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THE GUILFORD PRESS

Treating Sexual Desire Disorders
Treating
Sexual Desire
Disorders
A Clinical Casebook

Edited by
Sandra R. LeibluM

The Guilford Press

New York   London
© 2010 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com

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Library of Congress Cataloging-in-Publication Data

Leiblum, Sandra Risa.

Treating sexual desire disorders: a clinical casebook / Sandra R. Leiblum.
    p. cm.
Includes bibliographical references and index.
ISBN 978-1-60623-636-9 (hard cover: alk. paper)
1. Sex therapy. 2. Sexual disorders—treatment. I. Title.
RC557.L35 2010
616.85′8306—dc22
2010001285
 IN MEMORIAM
Sandra R. Leiblum (1943–2010)

Sandy Leiblum, born in Brooklyn, New York, and never without that
distinctive accent, was a true sexology star. She contributed some of
the most important books to the field over a period of decades, special-
izing in clinical compilations that showed the diversity of treatment
approaches to a wide variety of sexual problems. Much of her experi-
ence came from decades of teaching and mentoring young psychology
and medical colleagues in New Jersey. Sandy was an active participant
in and was repeatedly elected president of the leading professional
organizations in the field, receiving all their important honors. She
pioneered the recognition of persistent genital arousal as a problem.
She wrote swiftly, and with clarity. She was an excellent friend and
collaborator to many of us and a superb mother to Jonathan (Jake).
Her death was unexpected and far too soon. Sandy was involved in
many important professional developments and was at the height of
professional recognition. She is mourned by her husband, Frank, and
by her numerous friends in the United States and around the world. A
bright star, a snappy dresser, a warm and loving friend, is gone.

v
 About the Editor

Sandra R. Leiblum, PhD, was, until her death in January 2010,

Professor of Psychiatry and Obstetrics/Gynecology, Director of the
Center for Sexual and Relationship Health, and Director of the Psy-
chology Internship Program at the Robert Wood Johnson Medical
School, University of Medicine and Dentistry of New Jersey, in Pis-
cataway, New Jersey. An internationally recognized authority in sex
therapy, Dr. Leiblum received numerous awards for her professional
contributions, including the Masters and Johnson Award from the
Society for Sex Therapy and Research and the Professional Stan-
dard of Excellence Award from the American Association of Sexu-
ality Educators, Counselors and Therapists. She was the author or
editor of over 125 journal articles, chapters, and books on various
aspects of male and female sexuality and was widely recognized for
her teaching and clinical activities. Her book Principles and Practice
of Sex Therapy, Fourth Edition (Guilford, 2006) received the 2010
SSTAR Health Professional Book Award from the Society for Sex
Therapy and Research.

vii
 Contributors

Rosemary Basson, MD, Sexual Medicine Clinic, Vancouver General

Hospital, Vancouver, British Columbia, Canada
Alisa Breetz, MA, Department of Psychology, American University,
Washington, DC
Lori A. Brotto, PhD, Department of Obstetrics and Gynaecology,
University of British Columbia, Vancouver,
British Columbia, Canada
Irwin Goldstein, MD, San Diego Sexual Medicine, Alvarado Hospital,
San Diego, California
Sue W. Goldstein, BA, San Diego Sexual Medicine, Alvarado Hospital,
San Diego, California
Kathryn Hall, PhD, private practice, Princeton, New Jersey
Marny Hall, PhD, private practice, Oakland, California
Peggy J. Kleinplatz, PhD, Faculty of Medicine and School of Psychology,
University of Ottawa, Ottawa, Ontario, Canada
Joanna B. Korda, MD, San Diego Sexual Medicine, Alvarado Hospital,
San Diego, California
Michael Krychman, MD, private practice, Newport Beach, California
Sandra R. Leiblum, PhD (deceased), Department of Psychiatry and
Obstetrics/Gynecology, Center for Sexual and Relationship Health,
and Psychology Internship Program, Robert Wood Johnson
Medical School, University of Medicine and Dentistry of New
Jersey, Piscataway, New Jersey
Barry McCarthy, PhD, Washington Psychological Center,
Washington, DC

ix
x   Contributors

Esther Perel, MA, LMFT, private practice, New York, New York
Bonnie R. Saks, MD, Department of Psychiatry, University of South
Florida, Tampa, Florida
David Schnarch, PhD, Marriage and Family Health Center of Evergreen
Colorado, Evergreen, Colorado
Douglas K. Snyder, PhD, Department of Psychology, Texas A&M
University, College Station, Texas
Susan Kellogg Spadt, PhD, Pelvic and Sexual Health Institute,
Philadelphia, Pennsylvania
Leonore Tiefer, PhD, Department of Psychiatry, New York University
School of Medicine, New York, New York
David C. Treadway, PhD, private practice, Weston, Massachusetts
Jane S. T. Woo, MA, Department of Psychology, University of British
Columbia,Vancouver, British Columbia, Canada
 Preface

There is no shortage of advice in bookstores and on media

talk shows for bolstering sagging sex drives: Pop some steamy porn
on the TV or computer, blindfold or bind a mate to the headboard,
arrange a weekend or night in a no-tell motel, titillate a vagina or
massage a phallus with sensual oils, and so forth. While these nos-
trums might work once or twice or maybe even for a whole week,
once the novelty wears off, so does the interest in sex. The sad truth
is, once couples fall out of the habit of regular sexual connection, it
is difficult to revive—and can explain the appeal of new relationships
or a change of partners. For most couples in long-term partnerships,
particularly those in which one partner has low, modest, or absent
sexual desire and the other does not, the challenge of reawakening or
creating desire is considerable. While it is certainly true that the expe-
rience of sexual arousal may whet desire, the knowledge that this is so
does not always lead folks to the conjugal bed. As clinicians, we are
constantly faced with the challenge of helping frustrated, thwarted,
and disappointed partners with complaints about their own or their
partner’s sexual apathy. This is not always easy or successful.
These are the reasons for undertaking this book: to acknowledge
the difficulty couples experience and to benefit from the wisdom of
expert clinicians who encounter these issues daily. How do clinicians
deal with the most prevalent sexual complaint of all—what has been
christened with the sanitized name hypoactive sexual desire disorder,
or HSDD? There are few long-term outcome studies of the successful
treatment of HSDD, unlike the impressive research literature that has

xi
xii   Preface

accumulated on the treatment of orgasmic disorders or erectile prob-

lems. It is far more common for clinicians to bemoan their failures
than to boast of their successes with these cases. Yet now, more than
ever, we are seeing a parade of both men and women complaining of
sexual apathy despite good health, good will, and even good relation-
ships.
In the chapters that follow, the reader will discover sage advice
and sound interventions for working with individuals and couples
who are struggling with desire issues. While not promising total suc-
cess, many contributors report significant improvement with treat-
ment. The complexity and diversity of these cases will illustrate how
varied the etiological and maintaining factors that characterize these
cases are and why, realistically, there can be no single treatment
approach.
As a clinician myself, I am very grateful to the impressive and
worthy group of authors who were willing to participate in this proj-
ect. All are busy and successful professionals with a host of other
commitments, yet each of them was willing to take the time to think
about and articulate his or her approach to treating desire problems.
And I hope you too, as a reader, will find much to enlighten and assist
you in working with these most challenging problems.

                      Sandra R. Leiblum

Note: Sandra R. Leiblum suffered a devastating accident after the

manuscript had been sent to the publisher. She died in January 2010.
Leonore Tiefer, one of the contributors and a long-time friend, agreed
to shepherd the manuscript through the final editorial stages.
 Contents

Chapter 1. Introduction and Overview: Clinical Perspectives 1

on and Treatment for Sexual Desire Disorders
Sandra R. Leiblum

Chapter 2. The Double Flame: Reconciling Intimacy 23

and Sexuality, Reviving Desire
Esther Perel

Chapter 3. Using Crucible Therapy to Treat 44

Sexual Desire Disorders
David Schnarch

Chapter 4. The Canary in the Coal Mine: Reviving Sexual 61

Desire in Long-Term Relationships
Kathryn Hall

Chapter 5. Confronting Male Hypoactive Sexual 75

Desire Disorder: Secrets, Variant Arousal,
and Good-Enough Sex
Barry McCarthy and Alisa Breetz

Chapter 6. “Desire Disorders” or Opportunities 92

for Optimal Erotic Intimacy?
Peggy J. Kleinplatz

Chapter 7. A Skeptical View of Desire Norms 114

and Disorders Promotes Clinical Success
Leonore Tiefer and Marny Hall

xiii
xiv   Contents

Chapter 8. Complaints of Low Sexual Desire: 133

How Therapeutic Assessment Guides
Further Interventions
Rosemary Basson

Chapter 9. Cognitive-Behavioral and Mindfulness-Based 149

Therapy for Low Sexual Desire
Lori A. Brotto and Jane S. T. Woo

Chapter 10. Dancing to Their Own Music 165

David C. Treadway

Chapter 11. Treatment of Low Sexual Desire 181

in the Context of Comorbid Individual
and Relationship Dysfunction
Douglas K. Snyder

Chapter 12. The Role of Androgens in the Treatment 201

of Hypoactive Sexual Desire Disorder
in Women
Joanna B. Korda, Sue W. Goldstein,
and Irwin Goldstein

Chapter 13. Sexual Psychopharmacology 219

and the Treatment of Desire Deregulation
Bonnie R. Saks

Chapter 14. The Desire to Feel Whole Again: The Quest 234
for Sexual Desire after Breast Cancer
Michael Krychman and Susan Kellogg Spadt

Index 247
 Chapter 1

Introduction and Overview

Clinical Perspectives on
and Treatment for Sexual
Desire Disorders

Sandra R. Leiblum

S exual desire is the most elusive of passions. While easily

ignited in a new relationship or a forbidden encounter, it can also be
readily extinguished. Anxiety, hostility, bad memories, or frightening
flashbacks can thwart it—even something as simple as the sound of a
door opening or a child crying. And yet, when aroused by an image
or scent or fantasy or person, it can feel powerfully intense, driven,
lively, and life-affirming. Interest in and concerns about absent or
diminished desire have never, perhaps, been greater.
Historically, sexual desire has rarely been viewed from a neutral
or disinterested stance. Attempts have always been made either to
stimulate libido—whether through perfumes, potions, prostitutes, or
pictures—or to stifle it. Whereas in previous decades, sexual com-
plaints may have centered on “performance”—erectile or orgasmic
problems—in the recent past, concerns about sexual desire have
become paramount. There are several reasons for this.
An active and satisfying sexual life is widely regarded not only as
desirable but as a sign of emotional and physical health. When desire

1
2   TREATING SEXUAL DESIRE DISORDERS

ebbs, intimate connections seem to diminish as well. Many sexually

apathetic individuals worry that their partners will look elsewhere for
sexual stimulation or gratification. There is no shortage of technolog-
ical options for satisfying sexual curiosity and piquing sexual arousal.
The availability of pro-erection drugs, arousal creams and gels, vibra-
tors and massage oils provides frequent reminders that sex can and
should be part of life. The sexually disinterested person is made to feel
deficient, dissatisfied, or dysfunctional. This pressure to conform to
current norms has led a growing group of women and men to believe
that if they no longer experience sexual interest or desire, something
is wrong with them rather than with their expectations or with their
partner or with society’s (and the media’s) ever-constant preoccupa-
tion with sex.

What Is Sexual Desire?

