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Rosemary, 66, describes her younger self as “one horny chick.”
“I was very sexual,” she says. “I was usually the initiator.” But when she went through menopause, something changed. “It was gone,” she says. “My desire just disappeared.” She spoke with her doctor about it, then another, and another. One prescribed her testosterone, which didn’t help, and another told her there was nothing else they could do. She eventually gave up. “It was very frustrating for me, because I wanted to be more sexual,” says Rosemary. “I wanted to want sex, but it was like a switch got turned off.” »
Decreased sexual desire is the most common sexual health concern among women of all ages. Dr. Jamie Feldman, a family physician at the University of Minnesota’s Center for Sexual Health, has been treating female sexual dysfunction for 18 years. She defines hypoactive sexual desire, or a low libido problem, as a decrease in sexual thoughts, feelings, and interest in sexual activities (compared to previous functioning) that’s distressing to the patient.
Feldman is quick to point out that, no matter what magazine covers and reality TV suggest, there is no normal when it comes to sex. “There’s no mandate about how often you should have sex, or what kind of sex you should have,” she says. “People have this idea that we must have penis-vagina intercourse at least once a week or three times a week, and if I have less, then I have a dysfunction. There’s no definition like that.” The only thing that makes someone’s current level of desire problematic is if it’s a change that’s causing her distress.
Rosemary certainly fit that description. But aside from looking into some experimental trials, there was nothing Rosemary’s doctor could recommend. “Every time I turned on the TV, I saw ads for Viagra, showing older men with their smiling, silver-haired wives, and I’d think, ‘Oh please,’” says Rosemary. “‘That woman just wants to be left alone.
Why can’t we find a pill to give her?’”
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The search for a pharmaceutical option to increase women’s desire is ongoing. In 2015, the FDA approved a drug to treat low desire in women for the first time. The pill, called Addyi, must be taken daily, isn’t covered by insurance (unlike Viagra, which is covered by some private health insurance plans), and costs around $600 a month. To qualify for a prescription, a woman must be premenopausal (no help for Rosemary), have no other identifiable factors contributing to low desire, and sign a waiver promising not to consume even one alcoholic beverage while taking the drug.
Despite all these hoops to jump through, in a study published earlier this year in JAMA Internal Medicine, researchers found that taking Addyi resulted in an increase of .5 additional “sexually satisfying encounters” per month. So, not exactly a bullet train to ecstasy town.
The main reason an effective “female Viagra” to treat low desire in women hasn’t come along is that Viagra actually addresses another problem entirely in men. “Erectile dysfunction isn’t a desire problem,” explains Feldman. “It’s an arousal problem—a vascular problem.” Viagra solves the plumbing problem that prevents the body from responding to existing desire, but it doesn’t itself inspire the desire. As Feldman puts it, “You can give a man Viagra and send him shopping with his mother, and he’s not going to want to have sex any more.”
The good news is that the possibility of a lucrative payday from a magic pill (elusive though it remains) has inspired a boom in studies on how female sexual desire works—an area sorely lacking in research. One of the first breakthroughs in understanding the mechanisms underlying sexual desire came in the late ’90s from researchers at the famed Kinsey Institute at Indiana University. They introduced the dual control model, which posits that rather than being a single “drive” with varying degrees of intensity, sexual response is actually a more complex system consisting of factors that can increase desire along with others that can decrease it—or stop it entirely.
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Dr. Jordan Rullo, a clinical health psychologist and sex therapist at Mayo Clinic, explains: “If we think of sexual function as comprising a gas pedal and brake pedal, it’s clear we’ve got to have more pressure on the gas than the brake in order to function.” If the brake is on, it doesn’t matter how much pressure you put on the gas pedal—how many candles you light, massages you get, or blood-flow- augmenting pills you take. You’re just going to spin your wheels. “To treat a sexual function concern,” says Rullo, “we need to figure out what is pressing on that brake, and what we can do to remove it.”
Rullo says one of the biggest factors that hits the brake pedal for women is an inability to simply be present. “Most of the women I see in my practice who have low sexual
desire also report that when they are being sexual with their partner, they’re distracted with other things: thinking of their to-do list, experiencing cognitive intrusions about their body image or the kids in the house or a history of sexual trauma or past negative messages about sex. Long story short, they’re not thinking about the sex they’re having or about to have.”
This disconnect between mind and body, particularly around sex, has been shown to be more pronounced in women than men in general. In studies measuring the overlap between genital response and subjective, self-reported arousal, male and female subjects were shown a variety of erotic film clips and asked to rate their level of arousal while blood flow to their genitals was measured. Men showed about a 66 percent overlap (if their bodies were aroused, their minds were likely to be too). For women, the overlap was 26 percent. And for women with sexual dysfunction, the rate of concordance (both genital and subjective arousal co-occurring) was only 4 percent. Even if their bodies were turned on, their minds were saying I’m not into this. “We believe that this discordance is a key player in sexual dysfunction in women,” says Rullo, “and mindfulness can lessen that disconnect.”
