Sexual desire problems are among the most common problems seen in a therapist’s office, and these can be among the most difficult sexual issues to address. According to Psychology Today (Oct. 2006), a condition known as hypoactive sexual desire (HSD) occurs in perhaps 20% of the population, more frequently in women, although both men and women are affected.

There are many possible causes of desire problems, both physical and psychological, the causes may overlap, and sorting through them can be time consuming and frustrating, particularly if one partner wants the problem remedied quickly. The sex counselor or therapist is often expected to have a magic cure, even for on-going problems that have persisted over time.

Typically a couple will present complaining of differences in sexual desire, in other words, a “desire discrepancy.” The most difficulty arises in couples with the greatest polarity in amounts of desire—one person may want some type of sexual activity one or more times a day, whereas the other may be content with sexual expression once a week, once a month, or even less frequently (perhaps never).

These differences in desire often result in shame and anger in both members of the couple. The low desire person may feel shame that s/he is inadequate and/or angry about feeling used and about the partner’s perceived insensitivity. The high desire person may feel unloved, undesirable, and angry at having to “beg” for sex. Blame and a sense of hopelessness abound on both sides, with the high desire person often feeling betrayed and saying, “When we first got together, s/he really liked sex, and then after we’d been together for a while it [her/his desire] went away.”

Indeed there is an old saying that, “As soon as we got married, things changed,” suggesting in some instances that the partner had only feigned sexual interest until s/he got what s/he wanted, i.e. marriage. On the other hand, the lower desire person may begin to feel used and that the partner is “overly sexed” and is only interested in him/her for the purpose of having sex.

A list of common causes of desire problems is presented below. Each of the causes will be discussed.

CAUSES OF DESIRE PROBLEMS

1. Differences in baseline sexual desire
2. Fatigue
3. Sex-negative religious orthodoxy
4. Depression (with or without anhedonia)
5. Phobias or aversions
6. Triggering of childhood trauma, rape, etc.
7. Fear of loss of control over sexual urges
8. Hidden sexual deviation
9. Fear of pregnancy
10. Widower's or Widow’s Syndrome
11. Hormones and neurotransmitters
12. Medications
13. Lifestyle Issues
14. Aging
15. Relationship issues
a. Lack of attraction to partner
b. Poor social and relationship skills
c. Fear of closeness ----> vulnerability
d. Passive-aggressive issues
e. Marital conflict
f. Madonna-Prostitute Syndrome
16. Medical, Surgical, and Disabling Conditions
1. Differences in baseline sexual desire

An excellent resource for learning about differences in baseline sexual desire and addressing these differences in relationships is the work of Dr. Pat Love. Dr. Love stays on the cutting edge of research in the psychology and biology of desire and presents compelling information that our sexual desire is likely “rooted, to a large degree, in powerful, biochemical processes that have little to do with how attractive couples find one another or how much they care for each other” (Love, 1999, p. 36).

Findings in the emerging fields of behavioral endocrinology and psychophysiology suggest that there is a biological basis to the intense attraction we feel in the beginning stages of a new relationship—the time when we can hardly stand to be apart, when this new person is the most wonderful human being on the planet, and we feel enlivened and exhilarated when we are with him/her.

Dr. Love states, “Some scientists now believe that the frenzied euphoria of romantic love may well be a bona fide, altered state of consciousness, primarily brought on by the action of phenylethylamine (PEA), a naturally occurring, amphetamine-like neurotransmitter.

Michael Liebowitz, a research psychiatrist at the New York State Psychiatric Institute, believes that when we come into contact with a person who highly attracts us, our brains become saturated with a ‘love cocktail’ comprised of PEA and several other excitatory neurotransmitters, including dopamine. This chemical brain-bath theory explains why new lovers can talk till dawn, make love for hours on end, lose weight without trying and feel so outrageously, unquenchably optimistic. Their neurons are soaking in natural speed” (Love, 1999, p. 37).

We hope, and some may expect, this state of romantic love and attraction will last, perhaps forever. After a time of being together however, typically 18 to 36 months, we begin to experience a lessening in desire, and this decrease may seem to occur to a greater degree primarily in one partner. We are left to wonder what happened.