For most people, the concept of sexual desire conjures up visions of

an energizing force that motivates one to seek out or initiate geni-
tal expression and relief. Like hunger or thirst, the so-called sexual
“drive” has been regarded traditionally as an instinctive, spontane-
ous, and insistent source of sexual motivation. It was believed to
dwell within the individual and to be biologically based. Linked to
this idea is the antiquated belief that if the so-called sexual drive is not
permitted free expression, it will seek an outlet through other means.
The “drive reduction” model of sexual desire reached its acme with
Freud’s (1962) libido theory. This view asserted that the primary goal
of sexual expression is to relieve libidinal tension and to restore emo-
tional equilibrium. It suggests that sexual desire is endogenous and
inevitable: everyone has it, albeit in varying amounts and to various
degrees. From a traditional analytic perspective, a lack of desire results
from the active repression or inhibition of the spontaneous urge for
sexual contact as a result of internal conflict or ambivalence.
Current thinking challenges this view in many instances, even
questioning the importance of a biological basis for libido. While the
androgens, particularly testosterone, are widely credited in both the
professional and popular press as the hormone responsible for libido,
many sexual theorists now suggest that relational, cognitive, motiva-
tional, and evaluative factors play a more significant role. In young
hypogonadal men, testosterone is usually recommended for enhanc-
ing quality of life. But there has been greater controversy about the
 Introduction and Overview   3

use of androgens for triggering libido in men with late-onset hypogo-

nadism, principally because other conditions may be responsible for
diminished sexual desire, for example diabetes mellitus, hyperpro-
lactinemia, metabolic syndrome, or a host of medications (Wang et
al., 2009).
In women, recent research has found that the correlation
between testosterone (however measured) and various parameters of
sexual behavior is far from clear (Davis, Davison, Donath, & Bell,
2005). While there are several good studies supporting the use of
androgen supplementation for increasing desire both in natural and
in surgically post-menopausal women (Shifren et al., 2000; Buster
et al., 2004; Simon et al., 2005), there is also sound research ques-
tioning the significance of serum levels of androgen in motivating
sexual behavior (Davis et al., 2005). Given that androgen levels are
extremely low in women and difficult to measure precisely, the role
of androgens in female sexual drive is hotly debated. At this time,
there are no testosterone products approved by the Food and Drug
Administration (FDA) that are available for women in the United
States, although such products are available for men. While it is
beyond the scope of this chapter to review the ongoing controversy
surrounding the role of testosterone in stimulating libido, many of
the authors in the chapters that follow address this issue in more
detail. In particular, Korda, Goldstein, and Goldstein (Chapter 12)
discuss the successful use of androgenic therapy in their treatment
of a young woman presenting with a chronic lack of both desire and
arousal. Basson (Chapter 8) presents a more cautionary view of the
conclusions that may be drawn from the current research on andro-
gens and sexuality.
Certainly, a serious flaw in the “drive” theory of desire is the
erroneous belief that the internal or spontaneous experience of desire
is not only ubiquitous but a necessary prerequisite to the experience
of sexual arousal. In fact, several sex researchers persuasively argue
the opposite, namely, that desire is more often secondary to arousal.
It is the awareness of arousal, whether genital or subjective, that is
basic in both triggering and maintaining sexual desire. This position
has been eloquently articulated and described by Basson (2001) in her
reformulation of the sexual response cycle, although many theorists
prior to Basson emphasized the importance of arousability and exter-
nal motivation as triggers for sexual desire (Beach, 1956; Whalen,
1966).
Finally, there is a growing awareness of asexuality, or the absence
4   TREATING SEXUAL DESIRE DISORDERS

of sexual desire or interest, as a normative and legitimate life style and

sexual orientation for some women and some men (Bogaert, 2004,
2006). A 1977 paper by Johnson entitled “Asexual and Autoerotic
Women: Two Invisible Groups,” defined asexuals as those men and
women “who, regardless of physical or emotional condition, actual
sexual history, and marital status or ideological orientation, prefer
not to engage in sexual activity.” Johnson (1977) contrasted auto-
erotic women with asexual women: the latter are said to have no
sexual desires at all, whereas the “autoerotic woman . . . recognizes
such desires but prefers to satisfy them alone.” Johnson’s evidence
is quite tenuous, consisting mostly of letters to the editors of wom-
en’s magazines. However, her theorizing concerning asexuality as a
distinct sexual orientation received support from analysis of a pro-
vocative question included as part of a large-scale survey of more
than 18,000 British men and women that was conducted in 2004. A
professor at Brock University in Canada, Anthony Bogaert, exam-
ined their answers to a question regarding sexual attraction to others,
one of whose choices was “I have never felt attracted to anyone at
all.” He found that about 1% of the respondents reported having no
sexual attraction to anyone. While it is unclear whether asexuality
represents a distinct sexual orientation, like homosexuality or het-
erosexuality, or whether it simply represents a variant of hypoactive
sexual desire disorder, it is interesting that an online community has
developed around the legitimacy of asexuality as a normal lifestyle of
healthy but sexually disinterested individuals. There is even an online
community and support organization, the Asexual Visibility and Edu-
cation Network (AVEN), founded in 2001 with two primary goals: to
create public acceptance and discussion of asexuality and to facilitate
the growth of an asexual community.
The authors of the chapters that follow provide many defini-
tions and theories of sexual desire, its wellsprings, and its mutations.
Despite the passage of more than 20 years, a definition of sexual desire
presented in the 1988 edition of Sexual Desire Disorders (Leiblum &
Rosen) still makes some intuitive sense—namely, a view of desire as a
subjective and motivating feeling state triggered by both internal and
external cues, which may or may not result in overt sexual behavior.
Adequate neuroendocrine function seem to be essential for this feeling
state to occur, along with exposure to sufficiently intense sexual stim-
uli, cues, and motives or incentives. These arise from sources within
the individual (a stimulating fantasy, a decision or wish to please a
partner, an awareness of genital vasocongestion) but also from the
 Introduction and Overview   5

environment—sexy words and provocative touch over a candlelit din-

ner; a photo of a restrained woman in 6-inch heels and little else;
a man in tight briefs with a silky whip. Furthermore, sexual desire
appears to be readily conditioned and “scripted” to socially sanc-
tioned as well as to socially proscribed cues. Not surprisingly, in light
of this last observation, we are now seeing an ever-increasing num-
ber of men and women who have been labeled as sex “addicts” for
their obsessive and, at times, compulsive pursuit of both conventional
and unconventional sex. It is interesting that concerns about exces-
sive sexual interest (hypersexual desire) have now joined the litany of
sexual complaints presented to sex therapists.
Finally, it must be acknowledged that the motivations or incen-
tives to either initiate or respond to a sexual invitation or overture are
quite varied. In a clever and provocative research study conducted by
Meston and Buss (2007), 237 possible reasons for having sex were
collected. These ranged from the spiritual (“I wanted to get closer
to God”) to the instrumental (“I wanted to experience physical plea-
sure”). A large sample of undergraduates (N = 1,549) were asked
to evaluate the degree to which each of the 237 reasons led them to
have sexual intercourse. Using factor analysis, four main factors and
13 subfactors emerged: Physical (stress reduction, pleasure, physi-
cal desirability, and experience seeking), Goal attainment (resources,
social status, revenge, and utilitarian), and Emotional reasons (love
and commitment and emotional expression). The three Insecurity
subfactors were elevation of self-esteem, duty/pressure, and mate
guarding.
Past research has repeatedly demonstrated that desire, arousal,
and the presence or absence of sexual behavior do not always coincide
in women. In 2003, Weijmar Schultz and Van de Wiel observed that
despite reports of negative genital sensations, pain, and diminished
desire from women who had undergone cervical cancer, these women
were statistically no different in terms of frequency and motivation
for sexual interaction from an age-matched control group. These
authors wondered if women’s “love ethos” made them more inclined
to adapt to the wishes of their partners. Obviously, it is also possible
that the threat of losing a lover as well as the threat of punishment or
abuse may lead many disempowered or fearful women to acquiesce to
sexual interactions, despite a lack of desire.
Obviously, knowing that a sexual experience has occurred tells
us nothing about either the desire accompanying it or the diverse, and
not necessarily sexual, motives for engaging in it.
6   TREATING SEXUAL DESIRE DISORDERS

Sexual Desire: Too Little, Too Much,

Too Different, or Just Right?

In some respects, sexual desire complaints resemble the experience

of the three bears entering the cottage in the woods and surveying
the three beds lying within. “Too big,” announces Momma Bear,
when gazing at one bed; “Too small,” announces Poppa Bear, test-
ing out another; “Just right,” pronounces Baby Bear, as he hops up
and down on the middle bed. Though our patients are not bears
(except perhaps when they become disgruntled), desire problems
often fall into these categories as well—too little or too much. “Too
little,” or hypoactive sexual desire disorder (HSDD), is the most
common complaint clinicians encounter, often delivered by a dis-
appointed mate who wants greater sexual frequency and certainly
a more enthusiastic sexual partner. “Too much” is also a com-
plaint, typically made by a weary mate who finds himself or her-
self deflecting the sexual overtures of an indefatigably ardent lover.
But “just right” sexual desire is rarely heard by clinicians, although
it probably characterizes the majority of individuals who are basi-
cally satisfied with their sexual life. It should be pointed out that
there is absolutely no frequency of sexual encounters that defines
sexual “normality.” Recent research (Schneidewind-Skibbe, Hayes,
Koochaki, Meyer, & Dennerstein, 2008) highlights the fact that the
mean frequency of sexual intercourse, to consider only one mea-
sure of sexual behavior, varies significantly cross-globally across all
age groups. Higher rates are reported by European and American
women and lower rates reported by Asian women. Many factors
were found to be associated with these differences in intercourse
frequency: age, parity, relationship duration, pregnancy, time, rela-
tionship status, fertility intentions, and use of contraception. Given
the wide range of frequency reported, as well as the varying cultural
and social context in which sexual behavior occurs, it would be
arbitrary to establish where “normal” sexual frequency ends and
pathologically low or excessive sexual activity starts. As clinicians
we are most concerned not with how often or how infrequently our
patients engage in sex, but rather with how concordant their sexual
preferences and satisfaction are. Clinically, it is “too different” or
too discrepant sexual interest that is the problem we must often
address, since it is this complaint that leads to relationship discon-
tent, disharmony, and distress.
 Introduction and Overview   7

