When she’s low on libido…


There is heated controversy[1] among feminists, researchers, sexual medicine specialists, and pharmaceutical companies over sexual desire and desire difficulties:[2] how it is described, defined in the DSM, represented in the media, and most importantly, how to address or treat it.  The current DSM-5 amalgamated female disorders of desire and arousal into a single diagnosis called “female sexual interest/arousal disorder,” replacing the previous term of hypoactive sexual desire disorder (HSDD). As Jenny Higgins and Patty Cason write in Contraceptive Technology,[3] clinicians who interact with women concerned about levels of desire may be helped by understanding the changing perception and meaning of sexual desire, and the changing landscape within which sexual desire complaints have developed. In addition to considering a diagnosis of “female sexual interest/arousal disorder” as defined by the DSM-5, clinicians can embrace a more complex and holistic view of sexual desire to help patients explore how familial, religious, cultural, or societal expectations or in many cases, sexual trauma, may be influencing their concerns or limiting their own experience of desire.

Interestingly, the current emphasis on female desire is relatively new.[4] Following the introduction of the oral contraceptive pill in 1960 and the following evolution of sexual mores in the 1960s and 1970s, women in the United States were increasingly acknowledged to be sexual beings. Simply defined, sexual desire is the motivation to engage in sexual acts.[5] Often, the term refers to “spontaneous” desire rather than desire that is experienced in “response” to arousing sexual stimuli.[6],[7] However, a body of evidence supports the concept that “spontaneous desire” does not exist and even desire that seems spontaneous is actually in response to sexual stimuli.[8]

When queried, individuals report motivation to engage in sexual acts for a range of reasons, including sexual release, orgasm, pleasing their partner, desire for intimacy, emotional closeness, love, and feeling sexually desirable. Clearly, what is meant by sexual desire and what individuals in fact “desire” is complicated and highly influenced by biology, psychology, and society.[9]

An individual’s perception and interpretation of sexual desire and sexual self in general is shaped by personal psychosexual history and thus influenced both positively and negatively by conditioning.[10],[11] For a given individual, there is a statistically reasonable chance that sexual difficulties are the consequence of sexual trauma. Another likely contributing factor is familial, societal, religious, and cultural rules about what is acceptable or taboo regarding sexuality.[12],[13]

Thankfully, a simple and very welcome fact that all parties agree on is that that a person does not have to experience “spontaneous desire” in order to have pleasurable, satisfying sex.7 Sexual experiences are equally satisfying in the absence of “spontaneous desire” because human beings easily respond to arousing sexual stimuli with “responsive desire.” Reassure patients that spontaneous desire may not exist, as such, and is not necessary for sexual arousal or pleasurable, satisfying sex; this knowledge can help normalize and validate an individuals’ experiences and support them as agents of their own sexuality.

Although 39% of women reported “low sexual desire” in a 2008 nationally representative panel study of 31,640 women, aged 18 to 102 (mean age of 49 years), fewer than 1 in 3 (27.5%), or 10% of the entire sample, reported sexual distress.[14] This sizeable gap between the prevalence of low sexual desire and the prevalence of any distress associated with it is an important reminder of how the nature of a sexual problem depends on whom you ask, when, and in what context.[15],[16]

Clinicians who are not experts in sexual medicine can help patients who experience sexual difficulties, which can include low sexual desire.[17] Some clinicians may be reluctant to bring up sexual health if they feel unprepared to adequately handle patient concerns. An open conversation to identify problems may in itself naturally provide education and simple suggestions that help. Simply being asked respectful but direct questions may encourage patients to think more openly about sex and sexuality and may support sexual self-comfort. Below are some helpful questions to get you started: [18]

Suggested questions clinicians can ask to offer a conversation about sexuality

  1. Sexual health is important to overall health; therefore, I always ask patients about it. Is it okay with you if I ask you a few questions about sexual matters now?
  2. Are there any sexual problems or worries that you would like to discuss?
  • Normalize issues. For example, “It’s not uncommon for people (who have diabetes, as they get older, who have a new baby/young children, around menopause, etc.) to have that problem.”
  • “For many people, (orgasm, pain, decreased interest in sex, etc.) can be a problem. I would be happy to discuss these or other issues with you. I can’t answer your question, I’ll find someone who can.”