A Canadian study earlier this year found that mindfulness training did indeed have a positive effect on women’s subjective and genital arousal concordance, suggesting that tuning into the sensations of the body, being present in the moment, and decreasing attachment to future-oriented or distracting thoughts can lead to increased desire. With a new Mayo study, Rullo will test whether teaching mindfulness in combination with an established stress management program called SMART (Stress Management and Resiliency Training) and sexual health education can not only improve women’s sexual function, but also the overall quality of their relationships. After all, Rullo says, “One of the largest predictors of a woman’s sexual dysfunction is if she’s unhappy in her relationship.”
Mayo’s Sex SMART approach aims to enhance gratitude, compassion, and forgiveness skills, while encouraging greater mindfulness through videos and exercises that emphasize attention to detail and the release of distracting thoughts. It’s a more complex intervention than popping a pill, to be sure, but female desire is a complex system. Feldman describes it as a stool with three legs: biological, psychological, and situational. “They all have to be working well in order to have good sexual desire.”
The distinction between desire and arousal (while the two are linked, generally speaking desire is largely psychological motivation, arousal primarily physical response) is also useful for understanding how women’s sexuality tends to evolve over time. While we usually think of a mental desire for sex preceding the physical process of the body preparing for it (erections in men, vaginal lubrication and swelling of the clitoris in women), mental desire can also be evoked by physical arousal in the right circumstances and conditions—and this tends to be the case more often as a woman grows older.
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“For many women, particularly in long term relationships, particularly as we get older, desire tends to be more responsive in nature,” says Feldman. “Rather than waking up and saying ‘I want sex now,’ desire responds to emotional or physical stimuli…that turns into sexual arousal.” When the spontaneous appetites of youth or a new relationship begin to fade, making sex a kind of (hopefully enjoyable) homework—committing to a dedicated time and space and letting mindful awareness of physical arousal (that feels good) lead to desire (I want more of that)—is a perfectly natural and healthy way to maintain a strong sexual connection.
Even when low desire can be increased, desire discrepancy—when one partner wants sex more often than the other—is another sexual issue that can lead to discord. If a couple with desire discrepancy doesn’t come up with a solution, they can develop what Feldman calls a “PacMan problem,” in which one becomes the “chaser” and suffers feelings of frustration and rejection, while the other interprets everything the “chaser” does as pursuing sex and grows averse to touch and familiarity. “It can become a real pathology, and it requires a lot of therapy,” says Feldman.
But caught early, there are ways to deal with it. Unsurprisingly, communication and compromise are key. One of the tools couples can use is alternating weeks, with each partner getting to set the number of sexual encounters every other week, or coming up with alternatives to intercourse to put in the mix. “It helps to be able to say not now, but when, or not this, but that,” says Feldman. “Women learn to hate sex by enduring it and resenting it rather than talking about it. And that makes low desire worse.”
But what about when a woman stops wanting sex at all? When life circumstances and psychological factors (she just had a baby or is overwhelmed by stress from work) are ruled out, the biology leg of the sexual desire stool may be the culprit. Physiological factors that can inhibit genital blood flow include genitourinary syndrome of menopause (GSM), which makes sexual arousal more difficult and results in vaginal dryness (which in turn leads to pain); disease or injury; and certain medications including those for blood pressure and depression.
Mayo is one of a few clinics nationally that has a Genito-Sensory Testing (GST) machine, which can help determine whether there’s been a loss of sensation in the genitals by using temperature and vibration to measure response thresholds. “This can help us determine if there’s some kind of biological compromise,” says Rullo, “or if perhaps this is really a concordance issue.”
Whatever the issue, today there is probably a treatment or therapeutic intervention available to help mitigate it, for those who are motivated to try. Though part of it, Feldman says, may be redefining your expectations for what sex is, or broadening your toolbox for what sex can look like. “Some women tell me, ‘I have three kids and we have sex only once a week,’ and I say ‘You can have bad sex more often or good sex as often as you do: Which would you like?’ Giving people permission to be where they are rather than where they think they should be—measuring up to an imaginary normal—just relieving that burden helps tremendously.”
Places women can go for treatment of low sexual desire in Minnesota include Mayo Clinic Women’s Health Clinic, University of Minnesota Center for Sexual Health, and Park Nicollet sexual medicine physicians. Certified sex therapists can be found at www.aasect.org.