who have a history where they were abused sexually or physically will retain aspects of the negative conditioning and can associate danger and threat with sexual intimacy. The messages that one absorbed about sexuality in the family of origin or religious training can also impact on adult sexuality. Growing up in a house that is hyper-religious and extremely repressive where, for example, masturbation is deemed sinful, will lead to certain conclusions about sexuality goes – none of it particularly helpful for healthy intimacy. Clearly, overall mental health mental health must be looked at in the assessment of female sexual desire disorder.
This factor refers to how the sexual activity itself is being experienced. This can include the feeling that her partner is being seductive and romantic, how much time is being taken in foreplay to assure arousal, and the skill level, if you will, the couple demonstrates in the giving and receiving of pleasure. In other words, how smooth and coordinated is the sexual dance between. An important consideration is the sexual communication between so that the need for necessary stimulation to augment arousal is signaled and responded to either verbally or non-verbally (non-verbal might be more graceful). This aids arousal and increases pleasure. Obviously, if the sexual experience is highly pleasurable there will be future positive anticipation (expectation of reinforcement). A basic law of learning is that any behavior that is highly reinforced has a greater probability of occurring in the future. If there is selfishness or the lack of mutual satisfaction due to poor communication interplay between partners sex will become at the very least unsatisfactory and obligatory. We would not expect great future sexual desire in this case.
Obstacles to Mindful Sex:
Another popular adage says that men are “unitaskers” and women “multitaskers.” Men have an easier time focusing on the “hunt” and can block out distracting stimuli. Women, on the other hand, are evolutionarily wired to mind the home, kids, food, and community and are juggling many roles. Their awareness is often focused on many simultaneous demands. Being able to let go of all the distractions and become truly present for sex a formidable challenge for many women. Perceived stress correlates poorly with a woman’s availability to become sexual. Concerns about the children, being interrupted; family difficulties, and unwanted pregnancy can make activating sexual desire and being fully present difficult at best. Basson (2006) makes the point that women might go along with the sexual demand of her partner and not take responsibility for her own enjoyment and then come to expect a poor outcome or low satisfaction of her sexual relating. This of course leads to avoidance or sex being a low priority. It has been helpful in my practice to teach women who are so distracted and stress basic Mindfulness techniques and meditation skills. Encouraging couples to discuss a more equitable sharing of domestic tasks and child care responsibility also makes sense in order to reduce the burden and lower stress levels.
Physical or biological factors can of course influence sexual desire and arousal. We have mentioned depression. Other chronic illnesses that affect sexual desire include diabetes, neurological disorders (e.g. MS), vascular disease, high blood pressure, and renal failure. If there is disease in the ovaries and/or low levels of androgen production (testosterone) there will low desire and poor arousal. Recent studies have attempted to demonstrate the importance of low testosterone levels in women and low desire. However attempts to replace testosterone have not been met with great success. There continues to be a lack of a safe pharmacologic intervention which would supplement for low androgen levels and shows clinical efficacy. The problem of finding a safe and reliable “magic bullet” is complex and there are many factors other than biological that are impacting desire. This being said, there is an important role for drug treatment and there are drugs that are being tried for women who present with low desire and arousal issues and who also have low androgen levels. These include L-Arginine amino acid cream, DHEA (natural precursor to androgen production), and testosterone therapy. What is clear is that women looking to boost testosterone levels should work with their physicians closely so that the hormone can be monitored. These drugs can have unwanted side effects.
Sexual desire disorder is a difficult and common problem. Experiencing the loss of desire and then avoiding sex can lead to feelings of shame and inadequacy. It can also be a threat to the marriage or relationship evoking conflict and hurt feelings and a general sense of losing control over one’s life and existence. Low sexual desire in women is a puzzle to be solved by the sex therapist and sexual medicine physician. It has been my experience that men are much more straightforward and treatment often ends with giving the “little blue pill” and/or testosterone replacement. Dr. Sandra Leiblum, a noted sex therapist who has written much on the subject said, “A woman’s lack of sexual interest is often tied to her relationship with her partner. The important sex organ (for women) is between the ears. Men need a place to have a sex – women need a purpose.”
The important point in all this is that it is impossible to assess and treat a woman for low sexual desire out of context. This context includes her emotional and psychological status, sexual history and biology. The level of emotional intimacy or satisfaction in the relationship is crucial as is the precise quality of the give and take in the sexual act that leads to increasing pleasure and arousal. All this calls for comprehensive evaluation: both from a sex therapist who can focus on psychological and relational data and a sexual medicine physician (urologist, OB/GYN, endocrinologist who is specially trained). Certainly low sexual desire can threaten the health and well-being of the relationship and lead to many unfortunate psychological effects. A holistic and multi-factorial perspective on the problem is what is needed to accurately assess and treat such a complicated issue.
1 Rosemary Basson, Sexual Desire/Arousal Disorders in Woman. In S. Leiblum, Principles and Practice of Sex Therapy, 4th Ed., 2006