For years we have known that men and women both produce testosterone and that testosterone is highly correlated with male libido. It has only been in recent years, however, that the role of testosterone in women’s libido has been studied, and a large body of psychoendocrinological research has established that libido requires a significant supply of testosterone in women as well as in men (Love, 1999).

Some men as well as women have high testosterone—“high-T” men and women, while others of both genders have low testosterone—“low-T” men and women.

(Note: The desire gap occurs in same sex couples also.)

“It is during the infatuation stage that the two major components of the biology of desire—the time-limited PEA factor and T-level mismatches—collide to create sexual catastrophe for many couples” (Love, 1999, p. 39). Initially the elevated PEA serves to keep sexual desire levels high and both partners exhilarated. After the PEA diminishes, however, the natural desire levels return to what the testosterone levels make available.

If the partners are mismatched in terms of testosterone levels, problems begin to surface, and the greater the degree of mismatch, the greater the number and frequency of potential problems (Love, 1999).

By the time couples come to the therapist’s office, they are often locked in a downward spiral of disappointment, shame, anger, and hopelessness and want the therapist to do something to create a quick reversal in the situation. Couples frequently have been to other therapists who focused on communication and injecting novelty into the sexual repertoire, and when these techniques failed to help, they have become discouraged and disheartened about their situation.

In the beginning session, the therapist can actually begin to give hope by presenting the biological information related to PEA and testosterone. The author has found that when the situation is normalized and partners can begin to get a better understanding of the probable biological influences on what is happening, their frustration and anger often lessen and they may begin to see a glimmer of hope for themselves and for the relationship. While there will likely be much work still to do in re-establishing the emotional and sexual connection, the seeds of hope are planted.

Even though couples may accept the explanation that their differences in desire have a biological basis, the next question may be, “So what? Is there anything we can do about it, or is this the way it’s always going to be?” The ultimate answer, given that PEA-spiked desire is gone, is that future sexual intimacy will have to be consciously created.

Love (1999) describes asking one couple to share with each other what kind of sexual-emotional activity would feel most loving and satisfying to them. The husband asked for a periodic 15-minute session of sex that gave him both a physical release and the feeling that his wife cared for him, and the wife asked for regular, leisurely massages from her husband, which might or might not culminate in intercourse, depending on her wishes. If these activities have positive outcomes, the groundwork is laid for future intimacy and greater emotional connection.

Incorporating desire education into therapy can serve to reassure couples and can also give a more complete focus as well as an effectiveness boost to traditional sex therapy techniques and methods focused on increasing communication effectiveness. Desire education avoids the medicalization of sex that frequently occurs with the use of terms such as “hypoactive sexual desire.”

In addition, desire education may eliminate the expectation that once relationship issues are successfully resolved, great sex will follow as a result.

Even in loving relationships, “hormonally mediated desire gaps exist between partners, and their ultimate erotic satisfaction will depend on a steady, vigilant effort to sustain their sexual connection. A couple’s work will involve each partner’s ‘stretching’ to understand, to empathize with and to accommodate the other’s unique experience of passion” (Love, 1999, p. 43). This is an ongoing relationship process that requires consciousness and commitment.

As an aside, “high-T” men in our society have been referred to as “lusty,” “studs,” “macho,” “real men,” while “high-T” women have been called “sluts,” “whores,” and “nymphomaniacs.” Our culture perpetuates the gender stereotypes in terms of sexual desire, with men portrayed as “always being ready,” and women having “headaches.”

When a man has less desire (possibly due to “low T”), and when he is the one with the “headache,” this is seen as outside the norm, and the dynamics in the relationship incorporate other, unforeseen issues. In these cases a female partner will often think one of three things: 1) I’m not attractive to him anymore, 2) he’s having an affair, or 3) he must be gay.