Lack of Desire: A Brief Historical Overview

At this juncture, someone might ask whether the attention being paid
to sexual desire complaints nowadays is not misguided or excessive.
Certainly, there have always been individuals who get along just fine
without craving or engaging in sex. Should we even diagnose low
sexual interest as a sexual dysfunction, since by so doing we may be
pathologizing normal variations in sexual interest that are due to a
host of sociocultural and relationship causes? This is certainly the
position of Tiefer and Hall, who present their “new view” model in
Chapter 7. They acknowledge that whether or not desire problems
are ubiquitous, they definitely are not indicative of a psychiatric dis-
order.
Thoughts about this issue have certainly changed over the decades.
One hundred years ago, excessive desire was regarded as aberrant.
While permitted and even applauded in men, too much sexual desire
in women was seen as worrisome. Sexually enthusiastic women ran
the risk of being labeled as nymphomaniacs and treated medically.
Times have changed, of course, and today, concerns about sex-
ual apathy are the most common complaint presented to sex thera-
pists. Despite the widespread assumption that it is women who are
shortchanged when it comes to libido, nowadays men are as likely
as women to be diagnosed with HSDD as defined by the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV-TR; American
Psychiatric Association, 2000).
In fact, this is not a new diagnosis. Since the mid-1900s, low
desire has been considered a psychiatric disorder and it was included
as one of the five psychosexual disorders listed in DSM-III (American
Psychiatric Association, 1980). In 1980, it was believed that without
psychological inhibition, all individuals would experience “normal”
desire. In DSM-IV (American Psychiatric Association, 1994), psycho-
sexual disorders were elaborated as disturbances in sexual desire and
in the psychophysiologic changes that characterize the sexual response
cycle which cause marked distress and interpersonal difficulty. There
was no attempt to specify a particular frequency of sexual behavior
or activity as normative or deviant. Rather, it was left to the clinician
to determine whether a condition warranted diagnosis, taking into
account such factors as the age and experience of the individual, the
frequency and chronicity of symptoms, the degree of subjective dis-
tress, and the impact on other areas of functioning. In addition, the
8   TREATING SEXUAL DESIRE DISORDERS

clinician was advised to consider the contributions of an individual’s

ethnic, cultural, religious, and social background that might influence
sexual desire, expectations, and attitudes about sexual performance.
In l998, the Sexual Function Health Council of the American
Foundation for Urologic Disease (AFUD) convened a consensus con-
ference to review and update the current classification of female sexual
disorders. One goal was to ensure that the diagnostic entities would
be applicable in both medical and mental health settings. Another
was to determine whether the current descriptions of female sexual
disorders reflected clinical reality.
The conference invited a multidisciplinary group of European and
North American research and clinical experts in the field of female
sexuality, comprising sex therapists, sex researchers, gynecologists,
urologists, and experts in sexual psychophysiology, among others. A
recommendation emerged from that meeting that the DSM-IV defini-
tion of HSDD be amended to reflect the fact that many women never
experience spontaneous sexual desire, but rather are receptive to, and
interested in sexual activity once it is started.
In 2000, a second consensus meeting was held and the recom-
mendation at that time was to rename HSDD as women’s sexual
interest/desire disorder and to define it as “absent or diminished feel-
ings of sexual interest or desire, absent sexual thoughts or fantasies
and a lack of responsive desire. Motivations (here defined as reasons/
incentives) for attempting to become sexually aroused are scarce or
absent. The lack of interest is considered to be beyond a normative
lessening with life cycle and relationship duration” (Basson et al.,
2003, p. 224). Even this definition has generated controversy. It is
likely that DSM-V (scheduled to be released in 2013) will offer yet
another definition of low or absent sexual desire, perhaps combining
it with diminished sexual arousal since it is often difficult, particularly
for women, to discriminate between arousal and desire complaints.
In recent years, the voices of some who question the legitimacy of
(and motives for) for diagnosing low desire have become louder and
more insistent. In 2003, for example, an editorial in the British Jour-
nal of Medicine by Ray Moynihan unleashed a storm of controversy
when he assailed and mocked the motives of those who regard, diag-
nose, and treat HSDD as a sexual dysfunction. Moynihan asserted
that the identification of low desire as a psychiatric disorder was
merely a ploy by pharmaceutical companies and naive clinicians to
create a dysfunction that they might then develop a pill to treat. His
 Introduction and Overview   9

article provoked much media controversy and many letters to the edi-
tor, with physicians, patients, and sex therapists supporting or refut-
ing his allegations. Countering his remarks, for example, were letters
highlighting the fact that desire complaints were identified as disor-
ders in the DSM decades earlier and that by 1977, lack of desire was
already acknowledged as a problem reported to clinicians by their
patients (Kaplan, 1977; Lief, 1977; Basson & Leiblum, 2003).
Despite honest debate among clinicians and researchers as to
how to define hypoactive sexual desire or whether to diagnose it as a
disorder, there can be little doubt that a discrepancy of sexual interest
and desire creates significant discontent and problems in the context
of a relationship. While judicious and careful assessment must accom-
pany any decision to treat desire complaints, an individual or couple
experiencing genuine distress at sexual apathy and lack of arousal
must be regarded as legitimately entitled to assistance.

Prevalence of Desire Disorders

Although it often appears as if every sexually active person complains

of sexual disinterest for some period of time, the actual prevalence of
desire disorders varies widely, ranging anywhere from a low of 8% to
a high of 55% (Deeks & McCabe, 2001; Richters, Grulichade Visser,
Smith, & Rissel, 2001). While it is possible that some of the differ-
ences are attributable to the unique population studied (e.g., young
vs. older individuals, pre- vs. postmenopausal women), much of the
variation in prevalence estimates is likely due to differences in the
way in which low desire is assessed (Hayes et al., 2007). In one study,
for example, Hayes and his colleagues used several different instru-
ments for determining the prevalence of a variety of female sexual
dysfunctions. For HSDD, they compared estimates using the Sexual
Function Questionnaire (SFQ; Quirk et al., 2002) either alone or in
combination with the Female Sexual Distress Scale (FSDS; Derogatis,
Rosen, Leiblum, Burnett, & Heiman, 2002), as well as two sets of
simple questions concerning sexual interest that were adapted from a
large-scale survey of sexual complaints (Laumann, Gagnon, Michael,
& Michaels, 1994). Respondents were asked to report on sexual diffi-
culties occurring during the previous month and on sexual difficulties
lasting for at least 1 month in the previous year.
Of the 786 women who received the packet of questionnaires
10   TREATING SEXUAL DESIRE DISORDERS

assessing sexual interest, 45% completed the instruments. Of note,

when assessed by the SFQ alone, 48% of the respondents reported
low desire while 58% reported lack of sexual interest lasting for more
than 1 month during the prior year. However, when the FSDS, which
assesses distress about sexual desire or function, was included, the
figures dropped dramatically. In fact, when assessed by the combined
SFQ-FSDS scales, the prevalence of HSDD was only 16%! Moreover,
changing the recall period from the previous month to 1 month or
more during the previous year approximately doubled the prevalence
estimates for all of the sexual complaints, while adding the questions
about distress resulted in a nearly two-thirds reduction in prevalence
estimates.
What can be learned from this study? First, how one assesses
the duration of sexual disinterest results in very different estimates
of prevalence. If women are asked about lack of desire that lasted 6
months or longer, prevalence estimates of HSDD will be lower than
if asked about difficulties that lasted for 1 month or more (Mercer et
al., 2003; Hayes, Bennett, Fairley, & Dennerstein, 2006). Moreover,
without the experience of significant distress either on the part of the
low-desire individual or the partner, it is unlikely that there will be a
significant inclination to seek treatment unless the problem is causing
relationship discord. Even then, it is likely that there will be ambiva-
lent motives for altering the status quo. Typically, once a pattern of
sexual avoidance or sexual apathy has become engrained, it becomes
a new status quo. It is for this reason that complaints involving desire
are so difficult to treat successfully—lack of desire is usually not expe-
rienced as a major problem for the low-desire individual, and many
couples adapt to a “sexless” marriage even though they may bemoan
the loss of sexual passion.

Gender Differences in Desire

For centuries, it has been believed that women lack strong, resilient,
and proactive sexual desire, unlike men, who are “always ready.”
As Maurice observes (2007, p. 183), “Men not interested in sex? To
most, the idea is an oxymoron.” The truth is that all women are not
limpid, lustless creatures, devoid of lively libidos, and all men are not
bursting with testosterone-infused sexual motivation.
In fact, contemporary clinicians report that the numbers of men
who are disinterested in sex are not dissimilar from the numbers of
 Introduction and Overview   11

women complaining (or accused) of having low sexual interest. Survey

results of data collected during the Massachusetts Male Aging Study
of 1,709 men between the ages of 40 and 70 found a “consistent
and significant decline with age in feeling desire, in sexual thoughts
and dreams, and in the desired level of sexual activity” (McKinlay &
Feldman, 1994, p. 271). Clearly male sexual desire, like female sexual
desire, declines with age. But it is not only older men who display
a decline in sexual interest. Many younger men, too, are identified
as lacking libido. While some of these men are secretly pursuing an
active masturbatory or fantasy sexual life (as in the case described by
McCarthy and Breetz in Chapter 5), it is also the case that there are
men with long-standing and generalized low sexual desire. Women
partnered with, or married to, such men are not only frustrated and
angry, they often feel unattractive and unloved since they cannot com-
prehend why their partners are avoiding sexual (and, often, physi-
cal) intimacy with them. Many such women also feel thwarted in
their desire to become pregnant and start a family. While women with
low desire can still engage in sexual relations at the insistence of a
demanding mate, or in order to forestall guilt and recrimination, men
with low libido often have secondary erectile problems and cannot
“deliver” sex in order to satisfy an insistent female partner.
Nevertheless, among older adults, the stereotype that women
need to be coaxed, seduced, or even coerced into having sex contin-
ues to exist. Recall the Ogden Nash verse, “Candy is dandy but liquor
is quicker.” In fact, even today, some health professionals, frustrated
by the absence of a pro-sexual magic elixir, suggest that with a little
alcohol-mediated disinhibition or relaxation, women will be more
sexually receptive.
Recent research has definitely challenged the notion that female
sexual desire is merely a pale imitation of male desire. The work of
Meredith Chivers (2005; Chivers, Rieger, Latty, & Bailey, 2004),
for example, is a case in point. In a series of clever experiments, she
highlighted the fact that women respond physiologically to sexual
stimuli as quickly as do men, and, significantly, that they also respond
genitally to a broader array of sexual images than men—images that
depict both preferred and nonpreferred scenes (e.g., heterosexual and
homosexual images, bonobo monkeys, exercising women, and even
depictions of rape).
While Chivers believes that women’s sexual desire may be more
receptive than aggressive, that women may be evolutionarily pro-
grammed to have reflexive physiological arousal to a wide array of
12   TREATING SEXUAL DESIRE DISORDERS

stimuli, and that their subjective sexual desire is discordant with their
physiological arousal due to cultural or social constraints, others
believe that intimacy is the major key to awakening female desire.
Rosemary Basson (2001) is an advocate of this position. So is Lisa
Diamond (2005). Diamond argues that female desire is quite mal-
leable and is predicated more on emotional closeness than on gender.
Flexibility and fluidity are viewed as the essence of female desire by
Diamond, who studied the erotic attractions of nearly 100 women
over 10 years. While many of these women initially self-identified
as lesbian or bisexual, a decade later, two-thirds reported occasional
attraction to men. Moreover, many women agreed with the statement
“I’m the kind of person who becomes physically attracted to the per-
son rather than his or her gender.” While this same research has not
been done with men, it is unlikely that one would find the same fluid-
ity in terms of the objects of desire.
Finally, still another female sexuality researcher, Marta Meana,
has suggested that being desired is the key to women’s experience of
desire (Bergner, 2009). She believes that female desire is essentially
narcissistic—that intimacy is not as much of an aphrodisiac as being
lusted after. However, she and other researchers all acknowledge that
the variability of desire within genders is greater than the differences
between men and women.

Age-Related Changes
in Sexual Desire and Distress

Most studies find that sexual desire diminishes with age for both men
and women. What is interesting is that distress about reduced or lack
of sexual desire also tends to diminish with age. Hayes, Dennerstein,
Bennett, and Fairley (2008) compared two populations of women
between the ages of 20 and 70 in Europe and in the United States. For
both European and American women, the complaint of low desire
increased with age—the proportion of European women with lack
of desire increased from 11% among women ages 20–29 to 53% in
women ages 60–70. However, the proportion of women with low
desire who were distressed about their low desire decreased with age.
In the 20- to 29-year age group, 65% of European women and 67%
of American women with low sexual desire were distressed by it, but
these numbers decreased to 22% and 37%, respectively, in the 60- to
70-year age group. Apparently many individuals come to accept the
 Introduction and Overview   13

reality that sexual desire diminishes with age and relationship dura-
tion, and there may be less distress about these changes. However, it
should be noted that clinically, we continue to see men and women
who regret their diminished desire and want to restore or reignite
their sexual passion. In Chapter 2, Esther Perel discusses the chal-
lenges of maintaining eroticism and desire in the face of domesticity
and predictability.