What’s the update on the idea of ‘Viagra for women’? As of this writing, there are several medications under development aimed at female-assigned people who want to increase their sexual desire. One FDA-approved medication, flibanserin, is indicated for “the treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD) as characterized by low sexual desire that causes marked distress or interpersonal difficulty.”[19] Of note for clinicians caring for reproductive-age women is flibanserin’s potential for drug interactions with alcohol and with medications that are CYP3A4 inhibitors. Strong and moderate CYP3A4 inhibitors such as ketoconazole, miconazole, fluconazole, and ciprofloxacin are contraindicated, and weak inhibitors such as oral contraceptives must be used with caution. In one small study supported by the company that developed the drug, 24 women pretreated with flibanserin for 2 weeks “did not produce a clinically relevant change in oral contraceptive drug exposure following single-dose administration of ethinylestradiol/levonorgestrel.”[20]  Bremelanotide, recently approved by the FDA and scheduled for sales in September, is administered by self-injection, no more frequently than 8 times a month. It can slow gastric emptying of certain medications taken orally. Oral contraceptive use is not contraindicated with bremelanotide.

[1] Driscoll M, Basson R, Brotto L, et al. Empirically supported incentive model of sexual response ignored. J Sex Med 2017;14:758–759.

[2] Tiefer L. Apples and oranges: “sexual medicine” and the effort to deny that counting and classifying are political acts. J Sex Marital Ther 2017;43:246–249.

[3] Higgins JA, Cason P. Sexuality & Contraception. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018.

[4] Kingsberg SA, Rezaee RL. Hypoactive sexual desire in women. Menopause 2013;20:1284–1300.

[5] Mark K, Herbenick D, Fortenberry D, Sanders S, Reece M. The object of sexual desire: examining the “what” in “what do you desire?” J Sex Med 2014;11:2709–2719.

[6] Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Arch Sex Behav 2010;39:221–239.

[7] Driscoll M, Basson R, Brotto L, et al. Empirically supported incentive model of sexual response ignored. J Sex Med 2017;14:758–759.

[8] Laan E, Both S. What makes women experience desire? Fem Psychol 2008;18:505–514.

[9] Mark K, Herbenick D, Fortenberry D, Sanders S, Reece M. The object of sexual desire: examining the “what” in “what do you desire?” J Sex Med 2014;11:2709–2719.

[10] Brotto LA, Petkau AJ, Labrie F, Basson R. Predictors of sexual desire disorders in women. J Sex Med 2011;8:742–753.

[11] Pfaus JG, Kippin TE, Coria-Avila GA, et al. Who, what, where, when (and maybe even why)? How the experience of sexual reward connects sexual desire, preference, and performance. Arch Sex Behav 2012;41:31–62.

[12] Ringa V, Diter K, Laborde C, Bajos N. Women’s sexuality: from aging to social representations. J Sex Med 2013;10:2399–2408.

[13] Peixoto MM, Nobre P. Dysfunctional sexual beliefs: a comparative study of heterosexual men and women, gay men, and lesbian women with and without sexual problems. J Sex Med 2014;11:2690–2700.

[14] Rosen RC, Shifren JL, Monz BU, Odom DM, Russo PA, Johannes CB. Correlates of sexually related personal distress in women with low sexual desire. J Sex Med 2009;6:1549–1560.

[15] Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Arch Sex Behav 2010;39:221–239.

[16] Carvalheira AA, Brotto LA, Leal I. Women’s motivations for sex: exploring the diagnostic and statistical manual, fourth edition, text revision criteria for hypoactive sexual desire and female sexual arousal disorders. J Sex Med 2010;7:1454–1463

[17] Binik YM, Hall KSK. Principles and practice of sex therapy. Fifth edition/ed. New York: The Guilford Press; 2014.

[18] Some questions taken from Nusbaum MR, Hamilton CD. The proactive sexual health history. Am Fam Physician 2002;66:1705–1712.

[19] Thurston RC, Ewing LJ, Low CA, Christie AJ, Levine MD. Behavioral weight loss for the management of menopausal hot flashes: a pilot study. Menopause 2015;22:59–65.

[20] Johnson-Agbakwu C, Brown L, Yuan J, Kissling R, Greenblatt DJ. Effects of flibanserin on the pharmacokinetics of a combined ethinylestradiol/levonorgestrel oral contraceptive in healthy premenopausal women: a randomized crossover study. Clin Ther 2019;40:64-73.