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For years, the dominant theory among anthropologists and evolutionary biologists has been that men are lusty, sexual creatures, primed by eons of evolution to spread their seed far and wide, assuring the propagation of their genes.

Women, on the other hand, mind the hearth and home. They trade sex for security and protection, saving the sweetest honey for the most viral suitor, who is also the one most likely to provide, protect, and produce robust offspring. Thus, women prefer monogamy and fidelity over sexual exploits.

That theory fits the predominant cultural paradigm. It’s a comforting, unthreatening explanation of how things are.

Except that it may not be accurate. Exactly.

Lately, this tried-and-true evolutionary theory has come under fire. Maybe the sexes don’t fall so neatly into “his” and “her” categories. Maybe previously overlooked research casts a different light on how humans interact sexually.

Maybe, for example, women aren’t so monogamous and passive. Maybe, despite even their own self-described diffidence, women are just at lusty and promiscuous at heart as men. That’s the thesis behind the new book What Do Women Want? Adventures in the Science of Female Desire by Daniel Bergner.

“Women’s desire—its inherent range and innate power—is an underestimated and constrained force, even in our times,” writes Bergner.

Consider that passion is one of the first casualties of long-term, committed relationships. According to Bergner, “flagging sex drive is not just an inevitability for women—it is specifically the result of long-term monogamy. Even [effects of] the hormonal decrease of menopause can be entirely overridden by the appearance of a new sexual partner.” (qtd. in this article in The New York Times. My italics)

So, dangle some studly dude before a menopausal lady, and she’ll be giggling like a teenager, but serve up the same old spouse and watch the sizzle drizzle.

Bergner references several studies that underscore the raw lust of the “gentle sex.” Female subjects were hooked up to a machine that measures vaginal blood flow. Then they were shown images of heterosexual and homosexual sex and even pictures of sex between bonobos—a species of ape. Women were turned on by all of it—even the apes—according to their vaginal reaction.

When heterosexual men were shown the same images, the response was predictable: they were slightly turned on by photos of men masturbating and male homosexual scenes, but they were overwhelmingly aroused by heterosexual and homosexual images of women.

But the really interesting thing?

In this study, both men and women also self-reported their levels of arousal as they watched the images. The men’s written responses were completely consistent with their physical responses—body and mind told the same story.

Not so with the women. Even though the instruments showed wide-ranging arousal at all the images, the women’s self-reported assessments were very different. The heterosexual women said they were turned on by the men but not by sex between apes or women. Right in line with cultural expectations and maybe their own idea of how they ought to feel.

Except that their bodies were telling a different story.

This female dichotomy between self-reporting and physical arousal has been repeated in several experiments that indicate women are turned on a lot more and by a wider range of sexual situations than previously thought, and also that women either aren’t aware of their own arousal or consciously under-report it.

Why is this? Why is the suggestion that women are naturally lusty such a shocking and forbidden topic? Why does this rattle the cage of cultural morés and expectations?

Women have, since time immemorial, been the kin-keepers, the caretakers, the foundation of the family, the social glue. But at what cost? Denial of their own primal sexual urges? Settling for sexual repression and boredom for the greater good?

No one is suggesting that monogamy, commitment, and long-term relationships ought to be tossed out, or that women should act on their urges. Clearly, stability, attachment, and intimacy create strong societies and families. Despite whatever sexual frustration it entails, monogamous relationships work for raising children and also perhaps for long-term psychological contentment.

But repression doesn’t work very well. So long as women feel they ought to ignore, deny—or to be puzzled or embarrassed by—urges that seem unacceptable or culturally unsanctioned, they will continue to be confused by and out of touch with their most primal urges. And maybe lose out on some healthy sexual energy as well.

No one has to act on their impulses, but acknowledging and accepting that they exist might be a healthy psychological choice, and one that puts women in touch with their sexuality.

How do men feel about all this female sexual sturm und drang? Well, “this scares the bejeesus out of me,” said one man in this article. The notion that, roiling beneath the domestic façade of the little woman tending hearth and home, may lie scary sexual urges has always been deeply unsettling, especially to men. Who’ll mind the children and navigate the social contract? Who’ll be the faithful one?

