Section 6: Sexual Desire Problems

We began this course by noting that, “Because sexuality is such an important part of each person’s life, it is presumed that most clinicians have had at least some background and education in sex and sexuality.” The knowledge base for the subject matter of this section on sexual desire problems must be considered absolutely essential for any mental health clinician.

Sexual desire problems are among the most common problems seen in a therapist’s office, and these can be among the most difficult sexual issues to address. According to Psychology Today (Oct. 2006), a condition known as hypoactive sexual desire (HSD) occurs in perhaps 20% of the population, more frequently in women, although both men and women are affected. Clinicians may practice for a lifetime without seeing a single case of vaginismus, but they will almost certainly see numerous cases where sexual desire problems are present.

There are many possible reasons why sexual desire problems will develop: physical, psychological, and relational. The causes may overlap, and sorting through them can be time consuming and frustrating, particularly if one partner wants the problem remedied quickly. The clinician working with a couple is often expected to have a magic cure, even for on-going problems that have persisted over time.

In preparing to conduct a thorough assessment of the client, a conscientious clinician will need to know what to look for in this arena. Towards this end, a list of common causes of desire problems is presented below.


1. Differences in baseline sexual desire
2. Fatigue
3. Sex-negative religious orthodoxy
4. Depression (with or without anhedonia)
5. Phobias or aversions
6. Triggering of childhood trauma, rape, etc.
7. Fear of loss of control over sexual urges
8. Hidden sexual deviation
9. Fear of pregnancy
10. Widower's or Widow’s Syndrome
11. Hormones and neurotransmitters
12. Medications
13. Lifestyle Issues
14. Aging
15. Relationship issues
a. Lack of attraction to partner
b. Poor social and relationship skills
c. Fear of closeness ----> vulnerability
d. Passive-aggressive issues
e. Marital conflict
f. Madonna-Prostitute Syndrome
16. Medical, Surgical, and Disabling Conditions

Additionally, and as a follow-up to the previous section, it must also be noted that problems with sexual functioning, such as erectile problems and premature ejaculation, or dyspareunia and vulvodynia, can contribute to the development of sexual desire problems. The normal expression of sexual feelings, designed to work best in a safe and secure, non-thinking flow state, can be disrupted by fears, worries, anxieties, disappointments and other emotions resulting from complications in one or both partners’ sexual lives. If one or both partners begin to dread the sexual experience, it can quickly dial down sexual desire.

Most clinicians with any experience working with couples understand the relevance and importance of this topic. An enormous number of crumbling relationships present with disturbances in the sexual life of the partners, with problems with sexual desire frequently at the center of the storm. The difficulty lies in discerning whether the desire problem is a symptom or a cause of larger relationship problems. At times, it can even be both.

For the clinician to be able to discriminate between the many possible causes of the sexual desire problems, it is absolutely essential for the clinician to have a great deal of confidence in his/her assessment skills and tools, as well as a very solid grasp of each of the factors noted above. If it is not clear what to look for, the clinician may not direct the right questions towards the client’s situation.

This is such a central issue in modern sexuality, that each of the contributors to sexual desire problems was covered in some detail in’s introductory course: Sex and Sexuality: An Introductory Overview for Mental Health Clinicians. This course is recommended reading for any clinician who is not clear on all of these potential factors. Of particular importance are the sections on medications and sexual desire problems, and medical, surgical and disabling conditions and their effects on sexuality in relationships.

With one exception, we will not repeat the material that was already presented in that course. The section below, covering differences in baseline sexual desire, is one of the most likely areas that a mental health clinician might encounter in the context of couples counseling. This will be presented because it is representative both of the complications involved in assessing these kinds of problems and in terms of some general strategies for resolving the problems. It is also just plain interesting.

1. Differences in baseline sexual desire

In many clinical presentations, a couple will present complaining of differences in sexual desire, in other words, a “desire discrepancy.” The most difficulty arises in couples with the greatest polarity in amounts of desire - one person may want some type of sexual activity one or more times a day, whereas the other may be content with sexual expression once a week, once a month, or even less frequently (perhaps never).

These differences in desire often result in shame and anger in both members of the couple. The low desire person may feel shame that s/he is inadequate and/or angry about feeling used and about the partner’s perceived insensitivity. The high desire person may feel unloved, undesirable, and angry at having to “beg” for sex. Blame and a sense of hopelessness abound on both sides, with the high desire person often feeling betrayed and saying, “When we first got together, s/he really liked sex, and then after we’d been together for a while it [her/his desire] went away.”

Indeed there is an old saying that, “As soon as we got married, things changed,” suggesting in some instances that the partner had only feigned sexual interest until s/he got what s/he wanted, i.e. marriage. On the other hand, the lower desire person may begin to feel used and that the partner is “overly sexed” and is only interested in him/her for the purpose of having sex.

In fact, there are many potential reasons for this scenario to play out in this way. One of these potential reasons, however, has to do with actual inborn differences in partners based upon some complex chemistry. There really are different baseline sexual appetites that appear to be at least somewhat genetically determined.

An excellent resource for learning about differences in baseline sexual desire and addressing these differences in relationships is the work of Dr. Pat Love. Dr. Love stays on the cutting edge of research in the psychology and biology of desire and presents compelling information that our sexual desire is likely “rooted, to a large degree, in powerful, biochemical processes that have little to do with how attractive couples find one another or how much they care for each other” (Love, 1999, p. 36).