Etiology of Desire Disorders

One of the challenges of treating sexual desire problems is the fact

that the etiology is so varied. All of the following may contribute to
sexual disinterest:

Biological factors: hormonal imbalance or insufficiencies, neu-

rotransmitter imbalances, medications and their side effects,
acute or chronic illnesses.
Developmental factors: lack of sexual education or permission; a
childhood or adolescence marked by emotional, physical, ver-
bal, or affectionate deprivation; sexual trauma or coercion.
Psychological factors: anxiety, depression, attachment disorders,
personality or other psychiatric disorders.
Interpersonal factors: relationship discord, insults, losses, or
partner sexual incompetence or dysfunction.
Cultural factors: religious or cultural mores and beliefs concern-
ing appropriate sexual conduct.
Contextual factors: environmental factors such as privacy, safety,
and comfort with surroundings.

Alternatively, desire problems are sometimes viewed as result-

ing from a variety of predisposing, precipitating, developmental, and
maintaining factors (Althof et al., 2004):

Predisposing factors include constitutional attributes such as

temperament (shyness vs. impulsivity, anatomical variations
or deformities, inhibition vs. excitation, personality traits).
Developmental factors include problematical attachment experi-
ences with parents, exposure to physical or sexual violence,
negative early sexual experiences, and so forth.
Precipitating factors can include life-stage stressors such as
14   TREATING SEXUAL DESIRE DISORDERS

divorce, infidelity, menopausal complaints, substance abuse,

or humiliating or shameful experiences.
Maintaining factors may include ongoing stress, fatigue, relation-
ship conflict, or body image concerns.

Given the heterogeneity of contributing factors, and the multiplic-

ity of considerations that are relevant to both the initiation and the
maintenance of sexual desire difficulties, the clinician must be creative
and skillful in planning sensible and effective treatment. It is obvious
that there can be no “one-size-fits all” model for therapeutic interven-
tion. As will be evident from the clinical illustrations presented in this
volume, each case is unique—every individual has an idiosyncratic
erotic blueprint or love map that may complement or conflict with
that of a partner. When erotic blueprints are in sync, couples easily
negotiate small differences in desire. When they clash, desire problems
may be more problematical to treat. And, from another perspective,
it is worth noting, as David Schnarch suggests in Chapter 3, that low
desire and high desire are often mutable positions in a relationship
system. Furthermore, the low-desire individual in one relationship
may be the high-desire partner in a new and different relationship.

Primary versus Secondary

versus Situational Desire

In diagnosing sexual desire disorders, it is important to ascertain

whether the complaint is primary or secondary, acute or chronic,
and acquired or generalized. Acute and situational problems usually
have a better prognosis than primary, generalized, and chronic lack of
desire. While there are many factors that may contribute to a second-
ary loss of desire, the full range of possible components can be daunt-
ing. Such factors can span everything from transient partner conflict
or the impact of disease or medication to a primary generalized lack
of sexual interest, where there is a total absence of sexual fantasies
or thoughts, masturbation, or any manifestation of sexual curiosity
or arousal. While some authors in this volume do report success in
treating such cases of primary absence (see Chapter 12, by Korda,
Goldstein, and Goldstein), the majority of successful cases described
in this book deal with situational or secondary lack of desire. In fact,
many clinicians report frustration and failure in their attempts to gen-
erate sexual interest in cases where the individual reports a lifelong
absence of desire.
 Introduction and Overview   15

Diagnostic Assessment:
Interview and Instruments

There are several standardized instruments and questionnaires for

assessing desire complaints (see Table 1.1), but nothing really replaces
the clinical interview where the individual and his or her partner are
seen individually and as a couple. Much light can be shed by learning
about the upbringing, family relationships, myths, and messages each
partner brings to the relationship, as well as by observing the verbal
and nonverbal exchanges of a couple together. Most of the chapters
in this volume attest to the utility of interviewing and treating desire
problems from a relational perspective.

Pharmacotherapy for Desire Disorders

At this time, there are very few pharmacological interventions for

enhancing desire. While sildenafil (Viagra) and the other phosphodi-
esterase (PD5) inhibitors (Levitra and Cialis) have proven extremely
useful in treating male erectile dysfunction, they do little for increasing
sexual desire itself in men (or women). One recent study did suggest
that sildenafil was a helpful adjunct in women experiencing sexual
dysfunction associated with antidepressant treatment (Nurnberg et
al., 2008). One of the more prosexual antidepressants is bupropion
(Wellbutrin), which has a lower incidence of sexual side effects than
the selective serotonin reuptake inhibitor antidepressants. There is
promising research under way with a new centrally acting drug, fli-
banserin, for the treatment of HSDD in premenopausal women, but
as of this writing it is not FDA approved. In Chapter 13, Bonnie R.
Saks provides a useful overview of the adjunctive use of medications
in working with individuals with desire problems.

Why This Book?

Desire complaints present a genuine conundrum. As we have seen,

changes in the amount or intensity of sexual desire are normative and
often inevitable over the course of a relationship, with life stresses
and developmental milestones, hormonal changes, and medications.
Nothing stays the same as we grow older and sexual desire is no
exception. The problem is often with false expectations—with the
fantasy that sexual desire is somehow immune from the whole array
 16   TREATING SEXUAL DESIRE DISORDERS

TABLE 1.1. Scales for Assessing Desire/Arousal Problems

Assessment of sexual desire/arousal problems is critical in planning meaningful and
sensible treatment interventions. The most common approach to diagnosing sexual
difficulties is via a comprehensive clinical interview of both the identified patient and
his or her partner. Such an interview includes discussion about the presenting problem
and the predisposing, precipitating, and maintaining factors that govern its appearance
and intensity (Grazziotin & Leiblum, 2005). It is also important to explore current
contextual factors that affect sexual expression and interest, such as relationship
satisfaction, privacy issues, current health of self and partner, medical or psychiatric
issues, use of medications or recreational drugs/alcohol that may affect sexual
expression, and current stressors.
Many clinicians find that the use of standardized self-report questionnaires can
be helpful initially in terms of saving time, identifying problem areas, and providing
direction or focus for a more extended clinical interview.
The following brief assessment tools have demonstrated good reliability and
validity:

• Brief Index of Sexual Functioning for Women (Taylor, Rosen, & Leiblum, 1994). A
22-item questionnaire that provides domain and total scores on the following aspects
of sexual function: desire, arousal, frequency of sexual activity, receptivity/initiation,
pleasure/orgasm, relationship satisfaction, and problems affecting sexual function.
• Decreased Sexual Desire Screener (Clayton et al., 2009). An easy-to-use five-question
instrument that provides rapid identification of generalized, acquired female hypoac-
tive sexual desire. It consists of four yes/no questions to determine whether a desire
problem and related distress exist. The more inclusive fifth question permits elabora-
tion of possible contributing or maintaining factors.
• Female Sexual Function Index (Rosen et al., 2000). A 19-item questionnaire specific
to women that assesses six domains (desire, subjective arousal, lubrication, orgasm,
satisfaction, and pain). It has been widely used in outcome research and has good
validity and reliability for diagnosing a variety of sexual complaints.
• Female Sexual Distress Scale (Derogatis et al., 2002). A 12-item assessment instru-
ment used to determine the amount of current distress experienced by a woman with
sexual difficulties. A cutoff score of 15 or greater is associated with personal distress.
• Female Sexual Distress Scale—Revised (Derogatis, 2008). The most recent validation
of the Sexual Distress Scale, which was undertaken in order to enhance the sensitiv-
ity of the instrument for patients experiencing HSDD. The new question that was
included is: “Are you bothered by low sexual desire?” and the respondent circles
never (0), rarely (1), occasionally (2), frequently (3), or always (4).
• Golombok–Rust Inventory of Sexual Satisfaction (Rust & Golombok, 1986). A
28-item questionnaire that encompasses five domains relevant to women: anorgasmia,
vaginismus, female avoidance, nonsensuality, and female dissatisfaction.
• HSDD Screener (Leiblum et al., 2006). A four-item screener that asks about loss of
desire and distress in postmenopausal women.
• Sexual Desire Inventory (Spector, Carey, & Steinberg, 1996). A 14-item questionnaire
that measures domains of dyadic and solitary sexual desire.
• Sexual Function Questionnaire (Quirk et al., 2002). A relatively new instrument
designed to assess eight domains of women’s sexuality: desire, physical arousal/sensa-
tion, physical arousal/lubrication, enjoyment, orgasm, pain, partner relationship, and
cognition.
 Introduction and Overview   17

of changes that occur with aging, that while we may lose our hair and
pack on the pounds, we somehow can maintain the sexual desire we
had as 18-year-olds.
Ridiculous, we all agree. And yet, while lack of desire is not a life-
threatening problem, it is often distressing and problematical to rela-
tionships and to our comfort with and satisfaction in them. A partner
who is repeatedly sexually rejected or only reluctantly accepted feels
hurt and frustrated and, finally, will often become angry or depressed.
Over time, the sense of intimate connection with a partner is compro-
mised. There is less physical teasing or affection, fewer spontaneous
hugs or passionate kisses. Physical avoidance may replace affection-
ate snuggling since affection may be misinterpreted as a sexual invita-
tion.
Alternatively, there may develop a greater reliance on pornogra-
phy or masturbation. Often, there is the defensive decision on the part
of the rejected partner that if any sexual intimacy is to occur, it must
be initiated by the low-desire mate; the pain of rejection has become
too great. The relationship is described as one of “roommates” rather
than “lovers.”
Whether seen as a psychiatric diagnosis or a relationship prob-
lem, complaints involving too little, too much, or discrepant desire
are indeed legitimate concerns that warrant intervention. But how to
intervene? Typically, desire concerns are not only frustrating to a cli-
ent or couple, they are frustrating to the clinician as well. Anecdotally,
many therapists say that they “dread” cases involving desire problems
because they are uncertain about how to successfully intervene. There
are no cookbooks or prescriptions for creating desire.
Clinicians also sometimes wonder if it is even possible to ignite
desire where none has existed. Can the person who reports lifelong
sexual apathy become sexually motivated or receptive? Should he or
she be encouraged to? Can sex become lusty when it has become
lackluster? What are reasonable expectations or treatment goals in
these cases?
These are the questions that prompted this book. In order to
find answers, prominent and expert clinicians of varying persuasions,
training, and therapeutic philosophies were asked how they approach
and treat desire problems. What has (or has not!) worked for these
experienced and thoughtful clinicians?
Of course, given the complex and multifactorial etiology of desire
complaints, there is not (and never will be) a standardized treatment.
But seeing how top-notch therapists think about desire cases is illu-
18   TREATING SEXUAL DESIRE DISORDERS

minating. The contributors to this volume represent a wide spectrum

of backgrounds and training. Each is skilled in his or her craft and
has earned the title of expert. The chapters that follow are both pro-
vocative and stimulating. They challenge stereotypes and they reject
the chimera of easy remedies for complex problems. But above all
they constitute a thoughtful, nuanced, and pragmatic reflection of
the many approaches to the assessment and treatment of desire com-
plaints in current clinical practice.
This book does not attempt to be comprehensive in its overview.
While there has been an attempt to balance examples involving men
and women, gay and straight, older and younger clients, the authors
were free to select cases they believed were representative of their
clientele and treatment philosophy. It is to be hoped that the reader
will come away from this volume with an increased appreciation of
the spectrum of approaches and interventions for assisting individuals
and couples with desire issues, and will feel awe and admiration for
the artful interventions of these skilled clinicians.