The growing scientific suspicion that women have a lot more going on beneath the surface than we let on or the culture sanctions is an interesting theory. While it may not be the whole story, I think somewhere we recognize it as at least partly true.

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Ever since Flibanserin was shelved after FDA rejection, the search for the next drug to treat lack of libido in women has been mighty low-key. To be sure, there were legitimate concerns about Flibanserin’s effectiveness, but as I’ve said before, we need more treatment options for women who suffer from hypoactive sexual desire disorder (HSDD).

Now, three years later, initial trials on another pink Viagra drug, which are actually two drugs (Lybrido and Lybridos), are just winding down. The results look “very, very promising,” according to Adriaan Tuiten, the drugs’ developer. If all goes well in the next phase of clinical trials, a pink Viagra could be on pharmacy shelves by 2016.

And that would be something to celebrate.

As I mentioned in my last post, HSDD is common; it’s complex; and it has confounded therapists and researchers for decades. Unlike pills for erectile dysfunction, low libido in women isn’t just a matter of hydraulics—increasing blood flow to the genitals (although it’s partly that).

Therapists and physicians have debated long and hard over female sexual desire—what creates it; what kills it; even what it is. Sexual desire probably has as much to do with our brains and our emotions as it has to do with our plumbing. And, possibly, desire may even be connected to the way women are hard-wired for sex, commitment, and monogamy.

It appears that women like novelty maybe even more than men. And while women don’t tend to be more promiscuous than men, they do tend to fizzle out, sexually speaking, more quickly and persistently within long-term relationships. They just lose interest.

“Sometime I wonder whether it [HSDD] isn’t so much about libido as it is about boredom,” says Lori Brotto, a therapist who has worked extensively on female libido, in this article in the New York Times magazine.

It’s also about loss of hormones that we experience—right about now.

This doesn’t mean that women who suffer from loss of libido don’t love their mates. It doesn’t mean that they can’t become aroused or even experience orgasm. It does mean that the sexual attraction, the heat and fizz, the interest in being sexual has waned or disappeared.

You know, the old “not tonight, dear. I have a headache” routine.

Every night.

Make no mistake, for many women this is a real heartbreak. “How much easier it would be if we could solve the problem by getting a prescription, stopping off at the drugstore and swallowing a pill,” writes Daniel Bergner, author of the forthcoming book What Do Women Want?

This next frontier may be attained if Tuiten’s sister-drugs for HSDD —Lybrido and Lybridos—continue to be as effective as early trials suggest.

The two drugs affect three chemicals thought to be involved with sexual desire and arousal in women: testosterone, dopamine, and serotonin. But each drug takes a slightly different approach.

Both have a testosterone coating that melts in the mouth and enters the bloodstream quickly. Lybrido then works something like Viagra, increasing bloodflow to the genitals, which may heighten a woman’s awareness of her own arousal, releasing a resultant cascade of dopamine, the neurochemical of passion, in the brain.

Lybridos, on the other hand, use an anti-anxiety drug, called Buspirone, instead of the Viagra look-alike. After the testosterone rush, Buspirone temporarily suppresses the production of serotonin, a “higher order” neurochemical that creates feelings of well-being and self-control. Squash the voice of reason (serotonin) and perhaps passion (dopamine) will gain the upper hand. Or so the thinking goes.

Preliminary results from these trials were recently published in The Journal of Sexual Medicine. The next round will involve a much larger study.

“Perhaps the fantasy that so many of us harbored, consciously or not, in the early days of our relationships, that we have found a soul mate who will offer us both security and passion, till death do us part, will soon be available with the aid of a pill,” writes Bergner in the Times article.

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Libido is a tender blossom. A cold blast of hormonal change. A whiff of illness or the wrong medication. Even routine and long-term sexual ho-hum can cause libido to wither like a sweet pea on a frosty morning.

The whole notion of female sexual desire and what causes it to bloom or to die on the vine isn’t well understood (like a lot of female sexuality, actually). But low libido in women is extremely common, according to the few studies done on it. Low libido conservatively affects between 8 and 12 percent of older women—those of us who are in the midst of or beyond the “change.” Other experts say that all women experience low libido at some point in their lives, and I wouldn’t quibble with that statement.