2. Fatigue

Fatigue from living in a fast-paced world and coping with the demands of careers and family often seem to sap the energy in many areas of life, including sexual expression. The magnitude of this issue was illustrated by a cover story in Newsweek Magazine a few years ago that showed a couple lying beside each other in bed—he was working on a computer, and she was eating ice cream. The caption read, “No Sex, Please, We’re Married” (Deveny, 2003; Jong, 2003).

3. Sex-negative religious orthodoxy

Religious orthodoxy that has fostered sex-negative attitudes can lead to many types of sexual problems including a lack of desire. It is important for therapists to ascertain the religious climate in the family of origin and to explore messages about sexuality that the client received from parents and significant others, including religious leaders. Negative messages can exact a potent long-term impact on individuals’ sexuality. Fears of invoking punishment from God as well as from parents can lead to blunting of sexual feelings and shutting down of sexual expression.

Since its beginnings as a country, the United States has had idiosyncrasies about sexuality. While sexual images appear seemingly everywhere in advertising and in media offerings, North Americans generally do not speak about the topic in ways that promote an accurate exchange of information, open questioning, or helpful exploration of issues.

4. Depression (with or without Anhedonia)

Depression generally has negative effects on sexual desire, particularly if the depression is severe and includes a hallmark symptom of clinical depression, i.e., anhedonia. Defined as the inability to experience pleasure, anhedonia has a direct impact on sexuality. One key question in assessing the degree of depression is to ask, “When was the last time you had a moment of pure joy?” You may get the response, “I don’t remember,” perhaps followed by tearfulness.

In addition to the anhedonia that accompanies depression, for many in this society, there seems to be an injunction against receiving pleasure, particularly in the area of sexuality. As professionals it is important to explore the role of pleasure and the reactions this brings up in clients.

While sexual interest and response are generally thought to decline in states of negative mood and depression, a recent study reported that some men were actually drawn to sexual experiences for contact or validation — “to get my mind off things…I’m looking for energy…I will get happier if I make her happier” (Bancroft, Janssen, Strong, Carnes, Vukadinovic, & Long, 2003).

Another study found a similar phenomenon in a small percentage of women (Lykins, Janssen, & Graham, 2006). This illustrates again that sexuality and sexual expression have a range of meanings, that individuals are diverse, and that psychosocial variables have differing impacts.

5. Phobias or aversions

Some people have phobias or aversions (even to the point of panic) to sexual contact of any kind, and others feel disgust and anxiety about specific types of sexual behaviors. While activities such as hugging, kissing, and cuddling may be enjoyed by some, for others even these types of touching are viewed as repellent.

One partner may consider the other partner’s requests for a specific activity to be abnormal and may wonder if the behaviors will progress and how far they might go. In some cases, the assessment interview may reveal a history of sexual abuse or other type of trauma, or the client may have experienced negative, fear-inducing messages while growing up.

The healthcare generalist would have to be aware of his/her ability to address such issues or consider referral to a sex therapist. The therapist’s task is to work with the individual and the couple to foster an understanding of what is happening, to set goals both individually and as a couple, and to begin some at home exercises that will promote greater connectedness, emotionally and physically.

It is important for clients to: 1) move at their own pace and not be rushed and 2) be in control of what is happening in touching interactions.

It is also important to note that there may be some sexual activities that one partner enjoys that are not acceptable to the other, and this may be related to personal preference and not to any type of phobia. As with other types of differences that couples experience, communication and empathy are key to a satisfactory outcome.

6. Triggering of childhood trauma

For individuals who were traumatized as children through some type of sexual victimization, sexual activity of a particular type (or any type) may recreate the feelings and reactions of the past. Also, a change in family dynamics may bring up past issues that were thought to be unrelated (recall the woman whose past unresolved issues were triggered by the birth of a child).

7. Fear of loss of control over sexual urges

Some individuals fear the full expression of their sexuality and worry that if they allow themselves to be sexual, they may lose control of their thoughts, feelings and behaviors.

8. Hidden sexual deviation

The definition of sexual deviation has changed over time, varies from society to society, and remains a topic of controversy. Behaviors that were once considered deviant, such as masturbation, are today considered harmless or even beneficial. Today, nontraditional sexual behavior is generally referred to as sexual deviation. In cases where the specific object of arousal is unusual, the sexual behavior is referred to as paraphilia.

