The most frequent phone call to my office begins with these seven dismaying words. Even young women say this. Hot women say this. In fact about 40 million women feel this.1 They all can’t be too busy for sex. Have you told your husband this? Has your wife told you this? Here’s how to analyze what’s going on.
The first time I heard those words from a client, I was flummoxed. It sounded so permanent; so hopeless. I’m sure their monogamous partner was devastated. But just like calculus seems impossible to understand, if you break it down and start with arithmetic you can figure out what is happening and solve the problems. In my experience with thousands of couples, a woman’s low libido can be understood. Most of the time, the couple can be helped to have loving sex at a frequency that makes both partners happier. The first step to healing low libido is discovering it’s foundation. Is the genesis of the low sexual desire inside the woman, in her self-image, in her sexual/relational history? Is sex caught between the couple in the power struggle? Have they enacted some withholding-greedy pattern that is trying to say something else but comes out in the bedroom? Is she actually more erotic than him but hides her knowledge in order to protect him from her criticism? Are there physiological problems that have caused pain and dryness? Or do the problems lay deeper in the unconscious, stemming from shame, trauma, or a toxic family of origin?
I’ve written a book Wanting Sex Again – How to Rediscover Desire and Heal a Sexless Marriage (Berkley Trade, Penquin) due out in less than a week to help couples figure out what is happening. It’s sex therapy in a book for the low libido woman.
In treatment, I often spend the first session or two determining when the low libido started and what is causing it. Here are some of the questions I ask the woman and her partner to help you begin to analyze their situation. Each section diagnoses a particular area contributing to the sexual disruption. For many women, there are several areas that are problematic.
1) The big O: Do you have orgasms? I want the woman who doesn’t experience orgasm (technically called anorgasmia) to be startled by the preeminence I put on this issue. Sex is about pleasure, sensation, passion and release. Certainly, women want more out of sex than a climax. But without a peak, their ache will diminish. Their arousal will become slower because the body is wise; it says, “Why should I go up that hill when there is nothing up there for me?” I educate both partners about just how long it takes a woman who has never had an orgasm to climax. I recommend a vibrator to help her experience a climax rapidly and with relative ease.
2) Pain problems: Do you have any pain during love-making or intercourse? Dryness, pain with intercourse, vaginal spasms, pain upon arousal, clitoral pain, pain post-cancer treatment – any and all of these can derail sex. It’s amazing to me how many women grit their teeth and keep having intercourse irrespective of it feeling like “sandpaper.” Most of the time, there is a physiological component to pain and recovery includes work with a gynecologist and a women’s health physical therapist. The disruption to a couple’s sex life may need sex therapy to design work-arounds and get love-making back on track. Menopausal symptoms are usually very treatable with hormones or natural remedies and do not have to interrupt a couple’s sex life. Typical diagnostic terms: vaginismus (spasms at the outer vaginal canal that prevent penetration and often consummation of the marriage), vestibulitis (pain at the entrance of the vagina often at the bottom arc of 4-7 o’clock if the vagina was a clock,) vulvadynia (pain anywhere in the vulva with or without arousal), dyspareunia (pain with intercourse) are almost all solvable or improvable. Don’t suffer one more day. Find a doctor specializing in pelvic pain and a sex therapist.
Sexual desire resides in a woman's imagination.
3) Imagination/fantasy: How often do you think about sex in a positive way in a month? A woman’s thoughts about sex may range from simple enjoyment of her partner’s morning hug, hearing a sexy song, seeing a show on TV that reminds her of good, positive, even former sexual feelings. Her fantasies don’t have to be about flesh on flesh. She may see a stranger and think he has nice legs or good hair. For the low libido woman, all these count in the positive column. If I hear the number “2” from a woman by way of answer, I’m hopeful. I know I can get the couple back on track sexually with a fair amount of ease. How? My goal is get her to act on at least one of these thoughts to initiate with her partner and allow receptive desire to carry the rest of the beginnings. One time she risks so her partner can feel wanted too and several other times a month using a slow build to arousal can increase frequency dramatically in sexless marriages. If her answer is 0, I’ll even capitalize on negative thoughts about sex like, “I hope he doesn’t want sex tonight.” At least sex is in her awareness. If she allows no thoughts about sex, we need to explore deeper issues about why she may be so shut down.