Findings in the emerging fields of behavioral endocrinology and psychophysiology suggest that there is a biological basis to the intense attraction we feel in the beginning stages of a new relationship - the time when we can hardly stand to be apart, when this new person is the most wonderful human being on the planet, and we feel enlivened and exhilarated when we are with him/her.

Dr. Love states, “Some scientists now believe that the frenzied euphoria of romantic love may well be a bona fide, altered state of consciousness, primarily brought on by the action of phenylethylamine (PEA), a naturally occurring, amphetamine-like neurotransmitter.

Michael Liebowitz, a research psychiatrist at the New York State Psychiatric Institute, believes that when we come into contact with a person who highly attracts us, our brains become saturated with a ‘love cocktail’ comprised of PEA and several other excitatory neurotransmitters, including dopamine. This chemical brain-bath theory explains why new lovers can talk till dawn, make love for hours on end, lose weight without trying and feel so outrageously, unquenchably optimistic. Their neurons are soaking in natural speed” (Love, 1999, p. 37).

We hope, and some may expect, this state of romantic love and attraction will last, perhaps forever. After a time of being together however, typically 18 to 36 months, we begin to experience a lessening in desire, and this decrease may seem to occur to a greater degree primarily in one partner. We are left to wonder what happened.

For years we have known that men and women both produce testosterone and that testosterone is highly correlated with male libido. It has only been in recent years, however, that the role of testosterone in women’s libido has been studied, and a large body of psychoendocrinological research has established that libido requires a significant supply of testosterone in women as well as in men (Love, 1999).

Some men as well as women have high testosterone - “high-T” men and women, while others of both genders have low testosterone -“low-T” men and women. (Note: The desire gap occurs in same sex couples also.)
“It is during the infatuation stage that the two major components of the biology of desire - the time-limited PEA factor and T-level mismatches - collide to create sexual catastrophe for many couples” (Love, 1999, p. 39). Initially the elevated PEA serves to keep sexual desire levels high and both partners exhilarated. After the PEA diminishes, however, the natural desire levels return to what the testosterone levels make available.

If the partners are mismatched in terms of testosterone levels, problems begin to surface, and the greater the degree of mismatch, the greater the number and frequency of potential problems (Love, 1999).

By the time couples come to the therapist’s office, they are often locked in a downward spiral of disappointment, shame, anger, and hopelessness and want the therapist to do something to create a quick reversal in the situation. Couples frequently have been to other therapists who may have focused on communication and injecting novelty into the sexual repertoire, and when these techniques failed to help, the couple became discouraged and disheartened about their situation.

In the beginning session, the therapist can actually begin to give hope by presenting the biological information related to PEA and testosterone. The author has found that when the situation is normalized and partners can begin to get a better understanding of the probable biological influences on what is happening, their frustration and anger often lessen and they may begin to see a glimmer of hope for themselves and for the relationship. While there will likely be much work still to do in re-establishing the emotional and sexual connection, the seeds of hope are planted.

Even though couples may accept the explanation that their differences in desire have a biological basis, the next question may be, “So what? Is there anything we can do about it, or is this the way it’s always going to be?” The ultimate answer, given that PEA-spiked desire is gone, is that future sexual intimacy will have to be consciously created.

Love (1999) describes asking one couple to share with each other what kind of sexual-emotional activity would feel most loving and satisfying to them. The husband asked for a periodic 15-minute session of sex that gave him both a physical release and the feeling that his wife cared for him, and the wife asked for regular, leisurely massages from her husband, which might or might not culminate in intercourse, depending on her wishes. If these activities have positive outcomes, the groundwork is laid for future intimacy and greater emotional connection.

Incorporating desire education into therapy can serve to reassure couples. It can also give more of a focus on the complete relationship, as well as an effective boost to traditional sex therapy techniques and methods focused on increasing communication. Desire education avoids the medicalization of sex that frequently occurs with the use of terms such as “hypoactive sexual desire.”

In addition, desire education may allow the clinician to discuss and reformulate the expectation that once relationship issues are successfully resolved, great sex will follow as a result. It begins the work of replacing fantasies of everlasting honeymoon sex with conscious decision making about how to create and sustain lasting intimate and sexual exchanges.

Even in loving relationships, “hormonally mediated desire gaps exist between partners, and their ultimate erotic satisfaction will depend on a steady, vigilant effort to sustain their sexual connection. A couple’s work will involve each partner’s ‘stretching’ to understand, to empathize with and to accommodate the other’s unique experience of passion” (Love, 1999, p. 43). This is an ongoing relationship process that requires consciousness and commitment.

It is not impossible for two partners to have very compatible baseline levels of sexual desire. This happy circumstance removes at least one obstacle from their sexual relationship. However, even having compatible baseline levels does not mean that the couple will sustain compatible operational levels of sexual desire. Aging, fatigue, stress or other emotional distractions, relationship problems, medications, and a wide variety of other factors can make it difficult for couples to remain at the same level of desire either consistently in the short-term or over the long journey of a romantic relationship lasting decades.

This approach is not only extremely useful for addressing this particular kind of sexual problem within a relationship, it can also be seen as a paradigm for addressing many of the potential causes of sexual desire problems and sexual desire differences between partners.

Whether the differences in sexual desire are the result of aging, fatigue, stress or other emotional distractions, medications, or some of the other factors from our list above, what will ultimately create improvements is the same combination of accurate assessment, education, normalizing, removing blame, increasing intimacy and bringing the couple together in a search for mutually acceptable solutions.

The next two chapters will be concerned with both a tool for supporting this kind of work - Sensate Focus Techniques - and a set of circumstances where much more than just this approach will be required – where unconscious saboteurs are operating to create sexual problems.