Clinicians distinguish between optional, preferred, and exclusive paraphilias. Sexual arousal patterns that depend exclusively on paraphilias often preclude committed romantic relationships. If a sexual deviation causes interpersonal or relationship problems, individuals may bring themselves in for therapy.

If, on the other hand, sexual behaviors become societally problematic as in the case of sex offending, individuals may be mandated by a court of law to receive treatment.

Because the newest Statistical and Diagnostic Manual, the DSM-5, has had a major revision to how sexual deviation is viewed, this topic will be expanded upon later in this module.

9. Fear of pregnancy

People with this fear may relate stories they have heard about women who became pregnant while using the most proven methods of birth control and, perhaps, while using two or three concurrent methods. This fear can manifest as a desire problem, particularly in women, and as an inability to ejaculate or to very rapid ejaculation (outside the vagina) in men.

10. Widower’s or Widow’s Syndrome

Widower's Syndrome usually affects a man in his mid-to-late 50s who has been voluntarily celibate for a year or more, often following the death of a spouse. When he finds a new partner, the man (who usually has no history of prior sexual problem), simply cannot achieve or maintain an erection.

Guilt or anxiety may contribute to the development of psychogenic erectile dysfunction. The trauma arising from this single episode of totally unexpected failure after a long period of celibacy may lead to partial or complete erection difficulty (ED).

Women who have been widowed can experience similar complications of celibacy. Often the celibacy is complicated by menopause. For the woman in her mid-50s or beyond, there are significant vaginal changes in elasticity, lubrication, and integrity of the vaginal walls. A year or more without sexual intercourse can set the woman up for pain with penetration, and a loss of desire can result from such repeated negative sexual experiences.

11. Hormones and Neurotransmitters

Hormones

Measuring Hormone Levels

Blood tests commonly used to determine hormone levels measure the total amount of hormones in the blood and not the protein-bound, inactive form of the hormone. Hormone levels measured in this way may appear to be normal when in reality deficiencies exist in the free and biologically active form.

As explained by Taylor and Taylor (2000), “Blood measurement gives you the number of Fed-Ex trucks in the blood and doesn’t tell you how many packages are being delivered.” Many practitioners are now using saliva testing to get a more accurate reading of free and active levels of hormones.

Low levels of free testosterone and dehydroepiandrosterone (DHEA), elevated prolactin, elevated serotonin, and low dopamine may cause or contribute to decreased sexual desire in both men and women. Low testosterone levels, particularly low levels of “free” i.e. bioavailable testosterone, can negatively impact sexual desire.

Free testosterone refers to the testosterone that is not bound to carrier proteins, in particular the protein Sex Hormone Binding Globulin (SHBG). Free testosterone is able to act directly upon target tissues to impact sexual desire. Concentrations of free serum testosterone levels decline with aging in men and women and may also be affected by chronic illness (including heart disease), infection, smoking, trauma, and other factors. (Lichten, 2000).

Men between the ages of 40 and 55 can experience a phenomenon similar to menopause in women, although there is no clear-cut sign such as menstrual cessation to indicate this is occurring. This phenomenon, known as andropause (aka male menopause), occurs as a result of decreasing testosterone, and typically occurs so gradually that individuals may not realize what is happening.

Symptoms may include lethargy or decreased energy, decreased libido or interest in sex, muscle weakness and aches, a loss of physical agility, inability to sleep, hot flashes, night sweats, depression, infertility, and thinning of bones or bone loss (Gearon, 2008).

Testosterone

While testosterone replacement has been shown in some studies to increase levels of sexual desire in both men and women, the decision to institute testosterone replacement therapy remains a complex and controversial practice. There is some concern about its use due to a possible risk of potentiating cancer and heart disease and also of causing masculinizing effects in women.

In addition, oral preparations have the potential risks of liver toxicity and raising levels of bad cholesterol. Some experts advise that testosterone replacement is best instituted only after an initial assessment of bioavailable levels of the hormone to establish clinical need. Others state that androgen deficiency, particularly in women, is difficult to diagnose via lab tests and is better determined by symptomatology and clinical presentation.