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Taylor, J., Rosen, R., & Leiblum, S. (1994). Self-report assessment of female
sexual function: Psychometric evaluation of the brief index of sexual
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L., et al. (2009). ISA, ISSAM, EAU, EAA and ASA recommendations:
22   TREATING SEXUAL DESIRE DISORDERS

Investigation, treatment and monitoring of late-onset hypogonadism in

males. International Journal of Impotence Research, 21(1), 1–8.
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Whalen, R. (1966). Sexual motivation. Psychological Review, 73, 151–163.
 Chapter 2

The Double Flame

Reconciling Intimacy
and Sexuality, Reviving Desire

Esther Perel

“Love is about having and desire is about wanting.” This is the major obser-
vation that guides Esther Perel’s therapy as she works with couples com-
plaining of loss of desire. She observes that lack of desire does not neces-
sarily reflect a disordered relationship and that erotic ruts are part of being
a loving, caring couple. She lays out a paradox: the very ingredients that
nurture love are often the ones that erode erotic passion. Perel turns the
usual therapeutic approach on its head with this suggestion: first improve
the sex, an improved relationship will follow.
In order to reconcile the paradox that inevitably exists between the wish
for an all-knowing intimacy and the heightened passion that accompanies
the unfamiliar and unpredictable, it is necessary to cultivate mystery and
tolerate separation. As she observes, “Desire balks at consistency and is
motored by absence and longing.” Fantasy and imagination constitute key
ingredients in liberating and reawakening desire, not insistence, demands,
or negotiation. It is not the innovative techniques she is after, but the experi-
ence of anticipation surrounding the mystery of the other and the unknown
in ourselves.
In her fascinating case description, Perel illustrates how the unique
erotic blueprints of Alicia and Roberto developed and were initially effec-
tive in supporting their erotic life. But in their current relationship they have

23
24   TREATING SEXUAL DESIRE DISORDERS

fallen into the familiar roles of pursuer and distancer, which satisfies neither.
Furthermore, the way they are emotionally organized around each other is
too reminiscent of their original families, which inevitably numbs all forms of
sexual expressiveness.
The therapy engages the partners to uncover and to free themselves
from their erotic blocks. Like so many women, Alicia dislikes Roberto’s sexual
directness, which she experiences as neediness. She wants seduction and
transgression to lift her from her internalized prohibitions. For Roberto, famil-
iarity breeds content and he values comfort and intimacy to spark his desire.
Once they are encouraged to use their imagination and to discover new
ways of seducing and beguiling each other, their erotic desire increases.
Perel concludes her chapter with the reminder that in long-term rela-
tionships, active engagement and willful intent are needed to nurture eroti-
cism and maintain desire.
Esther Perel, MA, LMFT, is a practicing marital and family therapist
in New York City. She is the author of Mating in Captivity: Reconciling the
Erotic and the Domestic, which has been translated into 24 languages. She
is recognized as one of the most original and provocative theorists in the
field of sex therapy today.

The Domestic and the Erotic

As a couple therapist, I see young and old, married or not, gay, bisex-
ual, and straight, with passports from all over the world. Plenty has
changed in my 25 years of private practice, but not my patients’ open-
ing lines. They tend to go something like this: “We love each other
very much, but we have no sex.” Next they’ll move into describing
relationships that are open and loving, yet sexually dull. Time and
again they tell me of the paradoxical relationship between domestic-
ity and sexual desire. They treasure the stability, security, and predict-
ability of a committed relationship, they miss the excitement, novelty,
and mystery that eroticism thrives on.
When they complain about the listlessness of their sex lives, they
sometimes want more frequent sex, but they always want “better”
sex. They want to recapture the feeling of connection, playfulness,
and renewal that sex used to allow them.
Modern committed couples have a long list of sexual alibis that
claim to explain the death of eros. They are too busy, too stressed,
and too tired for sex. Eventually lamentations about the kids, the
house, the job trail off, and more complex and nuanced obstacles
 The Double Flame   25

come forward: couples who are such good friends they cannot sustain
being lovers; lovers so set on spontaneity that sex never happens at
all. I see power struggles that escalate into erotic stalemates, emo-
tional arrangements that are overly familial and blatantly desexualiz-
ing. Some clients feel sheepish, others rejected, and some are just plain
confused—all of them, however, have experienced a genuine loss.
So why does great sex so often fade for couples who love each
other as much as ever? Why does good intimacy not guarantee good
sex? Why does the transition to parenthood spell erotic disaster? Can
we want what we already have? Why is the forbidden so erotic? When
we love, how does it feel, and when we desire, how is it different?
I seek to probe the ambiguities of love and desire in long-term
relations, to explore the fears and anxieties that arise when our pursuit
of safety and security clashes with our quest for passion and adven-
ture. We seek predictability on one hand, and thrive on discovery
and adventure on the other. Psychoanalyst Steven A. Mitchell (2002)
makes the point that these are two fundamental, yet opposing human
needs that pull us in different directions. Partners today need to negoti-
ate their dual needs for familiarity and novelty, their wish for certainty
and surprise. Yet it is difficult to generate excitement and anticipation
with the same person we look to for comfort and stability.
In the West we take for granted the idea that marriage is the key
to everything. We turn to one person to fulfill what an entire village
(friends, community, extended family) once delivered. We expect our
partners to be the primary supplier for our emotional connections, to
provide the anchoring experiences of life. Intimacy and transparency
in the romantic marriage are paramount, meant to help us transcend
the aloneness of modern existence and be a bulwark against the vicis-
situdes of everyday life. We seek security, as we always have, but now
we also want our partner to love us, cherish us, and excite us. For
the first time in history, we have sex not because we want eight kids
or because it’s the woman’s marital duty; today’s couples count on
desire and sexual fulfillment as key ingredients to a happy marriage. I
believe we must recognize that reconciling the erotic and the domestic
is not a problem we can solve, it is a paradox we manage.

The Numbing of Desire

Traditional couple therapy believes that sexual problems stem from

relationship problems. Poor communication, lack of intimacy, and
26   TREATING SEXUAL DESIRE DISORDERS

accumulated resentments are some of the explanations given to

explain the numbing of desire. Find out about the state of the union
first, see how it manifests in the bedroom second. The premise is that
a troubled relationship equals no sex; improve the emotional relation-
ship, and the desire will follow.
But my practice suggests otherwise. I’ve helped plenty of couples
buff up their relationship and it did nothing for the sex. It made a
difference in the kitchen, but it did little for the bedroom. Strengthen-
ing the caring and the companionate affection is often not enough to
generate erotic desire. In such situations, I invert the traditional thera-
peutic priorities, asking about the partners’ sexuality first. It becomes
a window into the self, the couple’s dynamics, and their families of
origin. I flip the equation: improve the sex, and the relationship will
follow. Sex is not a metaphor for the relationship, but rather a parallel
narrative, one that speaks its own language.
Love and desire—they relate and they conflict, and herein lies the
mystery of eroticism. The rules of desire are not the same as the rules
of good citizenship. It is not always the lack of closeness that stifles
desire, but too much closeness. Many couples are disappointed to
discover that the closeness and comfort they crave are exactly what
douses the fire. More intimacy doesn’t always make for more sex. In
fact, sometimes the very qualities that nurture intimacy—grounding,
familiarity, and continuity—can be sexually deflating and drain the
passion right out of our relationships.
Stability, understanding, and compassion are the handmaidens of
a close, harmonious relationship, while eroticism thrives on novelty,
mystery, and the unexpected. There is a complex relationship between
love and desire—between a couple’s emotional life together and their
physical life together, and these don’t always correspond. What is
emotionally satisfying isn’t necessarily sexually exciting. That’s one
reason why, to the chagrin of many, you can often “fix” the relation-
ship and it will not do anything for the sex. Intimacy begets sexuality
only sometimes.
If love is about having, desire is about wanting. Love wants to
contract distance, and minimize the threat; it wants to collapse the
tension. It seeks closeness and wants to know the beloved. Desire
balks at consistency and is motored by absence and longing. For some
of us, love and desire are inseparable. But for many others, emotional
intimacy inhibits erotic expression. For them, the caring, protective
elements that foster love block the freedom and unself-consciousness
that fuel erotic pleasure.
 The Double Flame   27

Let me illustrate: Think of a little child who sits comfortably nes-

tled on your lap. At some point she jumps off and runs out. At a dis-
tance, she stops, turns, and get her cues from the adult she just left. If
the adult says, “Go ahead, kiddo, the world is a beautiful place with
lots to discover. Have fun,” the little child turns away and runs fur-
ther. She experiences both freedom and connection, and at the same
time, the security of love and the autonomy of desire. This child who
plays hide and seek will one day turn to eroticism as the adult version
of hide and seek, where she’ll maintain playfulness and discovery,
alternating between the dangers of hiding and seeking and the relief
of finding and being found.
There is, however, another scenario with a very different outcome.
This time the adult says: “What’s so beautiful out there? Isn’t being
together enough? I am lonely, I am anxious, depressed . . . ” Here,
the child has a few choices. One of them is to return to base. They
learn that in order not to lose that connection with the other, they’ll
have to lose a part of themselves. In my experience these are often the
people who, later on, will have a hard time making love to the person
they love. The legacy of this bargain for attachment produces a puz-
zling inverse correlation where growing intimacy leads to diminished
desire. In his book Arousal: The Secret Logic of Sexual Fantasies,
Michael Bader (2002) explains that it isn’t a fear of intimacy or a
lack of commitment that solders their block, rather it is the nature of
their love—burdensome and confining—that stands in the way of the
desire. The worry and responsibility they feel for their beloved fore-
closes the necessary spontaneity and selfishness for erotic abandon.
Sexual intimacy is an act of generosity and self-centeredness, of
giving and taking. We need to be able to enter another without the
terror that we will be swallowed and lose ourselves. At the same time
we need to be able to enter ourselves, to surrender to self-absorption
while in the presence of the other, believing that they will still be
there when we return, that they won’t feel rejected by our momentary
absence. The self absorption inherent in sexual excitement obliterates
the other in a way that collides with the ideal of intimacy. So many
people believe that they can be safely lustful and intemperate only
with people they don’t know as well, or care about as much.
Tell me how you were loved, I’ll tell you how you make love. This
is a construct I often work with. Our sexual preferences arise from the
thrills, challenges, and conflicts of our early life. How these bear on
our threshold for closeness and pleasure is the object of our excava-
tion. Not coincidentally, our entire emotional history plays itself out
28   TREATING SEXUAL DESIRE DISORDERS

in the physicality of sex, and our erotic blueprints are layered with
these childhood experiences.

Fire Needs Air

Desire wants to go where it hasn’t yet been. It needs otherness, differ-

ence. But for erotic élan there needs to be a synapse to cross. Modern
couples strive for oneness, yet eroticism thrives in the space between
self and the other.
Because this concept may seem abstract, I routinely ask the fol-
lowing question: “When do you feel most drawn, most attracted to
your partner?” The answers resonate with a remarkable similarity.

“After we’ve been apart . . ., when he’s confident and passionate

about something he loves. . . . When she’s unaware I’m watch-
ing her. . . . When he is talking with friends. . . . When he surprises
me. . . . When we’re at a party and I see others looking at her. . . .
When she’s standing on the other side of a crowded room, and
she smiles just for me. . . . When he’s playing with the kids. . . .
[This is the only comment that is gender specific, for men rarely
think that a mother playing with the kids is sexy.] When we’re
away from home, and have fun together. . . . When we dance . . .
When I ride on the back of his motorcycle . . . When I see him
play sports. . . .

