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Sexual Health & Intimacy

Re-examining Sexual Desire

Heather Hoffmann, PhD

Lack of libido is a fairly common sexual concern for women. However, the actual definitions of terms such as “low libido” and “inhibited sexual desire,” and whether such a deficiency is actually present in everyone who claims to have it, are unclear. Some inquiries practitioners can make of patients with these types of complaints before assuming that they have a bona fide problem are:

Have you always had low sexual motivation, or is it that your desire for your current partner has waned?
Do you still desire sex with your partner, but find that you’re not in the mood when the time arises?
Do you still fantasize about sex but lack a physiological response to sexual stimuli?

The answers to these questions can help identify the cause of concern.

RECOGNIZING THE ISSUES

Unfortunately, research on sexual desire lags behind research on other aspects of sexuality. Early models of sexual behavior did not recognize desire as a separate part of the sexual response cycle. Rather, it was long assumed that sexual interest occurred spontaneously and/or that sex drive was a given.
Through research in patients experiencing sexual problems, desire was eventually recognized as being distinct from other aspects of sexuality. Subsequently, desire problems became part of sexual dysfunction, as described by the American Psychiatric Association’s Diagnostic and Statistical Manual IV-TR (DSM). However, the current disorders of hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD) are poorly understood and, some believe, wrongly conceptualized. HSDD is diagnosed if a person claims to have persistent or recurrently deficient (or absent) sexual fantasies and desire for sexual activity that causes distress, whereas FSAD is diagnosed with persistent or recurrent inability to attain or maintain adequate lubrication/genital swelling that causes distress. However, there are several problems with the way the DSM deals with sexual interest problems.

Disentangling Desire

First, women often do not differentiate between sexual desire and sexual arousal; the relationship between these factors and sexual behavior and satisfaction is far from straightforward. In addition, these variables interact differently for women and men. When a man has an erection, he often reports feeling sexually aroused. When a man is sexually aroused, he usually fantasizes about sex, masturbates, or seeks a sexual partner. Women, on the other hand, often do not show agreement among genital response, subjective evaluation, and behavior. For example, even when measurement devices used in research indicate increased genital blood flow and/or vaginal lubrication, the women being studied do not necessarily report being aroused. Sometimes, this is because they do not notice such physiological responses; however, even when they do notice them, women tend to use the context or situation as their guide for sexual feelings rather than genital response. Further, women may not necessarily engage in sexual behavior when they are aroused, but they may engage in sexual behavior when they are not aroused.¹

MODELING FEMALE DESIRE

An additional problem is that the DSM assumes a parallel construction for sexual dysfunction in men and women, which emphasizes physiological issues. As mentioned above, women’s sexuality is more often tied to other aspects (eg, relational context).² A different model of sexual response in women that does not “pathologize” low sexual interest has been proposed by Basson.³ This model begins with the assumption that women in longer-term relationships are not usually motivated to engage in sexual behavior by the release of sexual tension or other physical issues per se. Furthermore, many women operate in a state of sexual neutrality; a nonsexual trigger, such as the desire to please a partner or to establish intimacy, is often what prompts sexual behavior. Once engaging in sex, women become aroused, and it is at this point that they become aware of their desire to pursue sexual behavior for physical pleasure. Hence, desire is responsive rather than spontaneous. This is not to say that women do not have erotic thoughts or desires, but rather that after being in an established relationship (which is often accompanied by the increased demands of children and/or career), they may need a reminder “cue” to spark lustful desire. This model maintains that many women who are sexually functional and satisfied do not have conventional markers of sexual desire.

IDENTIFYING A PROBLEM

There are many reasons why a patient may have no sexual interest. If sex does not feel good, or it actually hurts, an assessment is warranted. The problem may be as simple as decreased lubrication due to hormonal fluctuations associated with childbirth or menopause. It could also be a sexual pain disorder (ie, dyspareunia) or related to a medical condition. If sex has never been enjoyable for a patient, she may need to become more familiar with her body. The Boston Women’s Health Book Collective Our Bodies, Ourselves is a good educational resource for such women. If a patient avoids sex because of negative attitudes about sex and/or a past traumatic experience, referring her to a therapist may help.

OTHER EXPLANATIONS

Certain interventions, such as selective serotonin reuptake inhibitors, oral contraceptives, and various recreational drugs, can negatively affect sexual desire. Other health conditions, such as depression, may decrease libido as well. Altered hormone levels are to blame in certain cases, but probably not many.
A common complaint among women is the incompatibility of their desire level and their partners’. Frequent sexual behavior occurring early in a relationship can mask differences in baseline desire. How often couples should want to have sex is not a question with a clear or consistent answer. Additionally, changing desire levels is not necessarily abnormal; high desire is not necessarily normal. Having a lower sexual drive than one’s partner may be something to be negotiated in the relationship.
Other factors in a patient’s life can alter desire levels. Preoccupation with other issues, the tolls that work and children exert on the patient’s energy, and emotional issues concerning the relationship are all relevant.

DISCUSSING PASSION

Some patients concerned about a perceived decrease in their libido may benefit from knowing that passion normally wanes in a relationship. Rising intimacy produces passion; however, as intimacy plateaus, desire tends to drop off.⁴ This is not an indication of sexual dysfunction. A sex therapist’s intervention may be helpful, but many times honest communication between partners will suffice.

REFERENCES

Laan E, Everaerd W. Determinants of female sexual arousal: psychophysiological theory and data. Ann Rev Sex Res VI. 1995;32-76.
Basson R. Rethinking low sexual desire in women. Br J Obstet Gynaecol. 2002;109(4):357-363.
Tiefer L, Hall M, Tavris C. Beyond dysfunction: a new view of women’s sexual problems. J Sex Marital Ther. 2002;28 (suppl):225-232.
Baumeister RF, Tice DM. The Social Dimension of Sex. Boston, Mass: Allyn and Bacon; 2001.