Testosterone therapy in women for limited periods of time may be of benefit, but safety of long term use has not been established. Testosterone replacement is available in the form of intramuscular preparations, transdermal delivery systems (patch or gel), subcutaneously implanted pellets, and transbuccal or sublingual forms. Involvement of a knowledgeable physician is strongly encouraged. (Johns Hopkins Health Alert, 2007).

Sources for Testosterone Replacement in Men

The following information related to androgen deficiency and testosterone replacement in men is taken in totality from Handelsman and Zajac (2004).

a) Androgen deficiency is a clinical diagnosis confirmed by hormone assays.
b) Among younger men, androgen deficiency is usually due to underlying hypothalamopituitary or testicular disorders.
c) Androgen replacement therapy should be started after proof of androgen deficiency and should continue lifelong with monitoring.
d) Men presenting with erectile dysfunction should be evaluated for androgen deficiency, but it is an uncommon cause; if overt androgen deficiency is confirmed, an underlying disorder needs further specialist investigation.
e) In the absence of characteristic underlying testicular or pituitary disorders, new diagnosis of androgen deficiency in older men is difficult because of the non-specific symptoms and the decline in blood testosterone levels seen in healthy aging and chronic medical disorders.

Note: There remains no convincing evidence that androgen therapy is either effective treatment or safe for older men unless they have frank androgen deficiency. And, while androgen replacement therapy is effective in overt deficiency, it is not an anti-aging elixir.

DHEA

Dehydroepiandrosterone, or DHEA, produced by the adrenal glands, is a steroid hormone, a chemical cousin of testosterone and estrogen. It circulates in the bloodstream as DHEA-sulfate (DHEAS) and is converted as needed into other hormones. DHEA can be called the adrenal stress, immunity, and longevity hormone.

Current research indicates that low sexual desire and arousal are common among women and that measurement of DHEA may be a better indicator of sexual dysfunction in young women than measurement of testosterone. Providing supplemental DHEA for women with low sexual desire, both younger and older women, is currently being studied with encouraging results being reported.

In addition to increased satisfaction with sexuality, women given DHEA showed reduced scores for depression, anxiety, hostility, and obsessive-compulsive traits and higher levels of general well being (Arlt, et al., 2000).

Despite the possible benefits of DHEA, researchers have also found that too much DHEA can be harmful to some older women, possibly leading to death. Conflicting study results and the lack of studies on the long-term effects of DHEA support the importance of close medical monitoring of individuals taking any type of supplementation (Natural Standard Patient Monograph, 2008; Nair, et al., 2006).

The bulk of the research does definitively show that low desire has much to do with the context in which it occurs and that it is rarely (if ever) related only to hormones. However, there are many situations in which hormonal considerations and approaches are an appropriate part of a comprehensive treatment plan.

Neurotransmitters

Dopamine is the neurotransmitter in the mesolimbic "pleasure center" of the brain. Increasing dopaminergic activity may enhance sexual response, while blocking it may have negative influences on response. Dopamine controls the release of the hormone prolactin from the pituitary gland; therefore, a reduction in dopamine results in an increase in prolactin.

Another neurotransmitter, serotonin, can also negatively impact sexual response. There is a reciprocal relationship between serotonin and dopamine: serotonin can diminish the release of dopamine in the mesolimbic area, thus decreasing sexual response. Serotonin also stimulates prolactin secretion.

Drugs that increase serotonergic activity, such as the SSRI antidepressants (Prozac, Zoloft, Paxil, Celexa) are most commonly associated with decreased libido, delayed ejaculation in men, and anorgasmia in men and women. The use of Bupropion (Wellbutrin) and mirtazapine (Remeron) as monotherapies in the treatment of depression specifically minimize the risk of sexual dysfunction, and their mechanisms may reverse sexual symptoms caused by serotonin agonists (Fredman and Rosenbaum, 2003).