It even has a not-very-sexy name: hypoactive sexual desire disorder (HSDD).

To be clear, the textbook definition of HSDD goes like this: “a deficiency or absence of sexual fantasies and desire for sexual activity. The disturbance must cause marked distress or interpersonal difficulty.” (My italics.)

In other words, it ain’t a problem until you (or your partner) say it’s a problem. Low libido isn’t a disorder per se unless it’s making you or your partner feel distressed, dissatisfied, guilty, or otherwise unhappy.

Interestingly, while sex drive does tend to diminish as we age, most older women are less distressed about it, “resulting in a relatively constant prevalence for HSDD over time,” according to this report by Dr. Sheryl Kingsberg, a friend of MiddlesexMD.

To some extent, women expect to lose their sexy juice after a certain age because that’s what our American culture tells us to expect, according to Mary Jo Rapini, a therapist and MiddlesexMD advisor in an article for FoxNews. Older women aren’t expected to be sexy. They’re expected to be invisible.

Yet, says Mary Jo, women shouldn’t passively accept this state of affairs just because they’re reaching midlife. “Accepting low sex drive because you’re getting older is the same as accepting drugs to control your diabetes when you could change your diet, exercise, and lifestyle regimen.”

For many women, however, low libido is a problem, causing all kinds of guilt, distress, and relationship disturbance, which may either be intense and unrelenting or intermittent and mildily distressing.

If good sex is correlated with general sense of well-being and higher quality of life and self-esteem, it’s not surprising that ongoing sexual frustration can negatively affect health and well-being. Dr. Sheryl mentions several studies that associate HSDD with health problems. In one such study, for example, “women with HSDD experienced large and statistically significant declines in health status, particularly in mental health, social functioning, vitality, and emotional role fulfillment.”

Ouch.

HSDD can be caused by a whole bunch of physical conditions, ranging from certain medications to certain illnesses to, yes, age-associated hormonal changes. But many women struggle with HSDD because of emotional issues, and that’s the focus of Mary Jo’s article. In her experience, the emotional causes of low libido are often relied to stress, relationship and intimacy issues, or to problems with self-esteem and body image.

“Addressing the emotional causes of low libido should be the first step you take in addressing why you no longer desire sex, your partner, or your intimate life,” she writes.

Mary Jo suggests some honest exploration, perhaps with a therapist, to get at the root of these emotional problems:

Are you stressed or depressed? Are you struggling with self-esteem or poor body image? Do you feel emotionally connected to your partner? Can you talk about sexual issues? Is there a history of abuse or infidelity in your relationship?

As with so many sexual matters, the causes of HSDD are complex, intertwined, and challenging to unearth. The cause could be as straightforward as adjusting a medication or as difficult as changing an unhealthy lifestyle or honestly assessing emotional issues.

If loss of libido is troubling you, tackling the underlying causes may also be a journey toward greater overall emotional and physical health, because just as sexuality is woven into the very fabric of emotional and physical well-being, you can bet that what affects sexuality is also affecting other parts of life as well.

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In the beginning, there was passion. Your feelings were almost painful. You wrote long letters and sent silly gifts and spent hours in whispered conversations on the phone. A lifetime ago. Remember?

Then came the long familiar years. You settled into a cozy, secure routine. You finished each other’s sentences; you knew the next move, the habits, the vulnerabilities, the quirks and preferences.

But what happened to the passion?

Psychotherapist Esther Perel has spent her career studying the sexual language of long-term, committed couples. She’s pondered the dynamics of the love/desire dialectic, and she’s identified the qualities that keep the sexual spark alive over the years. In a recent talk, she discussed her work with exceptional lucidity. You may intuitively know what Perel has to say, but few of us have articulated it so clearly. In any case, it’s good to be reminded—and challenged.

Desire and love are paradoxical. They’re mutually exclusive. Love, says Perel, is to have. It’s associated with security, with safety, with roots and foundations. To love is to know the beloved and to be known. But this contented intimacy isn’t a necessary component of good sex, “contrary to popular belief,” says Perel.

To desire, on the other hand, is to want. Desire craves adventure, novelty, risk. We desire mystery, the unattainable, the 50 Shades kind of guy.