4) Marital issues: Does your partner respect you? Does your partner listen to you? Do you share the burden of life’s chores fairly? These questions are more effective than asking is a woman has a good marriage which can generate simple defensiveness. The quality of the couple connection is going to be very important to a woman with low desire, in fact for most women, emotional attachment is a cornerstone for continuing lust. The dynamics of the distancer and pursuer are often played out over control for sex. Each partner must learn how to change their steps so that sex is freed from the power struggle. For help in figuring out which one you are, please use my handout Pursuer-Distancer Continuum or read my personal favorite previous blogs on the sexual pursuer and the sexual distancer. I also want to know if they are attracted to their partner and if they think their partner is attracted to them. Are you afraid of your partner; does he have a temper? When did the sexual excitement change – at the altar? After the honeymoon? After the children came? With menopause or aging? Has either spouse been unfaithful?
5) Body issues:
What mood problems might be affecting sex? Are you depressed or anxious? Is the medication used to treat the mood disorder (like an SSRI) one that dampens sex? Any other medication or illness that might impact sex?
Are you on birth control pills? BCPs are notorious at lowering libido and developing vaginal dryness or pain.
How did pregnancy and delivery change your body and vagina? Did you suffer post-partum depression? Do you allow yourself to be a sexy mama? Have both you and your husband started focusing exclusively on the needs of the children?
Are you menopausal and adequately treated for any sexually associated changes? Many menopausal women experience symptoms that interrupt sex: night sweats that leave them tired, reduction of testosterone and estrogen production that changes their craving-sex feelings, vaginal dryness and atrophy, etc. Women report more distress over their low libido in this age group of 45-60.2
Are you a breast cancer or gynecological cancer survivor? Is your self-image damaged due to the loss of a breast (the most highly visible and culturally esteemed symbol of femininity.) What cancer treatment was used and how is it affecting your sexual recovery? Were you even told that your treatment (chemotherapy, drug therapy, radiation) would impact your sexual life?
Is her husband a survivor of prostate cancer? Does he suffer any other physiological sexual dysfunction?
6) Eroticism: Is sex sexy? Do you have fun in bed once you get going? Or has sex devolved to getting ready, turning down the sheets, doing it, cleaning up, getting back in bed, going to sleep? Has sex become BORING? Are either you creative enough to inspire a thrill? I ask about her partner’s technique. How long does the whole thing last? How long does he touch her clitoris? Have you been more erotic in previous relationships? Does your partner have poor technique? How much courage have you exercised in talking about what you really need to get excited and reach orgasm? Are the partners tactful and kind when they discuss their needs in bed?
7) Frequency: How many times a week do you have sex? A month? A year? In listening to the reply I still am thinking about the quality of their bond - does she give one answer to this question and does he give another? A low libido woman might say it happens every week. Her husband will reply, “No, not on the week of your period and last month we didn’t do it the week your mother was visiting either.” If they can’t agree on how often it happens, this tells me that their relationship is fairly disrupted. Often partners want me to know that it is not simply a matter of getting more sex, but a matter of having sex where she is an involved, desirous partner. But very low frequency is an indicator of trouble in bed. Sometimes her partner has unreasonable expectations for frequency; her normal libido has been labeled dysfunctional because of the mismatch. Feeling sexually starved or sexually drowned cannot be resolved by simply finding the mid-point. Each partner must have empathy and deep understanding for the needs of the other when it comes to quantity.
8) Sexual History: What was your first sex experience like? Was it with someone you cared about and who was tender? Did you just get rid of your virginity like it was a burden? Did you masturbate in childhood and was it acceptable in your family? Did a parent tell you the facts of life? What were the teenage rules about acceptable sexual expression in your family? Does any particular genital or body part of yourself or your partner cause you to shudder when looking, touching, or talking about it? Did religion and faith play a role in the formation of your erotic self; was the message about sex a blessing or an evil? What was the romantic triumph or tragedy of your parent’s marriage? Was there alcoholism, adultery, addiction, anger in your family of origin? Is there a history of trauma, molestation, date rape, or violent rape?