Whatever the answer, it is never without an element of distance. It is a

description where we look at our partner from a comfortable distance.
Not too close because we cannot distinguish them from ourselves,
and not too far, for then they are no longer in our field of vision. We
see a partner who is separate, whose difference is magnified. And
this person who is otherwise already so familiar is momentarily once
again somewhat unknown, somewhat mysterious and elusive. More
importantly, in none of these situations is the other needing us, nor
do we need to take care of him or her. Caretaking may be very loving,
but it is also a powerful anti-aphrodisiac. In sex, people want to feel
wanted, not needed.
We create a bridge of things unknown by making a perceptual
shift, and it is on this bridge, in the space between us, that we can
meet and play with the erotic. Sometimes introducing mystery is
nothing more than a shift in perception. In the words of Proust, “The
 The Double Flame   29

real voyage of discovery consists not in seeking new landscapes but in

having new eyes.”
The question posed earlier—“Can we want what we already
have?”—invites us to admit that we never “have” our partners. It
is our willingness to engage with the mystery that keeps desire alive.
Faced with the irrefutable otherness of our partner, we can respond
with fear or with curiosity. We can try to reduce them to a knowable
entity, or we can embrace their persistent mystery. When we resist the
urge to control, when we keep ourselves open, we preserve the possi-
bility of discovery. Eroticism resides in the ambiguous space between
anxiety and fascination. We remain interested in our partners; they
delight us, and we’re drawn to them. It is not mere emotional anxi-
ety, but rather the existential reality that there is no permanence, no
lasting holding. When we trade passion for reality, maybe we are just
trading one fiction for another. In the words of therapist Anthony
Robbins, passion is commensurate with the amount of uncertainty
we can tolerate.

Eroticism as Aliveness, Pleasure, Imagination

My interest is in the erotic, not only in the act of sex. The physical act
of sex is often too narrow and it easily degenerates into conversations
about numbers and performance. The erotic landscape is vastly larger,
richer, and more intricate than the physiology of sex or any repertoire
of sexual techniques. What people long for is radiance, beating back
deadness.
This focus on eroticism comes from my work with traumatized
populations and from growing up in a community of Holocaust survi-
vors, where I always observed two groups. There were those who did
not die, and those who came back to live. Those who didn’t die lived
quite tethered to the ground, pouring their energies into finding basic
trust, alleviating their fears, and guarding against a dangerous world
outside. Pleasure for them was fraught with guilt and fear. Those who
came back to live were eager to reenter the world, forge ahead, recon-
nect with playfulness and pleasure and take risks. They understood
how to cultivate aliveness, vibrancy; they experienced the erotic as an
antidote to death. This distinction also applies to the couples I work
with: there are those who survive and those who are alive. I think of
eroticism beyond the sexual meaning that modernity has assigned to
it. Couples who have an erotic spark know how to cultivate a sense of
30   TREATING SEXUAL DESIRE DISORDERS

aliveness, vibrancy, and vitality over the long haul. They understand
that the central agent of eroticism is the imagination. Not the one that
focuses on new sexual positions, but one where we continue to imag-
ine our partner with a compelling curiosity and we remain interesting
and attractive to ourselves.

Sex and Intimacy Speak Many Languages

No matter which country you are from, which language you first
spoke, it is the language of the body that is the universal mother
tongue. The body is a vital language, a conduit for emotional inti-
macy. As Roland Barthes wrote, “What language conceals is said
through my body. My body is a stubborn child, my language is a very
civilized adult.”
The modern world of coupledom has done much in the way of
censoring both men and women in this primal parlance. For men, the
body is often the center of tenderness and vulnerability, and it longs to
speak. Our emphasis (or overemphasis, rather) on the macho, power-
driven aspects of male sexuality works to mute the very expression
we seek. Conversely, for women, the emphasis is on words, estranging
them from a rich panoply of connection to their bodies. Any thoughts
of lustfulness, physicality, or hunger are legitimized only when lay-
ered in relatedness or duty. With sex and intimacy at the epicenter of
the couple’s identity, they need to give themselves permission to be
bilingual.
In the case example that follows, I illustrate how these concepts
play out and how I use them to reignite desire in a couple that have
lost their erotic life.

Case Example: Alicia and Roberto

Alicia and Roberto, an attractive, intelligent, and loving couple come

for treatment, complaining of their moribund sex life. Alicia is 30,
born in a small village in Andalucia, to a devout Catholic bourgeois
family. Her mother came from a family of 12 children, ruled under
the strict authority of her father. After meeting her husband-to-be she
married him quickly and was whisked away. They both shared the
impatience of those who can’t wait to leave the hamlet and migrate to
the big city, get an education, and move abroad. This is exactly what
 The Double Flame   31

they did, with two daughters in tow. Alicia was the oldest, and in her
words: “I was my mom’s object.”
In the various European countries where her family lived, she
could attend local schools but not become a local girl. Her mother
was critical of the permissiveness she saw in the postmodern families.
Like many other traditional immigrant families who confront today’s
Western culture of family democracy and its unprecedented child
centrality, Alicia’s parents were critical of the permissiveness they
observed. They feared that unregulated freedom would expose their
daughters to male predators, who would take advantage of them,
sexually and emotionally.
Mom and Dad divorced, and the restrictions only grew. Alicia
had to jump through the window to play with her friends and rendez-
vous with her secret boyfriend. She pieced together a sexual education
bit by bit. From Mom she learned about the birds and the bees and
menstruation, and received warnings about sexual dangers. From her
friends she picked up her knowledge of romance and fun. One day
she was caught and severely punished for being with her boyfriend.
She opted for depression rather than rebellion.
With Alicia in a state of despondence, and Grandpa, the patriarch,
dead, her mother started therapy. Surprisingly, she embarked on a sys-
tematic journey of rejection and transformation. Once a traditional,
religious, compliant, rule-based, sexually numb, and discipline-driven
woman, she became independent, pleasure seeking, emancipated,
and liberated. She transformed so much that, according to Alicia, she
jumped two centuries in 2 years.
Roberto’s roots were Andalucian as well. His grandfather was a
world traveler, who brought his bewitching, dark-eyed Mediterranean
woman to the Americas. At 33, Roberto was about to start a degree
in public policy. He described an affectionate family—a father who
took him on long walks, where they enjoyed solving the riddles of the
cosmos. Mom was a jewelry maker, caring but withdrawn, and hard
to talk with. One day, Roberto confronted her about her hermetic
character, and her response came with tears: “That’s the way I am, I
will not change.” That was his last attempt to get through.
As far as he can remember, Roberto’s parents never shared a bed-
room, and only years later was he told why. Dad was physically and
romantically effusive, Mom was not. So he took his hands and body
to many other women. It was only in college that Roberto learned
of the incessant dalliances of his father, a piece of information that
became central to Roberto’s life. For reasons he is only now starting
32   TREATING SEXUAL DESIRE DISORDERS

to understand, he became a consummate lover. “Growing up, sex was

a normal part of development. I didn’t associate much anxiety with
sex. It was a source of pleasure, a conduit for intimacy and bonding.
When my mother found condoms in my room, she said it was smart
that I was using protection.”
Roberto liked girls, and girls liked him. He sampled and explored,
and beginning with his first girlfriend, “I was purposeful and unfaith-
ful. I became greedy, courting disaster to see how much I could handle
at once without imploding. I was profoundly selfish, even though I
was generous in bed. I was a master liar and cheater. Seeing how easy
it was to lie, I became terrified it could be done to me.” His jealousy
on constant alert, Roberto was afraid to be deceived himself.
After college, Roberto traveled to Spain for a fellowship, ready
for new emotional incursions. He met Alicia in Barcelona, where she
was studying at the university. She took him by the hand, leading
him through the winding narrow streets, and introduced him to her
favorite tapas, and they got tipsy on sangria. They fell madly in love.
Alicia was very different from his mother or other girlfriends—she
was vivacious, outspoken, and exuberant. Their sex was fast-paced
and adventurous. After a few months, they began a long-distance
relationship that lasted almost 2 years. Technology was their trusted
accomplice. Phone sessions, Skype sex, e-mails, texting, and a trip
here and there added fuel to the flame.
Finally, Alicia moved to Philadelphia, joining Roberto in his tiny
studio. The next phase of their relationship began. Immigration came
with many demands—learning to speak English, acquiring a visa,
finding a job. In addition, there was homesickness and the stress of
living in a noisy city. Roberto tried to cushion the shock. He showed
Alicia the ropes, wrote her application letters, and served as her cul-
tural translator.
Within a few months, their sexual ardor declined and slowly faded
away. They attributed it to the changes they were going through. As
Roberto later tells me, “It made sense, but none of the explanations
made a difference.” Nevertheless, he wanted to make Alicia feel safe,
so he curtailed his hobbies and social activities. Anything that Alicia
didn’t share with him was taken off the list, and with it, his individu-
ality. While this made Alicia feel safe, it made Roberto feel suffocated.
But he was fearful of making Alicia unhappy. After all, she had left
friends and family in Spain for him. How could he ask for more? But
without a sex life, he felt barren.
Roberto had always enjoyed a robust appetite for the pleasures
 The Double Flame   33

of the flesh. For him, the plummeting of their sexual relation feels
unending. He is frustrated and alarmed by the thought that things
will never change and that he will revert to old behaviors of finding
other women, but he is definite about one thing: he won’t accept a
carbon copy of his parents’ relationship—a sexless marriage with a
life of never-ending infidelities.

Initial Session
When I first meet the couple, they have been together for 6 years,
the last 3 teetering on the verge of sexual collapse. Alicia is the one
who withholds sexually, but she doesn’t like the situation any more
than Roberto. She vacillates between guilt and resentment, wishing
he would not give up, and then demanding that he stop badgering her
and leave her alone.
Roberto has become more clumsy, desperate, and unattractive.
Alicia says she likes a confident man, but Roberto objects that it is dif-
ficult to remain confident in the face of constant criticism and rejec-
tion. More rejection leads to more loss of confidence, which leads to
more neediness and then again more refusal.
Together we map the pattern of negative escalation, how it fol-
lows a sequence of complementary reactions. We draw from the other
behaviors that match our expectations of them. The more Alicia
reacts, the more Roberto pressures. The more he pressures, the more
she distances, bemoaning his lack of subtlety. His desperate groping
will make Alicia pull back even more although this is the opposite of
what he wants. Her keeping him at bay will make him become even
more needy, even though this is the last thing she wants. This dance of
pursuit and distance is quite common, and on the surface it looks like
a discrepancy of desire. I reflect that although it appears that Roberto
wants sex and Alicia does not, in fact, they both are frustrated.
I know that Alicia is baffled by her lack of wanting. This is not
the person she wants to be, nor the one she used to be and liked. As
is often the case when people are mired in this predicament, when I
ask Alicia to tell me about her sexual thoughts, she tells me about
his. Her mind is filled with Roberto’s wishes and disappointments,
and she ends up being out of touch with her own wanting and feel-
ings. Acutely aware of what he wants, she no longer knows what she
wants.
I ask that she carry a notebook where she will write any erotic
musings—catch them, write them, own them. We play with this tri-
34   TREATING SEXUAL DESIRE DISORDERS