Trouble is, we want both love and desire. We want security and passion. Intimacy and mystery. Safety and risk. So how can these opposing drives coexist in a marriage? How can we settle into the mature love of a long-term relationship without losing the hungry edge of desire that brought us together in the first place? How can we achieve the ideal of a “passionate marriage,” which fans the flame of desire within the intimacy of commitment?

As she studied couples around the world, Perel asked them when they found themselves most attracted to their partner. She heard variations of the same theme:

  1. When they reunite after an absence.
  2. When watching the other from a distance when the partner is completely engaged in an activity. “When I look at my partner, radiant and confident, [is] probably the biggest turn-on across the board,” says Perel.
  3. When there are no demands and no needs.  “Caretaking is mightily loving,” says Perel. But, “it’s a powerful anti-aphrodisiac.”
  4. When there is some novelty or newness. “When he’s in his tux,” said one person. Substitute cowboy boots, or a toolbelt, or motorcycle leather.

In these situations, there is a shift in perspective from the familiar to a sense of separation and distance. It’s the Proustian “voyage of discovery [that] consists, not in seeking new landscapes, but in having new eyes.”

Desire is a dialog we have with committed love. It’s a duet, a dance. The dynamic may be paradoxical, but both are necessary if a long-term relationship is to remain vital. It’s the language of poetry and mystery rather than of process and technique. Desire is more complex than bedroom gymnastics.

From her experience in studying and counseling couples, Perel has distilled several qualities that erotic couples seem to have in common. These aren’t on many “how-to” lists; they have more to do with essence than with activities. They may not be easy to incorporate because they’re not as straightforward as establishing a “date night.” But the concepts she delineates are worth some thought.

  1. Give each other some erotic privacy. Maybe this is the space that preserves mystery. It allows the other some personal freedom to explore. It acknowledges that you aren’t joined at the hip; that there is difference and distance. “Erotic privacy may mean different things to different people,” writes Pamela Madsen, author of Shameless. “It may mean the privacy to look at pornography and not share some desires with our partners. It may mean the possibility of exploring ourselves within agreed upon boundaries without our partners.”
  2. Foreplay isn’t optional. It isn’t a five-minute, pre-sex duty. “Foreplay pretty much starts at the end of the previous orgasm,” says Perel. These relationships cultivate a sense of erotic anticipation.
  3. Check the “good girl” at the door. Desire is selfish. You aren’t responsible for organizing or orchestrating. “Responsibility and desire just butt heads,” says Perel.
  4. Passion has seasons. Like the moon, it waxes and wanes. It will return, but keep on having sex in the meantime. “Willful, non-spontaneous sex,” says Madsen.

“Committed sex is premeditated sex,” says Perel. “It’s willful. It’s intentional. It’s focus and presence.”

To hear Perel’s talk in its entirety, visit the TED website here. This twenty minutes may be the best gift you could give your relationship today.

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Hypothyroidism, which is a low-functioning thyroid gland, is quite common in women; about one in eight will have thyroid disease in her lifetime. Interestingly, there’s been little research in understanding how thyroid function may affect sexual function.

The good news is that treatment for hypothyroidism—supplementation of thyroid hormone—is straightforward, and women receiving treatment seem to have little or no increase in sexual issues. Those who are not treated seem to have more issues with desire, lubrication, and orgasm.

As women get older, their risk of having thyroid disease increases. There are both physical symptoms (like weight gain, dry and yellowish skin, hair loss, fatigue, muscle or joint aches and pains) and cognitive symptoms (like slower thinking or speech, memory issues), but at age 50 and thereafter I recommend a screening—simple blood tests—at regular intervals.

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If one-third of women don’t fantasize and rarely feel sexual desire, does that mean they’re all sexually dysfunctional? (Actually, the term is “hypoactive sexual desire disorder.”)

Or does it mean that the medical community needs a better understanding of how women get turned on, why we want to have sex, and why we might not want to have sex?

The research is clear and consistent: A lot of us simply don’t feel much sexual desire. We don’t think about sex much “in between,” and we aren’t particularly motivated to initiate sex. We do, however, enjoy it once the ball gets rolling, and we feel pretty good about our sex lives overall. “Research confirms that women report sexually satisfying lives despite rarely or never sensing desire,” writes Dr. Rosemary Basson in an editorial in Menopause: the Journal of the North American Menopause Society.

