Low Libido - Treating Common Sexual Problems: Womens Sexual Health

Content provided by the Faculty of the Harvard Medical School

Low libido

Diminished sex drive is the most common and the most elusive sexual dysfunction. According to a 1994 landmark study of sexuality in America conducted by University of Chicago researchers, 33% of women and 16% of men reported they had gone through periods of several months when they had no interest in sex. A particularly challenging aspect of the problem is that it often exists along with one or more other sexual dysfunctions. For example, a woman who experiences painful intercourse will understandably shy away from sexual activity.

What is desire?

To determine what constitutes low libido, it's important to first understand the nature of desire. Desire can be dissected into three parts: sexual drive, sexual wish, and sexual motive. Sexual drive is a hormone-dependent impulse for sexual release. It can manifest itself as a longing to reproduce or to have sex, erotic thoughts or dreams, or an urge to masturbate. Sexual wish is the willingness to have sex. Even if an individual's physiological need for sex is weak, he or she may wish to participate in the activity to feel more connected to another person, to feel more masculine or feminine, or to feel more physically energetic. Sexual motive is the combination of factors that impel a person to want sex. All three of these elements have to be taken into account when examining libido problems. Of all the forms of sexual dysfunction, low desire is the most complex and challenging to treat.

Defining low libido is quite subjective. There are no physical signs to measure, and libido varies widely from person to person, with age, sex, and personality all playing a role. Medically, low libido is defined as the absence of sexual fantasies or a lack of desire for sexual activity that causes personal distress. However, this too can be variable. Because there's a range of desire levels within "normal" libido, differing amounts of sexual interest can create tension in a relationship, even if the person with the lower libido has some sex drive.

To complicate matters, female desire has been historically misunderstood. Researchers have questioned the assumption that libido manifests itself in the same way in women as in men. They propose that while men's desire is driven by the goal of intercourse and orgasm, women's desire is mostly driven by the need for intimacy. In addition, some women may need to be physically aroused before feeling desire.

Age is also a factor, as desire tends to wane with age. It can flag in midlife for a variety of reasons — some physical, some emotional. Hallmarks of aging such as declining hormones and lifestyle and relationship transitions can all affect a person's sex drive. So too can illness and the presence of other sexual problems, such as erectile dysfunction or vaginal dryness. Of course, if a lower sex drive isn't bothersome to the people involved, then they need not take any action. If diminished sex drive is troublesome, though, treatment is available.

Diagnosing low libido

When evaluating a loss of sexual desire, your doctor will first look for physical causes. Any of a number of chronic medical conditions can impinge on desire (see "Sexuality and health problems"). So, too, can a variety of treatments and dozens of prescription medications. The emotional effects of almost any chronic disease — such as frustration, depression, anger, fear of death, and altered body image — can indirectly lead to the loss of desire. In women, low libido may stem from dyspareunia, or chronic vaginal pain.

If there are no obvious physical reasons for low libido, your doctor will explore your attitudes about sex and your partner. One important distinction to be made is whether the problem is a lifelong lack of desire, a more recent loss of interest, or a problem that occurs only with a particular partner or in a certain situation. Sometimes, a history of physical or sexual abuse can manifest as low libido (or an aversion to sex) that may not show up until after the person has married or had children.

A lifelong history of low libido is extremely challenging to treat because the problem often stems from underlying issues that are complex and deeply ingrained. Also, someone who has been interested in sex in the past has a better concept of what he or she might be missing.

If your libido has dropped, your doctor will focus on the point when the change occurred and explore potential causes. He or she will look at changes in hormone levels from menopause or aging and ask about your relationship with your partner. The doctor will also ask about your stress level, self-image, and whether depression may be a factor.

Treating the problem

If a medication is to blame, your doctor may suggest switching to a new drug or changing your dose. While hormone deficiencies are sometimes the culprit, often the problem stems from a mix of psychological and relationship issues. Or a combination of all these factors may be at work. If, after careful questioning and preliminary tests of hormone levels and blood flow, your doctor decides that the problem has psychological roots, he or she will refer you to a sex therapist or other psychological counselor.

Sex therapy. Low libido is the most common, challenging, and complex dysfunction a sex therapist encounters. An early obstacle is that individuals with low libido often aren't eager to be treated — because they don't miss sex, they don't feel hopeful about the prospect of finding a solution, or both. Most of the time they consent to therapy when they feel the problem is damaging their relationship. Therapists may address this issue in a variety of ways. Usually, the problem is recast as a couples issue; therapy isn't a means to "cure" the person with the low sex drive. Also, the therapist aims to reassure the low-desire partner that he or she won't be forced or even pressured to have sex, while suggesting that the individual may be missing out on a valuable part of life by forgoing the activity. Finally, the therapist works to dispel any pent-up resentment on the part of the higher-drive partner by reiterating that he or she is making a choice to stay committed to the relationship by engaging in the search for a joint solution. The goal of treatment is to help create an atmosphere in the relationship that is less pressured, thereby allowing the low-desire partner to become more receptive to sex.

One important step is to have the partner with the lower libido recognize and come to terms with any hidden feelings of anger, resentment, guilt, fear, or disgust that surround sex. If these feelings are present, the couple and the therapist explore the origins and effect of these emotions. The therapist will also encourage the couple to examine the dynamics of the relationship that reinforce the discrepancy in desire. For example, the bedroom may be a venue for acting out power struggles, with the person who otherwise feels ineffectual in the relationship avoiding sex as a means of control.

Once most of the emotional roadblocks have been addressed, the couple moves on to behavioral exercises designed to increase trust and sensual awareness, such as sensate focus techniques. This can help the couple begin to reestablish physical intimacy. When a person's low desire is an outgrowth of a sexual dysfunction within the relationship, treatment for low desire is usually an easier matter once the original dysfunction is resolved.

Medical treatments. Medical treatments for libido problems are often combined with sex therapy. The following options are available:

• Hormone treatment for men. Although there's a clear link between testosterone production and male libido, researchers have yet to discover the exact nature of the connection. If a man's hormone level is clearly below normal, testosterone supplements can make a noticeable difference in his libido. On the other hand, supplements seem to have no effect on men whose natural testosterone is already within a normal range. The impact of testosterone supplements on men who have borderline or low-normal hormone levels is still unknown. Although desire wanes with age, this problem doesn't seem to be linked to declining testosterone.

• Hormone treatment for women. Many people don't realize that women also produce testosterone naturally, and this hormone affects libido in women as it does in men. The natural decline of testosterone that accompanies aging can affect a woman's sexual responsiveness. As a result, some doctors prescribe testosterone gel in additional to estrogen and progestogen therapy (see "Testosterone for women").

• Bupropion. This antidepressant seems to increase sexual desire and stimulation. In one small study published in the Journal of Sex and Marital Therapy, 60 women and men with sexual desire or arousal difficulties (but not depression) were given either bupropion or a placebo for 12 weeks. At the end of the study period, 63% of the participants taking bupropion reported improvements in their sexual functioning, compared with only 3% in the control group. People who take SSRI antidepressant medications, such as Celexa, Prozac, Paxil, and Zoloft, which may cause sexual side effects, may want to ask their clinicians about trying Wellbutrin instead.

Last updated:	January 23, 2007