partite equation, and in the coming weeks she will report if she was
aware of having any sensations, feelings, thoughts, inclinations. At
the next level, she’ll see if she was able to bring them inside her: when
we write, we commit ourselves on paper. And lastly, if she could own
and remember them, it would help draw a boundary between her
and Roberto, demarcating her sexual territory from his. This mindful
exercise has been valuable and Alicia has been doing it since treat-
ment began. Roberto is encouraged to do this as well.
In my work, I see the couple together, as well as individually. At
times Alicia talks about her sexual meanderings alone, other times she
shares them with Roberto. The individual sessions are always confi-
dential. This allows each person to think alone, examine and clarify
for themselves from a less defensive stance. They can decide what
insights and questions they want to bring to the joint session, and
how.
I see Alicia’s block, but I don’t immediately attribute it to a total
lack of desire. I check: It is completely gone? On hold? Directed some-
where else? Alicia’s sentence starts with “I have no desire,” and I want
to find out if the second part of the sentence will be “at home,” “with
him,” or generally?
Our conversation veers to Alicia’s dislike of Roberto’s straight-
forwardness, his lack of suggestiveness, and blatant advances. “When
he says, ‘here’s my cock, wanna take it’ that is not playful for me. It’s
very American this pragmatic approach to sex,” she says: “Direct, to
the point, don’t beat around the bush.” “Does it diminish Roberto’s
sexual appeal?” I ask. She nods. Alicia taps into a common myth, the
logic of which says: if I have to tell him what I like, what I am and
what I want, it means he needs instructions, and if so, then he lacks
intuitiveness, savoir faire. Conclusion: he is certainly not sexy, since a
sexy man needs no tutorial.
At this time we unpack another cultural quandary. Historically
and traditionally, the man who is sexually served by his wife needs
no instructions, for what she wants is unimportant. But the man who
hits the “right spots,” the one who knows intuitively what she likes,
is heralded as the man with the special touch, the one who doesn’t
need directions. Male arrogance has historically been met with female
deference. But these stances continue to be reinforced today. While
Alicia resents male superiority, she has difficulty accommodating to
the alternative. When Roberto asks her for guidance, she regards him
as less masculine. If he forges ahead with his lust, she reacts negatively
about his lack of sensitivity.
 The Double Flame   35

Dismantling traditional gender roles takes a bit of psychological

sleuthing, but little in one’s erotic imagination is happenstance.
Alicia wants more play, not foreplay, an elaborate seduction, the
“Juego,” as she calls it—a choreography of seduction that alternates
between approach and retreat, meant to stoke the wanting. The sub-
text reads: “You think I am attracted to you and that you can just
have me, but you’re wrong. You don’t have me yet. Now I distance
myself, I’ll make you want me more. I come closer again and you
think, this time, I got her. You’re wrong again. I move away once
more. You come after me. The more persistently you pursue me, the
more attractive and irresistible I feel, which makes me move away
some more to see if you’ll keep coming after me, if I can make you
want me even more.”
Alicia tries to explain to Roberto that sex isn’t something that
starts at 7:00 and ends at 8:00. It’s an attitude. Roberto replies that
in the beginning Alicia didn’t need any of this. She too was direct,
aggressive, and open to the raw edge of desire. She recognizes his
description, but she’s in a different place now. Roberto is very open
and willing—“I’ll try anything.” But rather than being receptive
to Roberto’s openness, Alicia responds that she doesn’t like having
to explain what she wants. I clarify that seduction isn’t only about
flooding the other with your wanting, but rather eliciting their own
wanting—to seduce is not to induce. Roberto is willing to venture
outside his comfort zone, but Alicia needs to be responsive. When she
redirects his advances, she has to curb her criticisms. She can guide
him and then resent him for not knowing, or she can appreciate a
new generation of men who invite being directed and don’t pretend
to know.
I discuss with them that this playful attitude, the “Juego,” is a
way of relating to each other that is not just about being turned on,
it is about maintaining an erotic interest for the other. They agree.
I know that Alicia and Roberto play, but they describe it as “silly
play,” and while it’s wonderful, it isn’t sexy. It is a kind of play that
is reminiscent of how children play: it can be sweet and affectionate,
but it is unerotic. In fact, it often operates as a sexual appetite sup-
pressor. When a couple becomes too familial, they desexualize the
relationship. A hint of incestuousness hovers over them. Alicia points
out that in order to engage in that other kind of play, she needs to feel
safe; she is not interested in having that kind of play with a random
person on the street. She’d like to be able to relax and let that side of
her go, with him.
36   TREATING SEXUAL DESIRE DISORDERS

Roberto is intrigued by the fact that on one hand Alicia talks

about wanting to be intimate with the person with whom she is play-
ing these seductive games, but on the other hand, her predilection is
for erotic games of anonymity, of not knowing the person. I clarify
that play involving anonymity and fantasies about strangers—like
going up to him at the gym and pretending she’s never met him in
the context of an intimate relationship—springs from a familiarity
that’s already been established. The secure connection is the base
from which we freely enjoy “a room of one’s own,” and one for our
partner as well.
Roberto tells me that for him, familiarity makes for better sex—
he likes to feel comfortable, unencumbered. He likes the comfort
released by emotional intimacy, the context, the sexual communica-
tion between him and his partner, and the ease he feels with him-
self. Comfortable is an erotic proposition for Roberto. When you feel
familiar with someone, you no longer need to seduce, and the ease
comes from the fact that the other person is there. At the same time,
he’s beginning to recognize that within this comfort, maybe he has
not left enough space for himself, and that his striving for transpar-
ency and wholesale sharing isn’t conducive to the mystery and the
unknown that ignite desire.
For Alicia, “comfortable” resonates with “obvious” and with old
expectations. “You’re supposed to have sex with your husband, obvi-
ously,” she says in her melodic Castilian accent. “And if it’s what you
should do?” I ask her. “Then it’s not exciting,” she replies. “Does
obviousness stir rebelliousness?” I pursue. “Yes,” she asserts. “When
you emit a resounding no, you’re certain not to do what you’re sup-
posed to do. It is a way to engage your free will.” As things stand
now, her sexual autonomy manifests as a sexual lobotomy.
Alicia makes the connection that coming from a strict Catholic
rule-based upbringing she learned that sex was a duty performed by
women for men. Roberto is quick to inquire, if he didn’t want to have
sex with her, would she be more interested? And the answer is yes,
because it would release her from a feeling of duty and obligation and
it would make room for her own independent wanting. It is difficult
for her to want what he wants and still feel that it’s her own. So if he
were not interested, then she could come forward, and there would
be a boundary delineating her interest. I clarify that Alicia’s reaction
isn’t about him. It is about insubordinance and autonomy, a rebellion
against the confines of matrimony and the traditional role of women
performing sexual duties.
 The Double Flame   37

There is another transaction between them that goes in the same

direction. Alicia is often interested in sex with Roberto after they’ve
had a fight—something that goes against everything he likes about
the comfort and ease of sex. For Roberto, who is always ready for
sex, this is the one time where he’s really turned off. When he’s angry
he’s less in touch with how much he cares for her. Fighting and argu-
ments create a greater separateness. Fighting legitimizes our thoughts,
our feelings, and our needs. When we defend our cause, we boost
our sense of entitlement. After a fight Alicia’s sense of obligation is
lessened and her sense of autonomy is heightened. Hence, she can
experience the freedom and the selfishness needed for desire while for
Roberto the opposite is true.
Understanding our erotic blueprint involves tracing the cultural
and familial messages that we were raised with. In Alicia’s case,
they were presented to her in black and white: premarital sex is
forbidden, marital sex is for babies—a woman’s duty toward her
husband—and pleasure is sinful. And while rationally she no longer
believes this, she feels that these beliefs are engraved inside of her,
reinforced by her large family of 12 uncles and aunts. It appears
that while mother and sister forged ahead on the new road, Alicia
became the repository of all that had been left behind. “I am the
one carrying our legacy. It’s as if all the prohibitions of my Catholic
upbringing have been transferred onto me. I’m the one who’s caught
in this sexual and emotional conundrum. It’s as if it all stayed with
me, all the taboos.”
I am aware that the forbidden can be very erotic, and that trans-
gression can be an essential ingredient, and so I ask Alicia, “If pleasure
is sinful, how does the forbidden become pleasurable?” The anonym-
ity of the back of the taxi, the public places, the restaurants—all those
forbidden places invite a lustful transgression for her. Digging into
the secret logic of sexual fantasies, Michael Bader (2002) explains
that in the sanctuary of the erotic mind we find a psychological safe
space to undo the inhibitions and fears that roil within us. Alicia’s
fantasies state the problems and offer the solution. Her sexual imagi-
nation allows her to negate and undo the limits imposed on her by
her conscience, by her culture, and by her self-image. Simply put: If
she doesn’t know him, she is free of the traditional female sexual duty
and obligation.
And with this new insight, Roberto is beginning to find his way
through the maze of Alicia’s erotic mind. At this point however, he
needs reassurance. He worries that he would have to give up one type
38   TREATING SEXUAL DESIRE DISORDERS

of closeness for another, that he would need to let go of a certain emo-

tional intimacy in order to experience a sexual intimacy.
But Alicia doesn’t make it easy for him. She feels she’s at an
impasse. She tells him of her conflict, between her love for the fam-
ily she could have with him and the fact that family is the last place
she can imagine having pleasurable sex. I suggest that they become
cultural translators for one another and help each other navigate the
split. I explain to them that I can imagine that all these public places,
where you’re not supposed to have sex, are exciting precisely because
they take Alicia out of the family. There are no two places more differ-
ent than the banquette in the restaurant and the matrimonial bed. At
this moment, I have images from many of the Spanish and Portuguese
movies I’ve seen of a room with a huge bed, complete with looming
headboard, a crucifix on the wall, and women dressed in black. For
a moment we enjoy naming some of movies with our favorite scenes
of pleasure morgues.
There’s a relief in the room, because for the first time both Roberto
and Alicia feel that they’re getting somewhere and that they’re touch-
ing some of the roots of what has been so stultifying in the last 3 years.
It is becoming clear why the circumstantial explanations always fell
short.
Roberto wants to understand what Alicia means by “leaving
home.” Is it the domestic activities that Alicia needs to get away from?
No. It is not the activities, it’s the bed, and what one is supposed to
do in that bed. In her mind, one is not allowed to experience pleasure
in that bed. Women who experience pleasure are “putas.” Roberto
grasps why she always comes on to him in outside places.
Now that we have understood that in order for Alicia to put the
“X” back in “sex” she needs to leave the home, we explore together
the many ways they can do so. Alicia has a fervent imagination. As
Roberto says, “she’s a creative act”; she refers to him as a “great audi-
ence.” Her rich fantasy life has helped her circumvent the pitfalls of
the prohibitions of her upbringing. Our fantasies combine the unique-
ness of our personal history with the broad sweep of the collective
imagination. Our flights of fancy bridge the gap between the possible
and the permissible. Fantasy is the alchemy that turns this jumble of
psychic ingredients into the gold of erotic arousal.
We explore erotic spaces they can introduce into their relation-
ship, all the while living in their tiny studio. Remembering their 2-year
long-distance relationship, I suggest they bring back some of the very
modes of communication that were so electrifying back then. I sug-
 The Double Flame   39