Basson is a champion for less labeling and a more open-minded understanding of female sexual arousal and response. (That’s why we love Rosemary!) She and others hypothesize that women have a different arousal mechanism than men, less straightforward and linear, more subtle and complex. Maybe desire and arousal overlap and reinforce each other in women. Maybe we need to light the kindling—a little nibble on the earlobe, a little stroke along the thigh—before desire and arousal begin to smolder. And sometimes life experiences affect our sexual appetite and responses. Longstanding personal issues, like childhood abuse or problems with our partner, for example, or recent developments, such as illness or depression.

Basson advocates careful consideration of all the variables when it comes to labeling one-third of women as sexually dysfunctional because sexual desire in women is subtle and many-faceted. Is a physical illness the impediment, or is it the financial worry that accompanies the illness? Or is it depression brought on by the medication for the illness?

Basson encourages a more “detailed, careful interview” to establish causation. And she is hesitant about blaming hormonal or neurochemical imbalances, which she says there is lack of evidence for.

When women are carefully examined, she feels that only a “theoretical sub-fraction… would merit a diagnosis of intrinsic sexual disorder.”

The bottom line, ladies? Lots of us don’t think about sex much in the course of daily life, but light the match, and we warm up nicely. For most of us, this isn’t a problem. So why consider it a sexual disorder?

And if it is a problem in our relationship, try to find a medical professional who’s willing to perform  the kind of “detailed, careful” examination that Basson recommends.

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That’s one of the questions MiddlesexMD medical advisor and sex therapist Sheryl Kingsberg often hears. I asked her to write about how she answers it.

Each of us is unique, with varied interests, beliefs, backgrounds, and experiences. Given how different we all are, it is often very difficult to define what is “normal.” This difficulty in pinning down such a definition holds true for many things, including one’s sex drive–everyone’s is a little different.

As a woman’s life changes, her sex life and interest in sex may change as well. For examples, at midlife, her balance between career and family may shift; perhaps more of her time and energy is pulled in a different direction. This may affect her interest and energy for sexual activity, and her idea of a normal sex drive may change as well. She may not have the same desires she felt when she was younger, or she may often find herself thinking about her to-do list and not about sex. However, it’s important to note that her sex life is still an important part of her personal life and her overall health.

For some women, however, it can feel like sexual desire is nearly gone, sexual thoughts or daydreams are rare, or other sexual problems develop, like difficulty with arousal, lubrication, or pain. These changes may not simply be due to changing priorities, other physical problems, age, or situational stress. In this case, women may be experiencing a sexual dysfunction.

While anyone who owns a television and has seen ads for Viagra or Cialis knows that sexual problems are common in aging men, there is much less discussion about aging women. The reality is, sexual problems affect over 40 percent of adult women and can present themselves at any stage of their lives. There are several specific sexual disorders, including Hypoactive Sexual Desire Disorder (HSDD), Female Sexual Arousal Disorder (FSAD), Female Orgasmic Disorder, Sexual Aversion, Dyspareunia (pain with sexual penetration), and vaginismus (the inability to have wanted sexual penetration due to an anxiety response).

HSDD is the most common sexual problem for women. Nearly one in 10 women reported low desire with sexually related personal distress; the distress associated with it can affect more than just a woman’s sexual life. Research has shown that the impact of HSDD can extend further, causing detrimental effects in other aspects of her life. These can include difficulty with personal and social relationships, a poor self-image, mood instability, and even depression.

As a clinical psychologist, I see firsthand how HSDD and other sexual problems negatively affect women’s lives. A woman’s sexual health is a basic human right and an important part of her overall health and well-being. It is normal for a woman’s desires and sex drive to fluctuate given all that life throws her way. However, a significant lack of desire, and/or absence of sexual thoughts or fantasies that causes distress, is a sign that this is not just a normal fluctuation but rather may be HSDD and should be discussed with a healthcare professional.

What is a “normal” sex life for a woman? It may be different for each woman, but it comes down to whatever she feels is right for her and her relationship. It’s not about how often a woman engages in sexual activity, but rather that her desire remains satisfying to her.

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