Supplements Purported to Increase Sexual Desire

Several herbal substances on the market today profess an ability to increase sexual desire in women and also to improve other variables in sexual functioning. These include Yohimbine, derived from the bark of the African yohimbe tree; Gingko Biloba extracts from the leaves of the Ginkgo biloba tree; Ginseng, a species of plants; ArginMax, a nutritional supplement; Zestra, an arousal oil that claims to reverse side effects of SSRI antidepressant medications; and Avlimil, an herbal pill.

Study results on Yohimbine, though not entirely clear, show possible positive effects in counteracting antidepressant-induced anorgasmia (Segraves, 1995) and also in having an “aphrodisiac effect” (Hollander & McCarley, 1992).

Gingko extracts were found to have beneficial effects on libido, arousal, and orgasm in women and men (Cohen & Bartlik, 1998). Ginseng has been shown to have aphrodisiac properties (Spinella, 2001). A study of ArginMax found significant improvements in women in the areas of sexual desire, reduction of vaginal dryness, frequency of sexual intercourse, and orgasm (Ito, Trant, & Polan, 2001).

Results from a study on Zestra (Ferguson et al., 2003) showed significant improvement in several of the variables (including desire) tested in women.
To date, study results for Avlimil have not been found in peer reviewed journals, but anecdotal reports from some patients who use this supplement indicate it is effective for them—others notice no significant changes.

At a recent teaching conference, a PharmD talked about Avlimil, stating that neurotoxins in salvia, the primary ingredient in Avlimil, can cause nausea, vomiting, and hallucinations and it is definitely not recommended in pregnant patients.

Clients considering taking any of the supplements should consult with a knowledgeable healthcare provider, as these substances may have undesired side effects and can also interact, sometimes in negative ways, with medications people may be taking.

12. Medications

Relationships between and among hormones, neurotransmitters, and medications are discussed in #11. Clinicians of all disciplines are increasingly being called on to counsel patients regarding psychotropic drug-induced sexual dysfunction.

Virtually all of these drugs have been reported to cause difficulties with desire, arousal, and orgasm, and distinguishing true drug-induced sexual dysfunction from a myriad of other possible causes is difficult. Educating patients about possible problems with medications and working with them to address sexuality-related side effects can reduce the possibility of patients’ decreasing their dosage or discontinuing pharmacologic treatment altogether.

13. Lifestyle issues

Alcohol, marijuana, or other drug use, lack of exercise, poor nutrition, being overweight, and other negative health habits may well be contributory factors in the reduction of sexual desire.

14. Aging

In the not too distant past, sexuality and aging were considered mutually exclusive, and sexual activity and enjoyment were seen as the domain of the young, healthy, and vigorous. The first reliable study on sex and aging did not appear until Masters and Johnson published their work in 1966.

Even today many people believe that sexual feelings and sexual expression are supposed to end at some point as people get older, and this idea is alive and well among healthcare providers as well as among the lay community. Recently at a seminar on sex and aging at a local geriatric care facility, one of the nurses remarked, “I think there are just some things that are supposed to end as you get older, and I think sex is one of them. So I’m probably not going to bring up the topic with any of our patients.”

Contrary to what some may believe, most men and women do not lose their need and desire for sex as they age. In fact, many seniors report that sexual experiences are enhanced with age.

Research has found that regular sexual activity is standard when a partner is available, that sexual practices are varied and include masturbation and oral sex in addition to intercourse, and that most elderly believe that sex contributes to both physical and psychological health. Other studies have shown that physical capacity for male erection and for male and female orgasm continue almost indefinitely and that achieving orgasm is desired, although not always achieved Sinclair Intimacy Institute, 2002b).

Note: With sexual activity there is a “use it or lose it” phenomenon. Continued sexual activity helps preserve successful sexuality by keeping the sexual response viable and also by helping to maintain the integrity of the vaginal walls.

Note: Seniors are often unaware that they are at risk for all types of STI infections, including HIV, and the proportion of older individuals infected with HIV is increasing.

Because of a lack of knowledge and self-perceived risk, seniors often do not practice safer sex behaviors. Also, HIV infections in this age group are frequently undiagnosed.

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