While these questions do not cover every possible origin of low libido, they often start an important conversation about when it started and what area might be the place to begin solving it.
1,2 Schifren J, Monz B, Russo P et al. Sexual problems and distress in United States women: prevalence and correlates. Obstetrics and Gynecology; Volume 112, No. 5, Nov 2008:970-978
I’ve written a book Wanting Sex Again – How to Rediscover Desire and Heal a Sexless Marriage (Berkley Trade, Penquin) due out in less than a week to help couples figure out what is happening. It’s sex therapy in a book for the low libido woman.
In treatment, I often spend the first session or two determining when the low libido started and what is causing it. Here are some of the questions I ask the woman and her partner to help you begin to analyze their situation. Each section diagnoses a particular area contributing to the sexual disruption. For many women, there are several areas that are problematic.
1) The big O: Do you have orgasms? I want the woman who doesn’t experience orgasm (technically called anorgasmia) to be startled by the preeminence I put on this issue. Sex is about pleasure, sensation, passion and release. Certainly, women want more out of sex than a climax. But without a peak, their ache will diminish. Their arousal will become slower because the body is wise; it says, “Why should I go up that hill when there is nothing up there for me?” I educate both partners about just how long it takes a woman who has never had an orgasm to climax. I recommend a vibrator to help her experience a climax rapidly and with relative ease.
2) Pain problems: Do you have any pain during love-making or intercourse? Dryness, pain with intercourse, vaginal spasms, pain upon arousal, clitoral pain, pain post-cancer treatment – any and all of these can derail sex. It’s amazing to me how many women grit their teeth and keep having intercourse irrespective of it feeling like “sandpaper.” Most of the time, there is a physiological component to pain and recovery includes work with a gynecologist and a women’s health physical therapist. The disruption to a couple’s sex life may need sex therapy to design work-arounds and get love-making back on track. Menopausal symptoms are usually very treatable with hormones or natural remedies and do not have to interrupt a couple’s sex life. Typical diagnostic terms: vaginismus (spasms at the outer vaginal canal that prevent penetration and often consummation of the marriage), vestibulitis (pain at the entrance of the vagina often at the bottom arc of 4-7 o’clock if the vagina was a clock,) vulvadynia (pain anywhere in the vulva with or without arousal), dyspareunia (pain with intercourse) are almost all solvable or improvable. Don’t suffer one more day. Find a doctor specializing in pelvic pain and a sex therapist.
Sexual desire resides in a woman's imagination.
3) Imagination/fantasy: How often do you think about sex in a positive way in a month? A woman’s thoughts about sex may range from simple enjoyment of her partner’s morning hug, hearing a sexy song, seeing a show on TV that reminds her of good, positive, even former sexual feelings. Her fantasies don’t have to be about flesh on flesh. She may see a stranger and think he has nice legs or good hair. For the low libido woman, all these count in the positive column. If I hear the number “2” from a woman by way of answer, I’m hopeful. I know I can get the couple back on track sexually with a fair amount of ease. How? My goal is get her to act on at least one of these thoughts to initiate with her partner and allow receptive desire to carry the rest of the beginnings. One time she risks so her partner can feel wanted too and several other times a month using a slow build to arousal can increase frequency dramatically in sexless marriages. If her answer is 0, I’ll even capitalize on negative thoughts about sex like, “I hope he doesn’t want sex tonight.” At least sex is in her awareness. If she allows no thoughts about sex, we need to explore deeper issues about why she may be so shut down.
4) Marital issues: Does your partner respect you? Does your partner listen to you? Do you share the burden of life’s chores fairly? These questions are more effective than asking is a woman has a good marriage which can generate simple defensiveness. The quality of the couple connection is going to be very important to a woman with low desire, in fact for most women, emotional attachment is a cornerstone for continuing lust. The dynamics of the distancer and pursuer are often played out over control for sex. Each partner must learn how to change their steps so that sex is freed from the power struggle. For help in figuring out which one you are, please use my handout Pursuer-Distancer Continuum or read my personal favorite previous blogs on the sexual pursuer and the sexual distancer. I also want to know if they are attracted to their partner and if they think their partner is attracted to them. Are you afraid of your partner; does he have a temper? When did the sexual excitement change – at the altar? After the honeymoon? After the children came? With menopause or aging? Has either spouse been unfaithful?
5) Body issues:
What mood problems might be affecting sex? Are you depressed or anxious? Is the medication used to treat the mood disorder (like an SSRI) one that dampens sex? Any other medication or illness that might impact sex?
Are you on birth control pills? BCPs are notorious at lowering libido and developing vaginal dryness or pain.
How did pregnancy and delivery change your body and vagina? Did you suffer post-partum depression? Do you allow yourself to be a sexy mama? Have both you and your husband started focusing exclusively on the needs of the children?
Are you menopausal and adequately treated for any sexually associated changes? Many menopausal women experience symptoms that interrupt sex: night sweats that leave them tired, reduction of testosterone and estrogen production that changes their craving-sex feelings, vaginal dryness and atrophy, etc. Women report more distress over their low libido in this age group of 45-60.2
Are you a breast cancer or gynecological cancer survivor? Is your self-image damaged due to the loss of a breast (the most highly visible and culturally esteemed symbol of femininity.) What cancer treatment was used and how is it affecting your sexual recovery? Were you even told that your treatment (chemotherapy, drug therapy, radiation) would impact your sexual life?
Is her husband a survivor of prostate cancer? Does he suffer any other physiological sexual dysfunction?
6) Eroticism: Is sex sexy? Do you have fun in bed once you get going? Or has sex devolved to getting ready, turning down the sheets, doing it, cleaning up, getting back in bed, going to sleep? Has sex become BORING? Are either you creative enough to inspire a thrill? I ask about her partner’s technique. How long does the whole thing last? How long does he touch her clitoris? Have you been more erotic in previous relationships? Does your partner have poor technique? How much courage have you exercised in talking about what you really need to get excited and reach orgasm? Are the partners tactful and kind when they discuss their needs in bed?
7) Frequency: How many times a week do you have sex? A month? A year? In listening to the reply I still am thinking about the quality of their bond - does she give one answer to this question and does he give another? A low libido woman might say it happens every week. Her husband will reply, “No, not on the week of your period and last month we didn’t do it the week your mother was visiting either.” If they can’t agree on how often it happens, this tells me that their relationship is fairly disrupted. Often partners want me to know that it is not simply a matter of getting more sex, but a matter of having sex where she is an involved, desirous partner. But very low frequency is an indicator of trouble in bed. Sometimes her partner has unreasonable expectations for frequency; her normal libido has been labeled dysfunctional because of the mismatch. Feeling sexually starved or sexually drowned cannot be resolved by simply finding the mid-point. Each partner must have empathy and deep understanding for the needs of the other when it comes to quantity.
8) Sexual History: What was your first sex experience like? Was it with someone you cared about and who was tender? Did you just get rid of your virginity like it was a burden? Did you masturbate in childhood and was it acceptable in your family? Did a parent tell you the facts of life? What were the teenage rules about acceptable sexual expression in your family? Does any particular genital or body part of yourself or your partner cause you to shudder when looking, touching, or talking about it? Did religion and faith play a role in the formation of your erotic self; was the message about sex a blessing or an evil? What was the romantic triumph or tragedy of your parent’s marriage? Was there alcoholism, adultery, addiction, anger in your family of origin? Is there a history of trauma, molestation, date rape, or violent rape?
While these questions do not cover every possible origin of low libido, they often start an important conversation about when it started and what area might be the place to begin solving it.
1,2 Schifren J, Monz B, Russo P et al. Sexual problems and distress in United States women: prevalence and correlates. Obstetrics and Gynecology; Volume 112, No. 5, Nov 2008:970-978
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