gest that they create separate e-mail addresses, ones that can not be
used for domestic chores. This e-mail address exists outside of the
family, so there is no need to navigate the two realms of experience:
sex and family. It segregates the erotic into a sacred space, one exclu-
sively reserved for erotic exchanges between them—their thoughts,
memories, fantasies, and seductions. I point out that it is not meant
to be a correspondence about the problems in their relationship, it
is meant to be a space for play. I want them to use cyberspace to
elicit curiosity, a sense of intrigue, and a kind of wholesome anxiety.
Writing has many advantages over talking. You get to say your fill,
craft your response, and give voice in writing to things your lips dare
not utter. It provides a built-in distance, and I hope this will help
them dismantle the inhibitions. There is a difference between sitting
next to someone and saying, “Want to go to a movie” and texting
them from the bathroom, “Do you want to go to a movie?” It can
instantly lift one from the matter-of-fact to a subtle frisson. In the
past 2 weeks this intervention has worked well, and they have used
the technological built-in distance and anonymity to tease each other
with unpredictability, playfulness, and mystery—all key erotic ingre-
dients.
I also go back to one of their cherished activities when the Atlan-
tic prevented them from touching each other: phone sex. They joke
with me, saying that their home is too small to imagine the Atlantic.
But once again, we agree that they will not get out of their quandary
through reason and understanding, but by the force of their imagi-
nations, which will take them away from la cama matrimonial (the
matrimonial bed).
I offer a few more suggestions. They can read out loud to each
other selected erotic writings, something they previously enjoyed
doing together. Alicia can take Roberto to the video store and choose
movies that show the kinds of seductive plots she enjoys. While these
initiatives lighten up the conversation, and usher in a sense of humor,
they don’t spark any more interest. I ask both of them to list the
things they enjoy doing—a comprehensive list of all that gives them
pleasure, nothing to do with sex. Roberto realizes that he has trun-
cated himself to such an extent that he feels uninteresting. I encourage
him to reconnect with his friends, his local pub, his soccer team—in
short Roberto needs to get Roberto back. That too will create some
psychological space that should be propitious for desire to kick in.
Another suggestion adapted from Gina Ogden (2008), is offered
to them. “Sit face to face and complete the statement: ‘I turn myself
40   TREATING SEXUAL DESIRE DISORDERS

off when. . . . ’ Take turns and try to go back and forth for at least 10
or even 15 responses.”
Alicia answers, “I turn myself off when I log on to Facebook
before going to sleep . . . I turn myself off when I don’t have time for
myself . . . when I bring up our problems and frustrations when we
finally have time to be alone for an evening . . . when I don’t feel good
about my body . . . ”
Roberto answers, “When I think how long it’s been since we’ve
had sex . . . when I think about how I’m losing my hair . . . when I am
resentful of Alicia . . . when I feel pressure to perform and powerless
to please her.”
They are then instructed to complete another sentence: “I turn
myself on when. . . . ”
Alicia says, “I turn myself on when I don’t feel pressure to have
sex . . . when I take care of my body and looks . . . when I think of our
early years . . . when I think of the great sex I have had with you and
with previous boyfriends . . . when I give myself permission to leave
the house chores for later . . . when I watch something that makes me
get hot . . . when I am proud of myself.”
Roberto says, “When I’ve just taken a shower . . . when I cook
great meals . . . when we are apart for a while . . . when I look at porn
. . . when I feel good about some accomplishments . . . when I look at
beautiful women . . . when I fantasize about my past . . . when we are
having fun going to the movies and walking the streets . . . when I feel
good about my looks.”
The lesson to be learned from this exercise is that we are the ones
responsible for our erotic energy, our sexual interest or lack thereof.
If we are open, then we are more likely to feel desirable and desirous.
Each of us makes choices: how not to let ourselves be shut down, and
how to keep ourselves sexually open and available. Moreover, all the
ideas are yours.

Commentary
For Roberto and Alicia, therapy is in full swing. After four sessions,
the undercurrents of the sexual stalemate have been brought to light.
From here on, we follow a two-pronged approach that navigates
between understanding, and doing. New awareness and creative
resources will jolt couples out of a state of complacency and helpless-
ness, but the challenge every therapist faces is to ensure the lasting
shelf life of the changes. Therapy runs the risk of following the Weight
 The Double Flame   41

Watchers trajectory: you gain the weight back as soon as you are out
of the program.
Many of the internal tensions that crackle in the sexuality of Ali-
cia and Roberto are located in the reverberations of their childhoods
and in the cultural transmissions they internalized. A multilayered
understanding, the motivation to change, and a good fit between the
partners are necessary to sustain change. But that too is not a guar-
antee. I will be meeting with each of them alone to further probe the
nuances of their predicament, but also to map ways to amp up their
erotic pulse. The rhythm of the therapy is like a metronome—the nee-
dle points back and forth between the individual and the couple. Each
partner brings memories, apprehensions, expectations, and judgments
to the relationship. They are personal at first, but they always become
relational later.
The topics of the individual sessions may be the same; the con-
versations will not. For example, the issue of seduction is high on the
list for both Alicia and Roberto. I will explore this with each partner
and will translate for the other afterward. I think that for Alicia, like
many women, seduction is key. It goes way beyond a simple string
of compliments and flattery. Seduction acknowledges that there is no
automatic yes, that sex is not a given, an a priori entitlement to the
other. Seduction recognizes the other as a free agent who can respond
overtly, or suggestively, or choose to ignore it altogether. What mat-
ters is that the receiver is free, not coerced in any way. This need for
autonomy and freedom is essential to desire. For some women it is
difficult to respond when their partner initiates. The dance I have seen
goes as follows: He initiates, she pulls back, a while later (5 minutes,
an hour, the next morning) she initiates, and then he welcomes her
and their bodies swiftly interlace. Quite often, though, he responds to
her approach by framing it as a power dynamic. He is hurt, interprets
her advances as a power maneuver where sex can take place only on
her terms, is angry that she will not take him in when he wants to, but
only when it suits her.
To my mind, this is a misunderstanding of the conflict. For Alicia,
and for many women, accepting his advances blurs the line between
giving and giving in. The refusal, the partner’s respect for that refusal,
and then the free return are the tortuous way some women need to
take to experience the autonomy of their desire. It is important to
stress that the manouver is not about power over, but an attempt to
delineate separateness, to ascertain ownership of desire. The lyrics of
this song are as follows: “If I respond to you, I feel that I am giving
42   TREATING SEXUAL DESIRE DISORDERS

in. How can I do what you want and feel that I want it too? The only
way I know it is my free will is if I come toward you alone. If the coast
is totally clear, all mine, then I know it is totally my desire. Otherwise,
I can’t hold on to my own wanting in the presence of a strong wanting
on your part. When I initiate sex, I know I want it, when you initiate
sex, I know you want it. I wish to find a way for my desires to live side
by side with yours, not needing to ignore yours as a way to protect
mine from the fear of obliteration.”
Over the years I have come to recognize the value of this interpre-
tation. If Roberto accepts it, he will be able to play, take risks, create
anticipation, and know that Alicia’s entanglements with her desire are
not meant as a rejection of him. She needs to say “NO” so that she
can then say “Yes,” and this quest for free choice is not a statement
about him. Helping Roberto out of the crucible of rejection and help-
ing Alicia grasp the conflict of autonomy will be separate conversa-
tions at first. Then once these concepts have been assimilated they will
be discussed together.
My teacher, Salvador Minuchin, once likened therapy to sculpt-
ing. I recall him saying that first you tackle the raw material, and you
carve out gross shapes. These are dramatic moves, big chunks fall off,
there is noise, instant change. But then comes the long, tedious period
of chiselling, where you steadily go over and over the small gestures,
trying to carve the lasting shape, the details, the enduring. That is the
middle phase of therapy, the longest one, and there is hard work, but
it isn’t very dramatic. The commitment to the project, the ability to
overcome frustrations, delighting in the glimpses of the envisioned
possibilities are all part of the course. The finale, followed by the
unveiling, is a rare bliss.
I would like for Roberto and Alicia to experience sex as pleasur-
able, inviting, and not dutiful. If we continue and chisel away, they
stand a good chance to find a space where they can revere the erotic
and delight in its irreverence. Nevertheless, I will tell them that all
couples go through periods where desire is dormant, that erotic inten-
sity waxes and wanes, and that desire can suffer periodic eclipses and
intermittent disappearances. But given sufficient attention, they’ll
learn to bring it back. Eroticism in the home requires active engage-
ment and willful intent. Committed sex is premeditated sex. It is an
ongoing resistance to the message that marriage is serious, more work
than play, that passion is for teenagers. We must unpack our ambiv-
alence about pleasure and challenge our pervasive discomfort with
sexuality, particularly in the context of family. Complaining of sexual
 The Double Flame   43

boredom is easy and conventional. Nurturing eroticism in the home

is an act of open defiance.

References and Bibliography

Bader, M. J. (2002). Arousal: The secret logic of sexual fantasies. New York:
St. Martin’s.
Giddens, A. (1992). The transformation of intimacy: Sexuality, love and
eroticism in modern societies. Stanford, CA: Stanford University Press.
Kipnis, L. (2003). Against love: A polemic. New York: Pantheon.
Mitchell, S. A. (2002). Can love last?: The fate of romance over time. New
York: Norton.
Morin, J. (1995). Erotic mind. New York: HarperCollins.
O’Connor, D. (1986). How to make love to the same person for the rest of
your life and still love it. London: Virgin.
Ogden, G. (2008). The return of desire: A guide to recovering your sexual
passion. Boston: Trumpeter.
Perel, E. (2003, May/June). Erotic intelligence: Reconciling sensuality and
domesticity. Networker.
Perel, E. (2006). Mating in captivity: Reconciling The Erotic and the Domes-
tic. New York: HarperCollins.
Person, E. S. (1988). Dreams of love and fateful encounters: The power of
romantic passion. New York: Norton
Schnarch, D. (1997). Passionate marriage. New York: Henry Holt.
Tiefer, L. (1995). Sex is not a natural act and other essays. Boulder, CO:
Westview Press.
 Chapter 3

Using Crucible Therapy

to Treat Sexual
Desire Disorders
David Schnarch

Over several decades of writing, teaching, and conducting therapy, David

Schnarch has developed a unique approach to treating sex and relationship
problems—an approach he terms Crucible therapy. While this approach
fosters self-differentiation and self-regulation as well as the ability to live
and love within a committed relationship, Schnarch’s therapy is far-reaching
in its use of confrontation, self-exploration, and personal challenge.
Schnarch believes that low and high desire are changeable positions
within a relationship system and are not stable characteristics of a single
individual. He notes that high- and low-desire partners are similar in differ-
entiation, but the low-desire partner always controls sexual frequency and
access. And while desire conflicts are inevitable and highly prevalent, they
frequently lead to major rifts in relationships because “you can’t agree to
disagree with your partner about having sex.”
In this chapter, he beautifully illustrates how he treats a couple in which
the male partner avoids sexual intimacy. By using the “two-choice dilemma”
(a situation where you want two choices but you get only one) as an orga-
nizing focus of treatment, Schnarch confronts the couple with their unspo-
ken agendas and internal resistances to change. In this case, the husband
embraces two contradictory wishes: “I don’t want to have sex, but I want to
be married to someone who wants sex” and “I agreed to monogamy, but

44
 Using Crucible Therapy for Sexual Desire Disorders   45

now I want to change it to celibacy.” The therapy centers on the resolution

of these dilemmas.
David Schnarch, PhD, is Director of the Crucible Institute and the
author of landmark books on sexual desire, including Constructing the Sex-
ual Crucible, Passionate Marriage, and Resurrecting Sex. His latest book
is Intimacy & Desire.

Modern treatment of sexual desire problems dates back to the

1970s with the work of Masters and Johnson, Helen Singer Kaplan,
and others. Crucible® integrated sexual–marital therapy offers totally
new ways to conceptualize and treat sexual desire problems. A cruci-
ble is a test of the most decisive kind, a challenge to your integrity and
core values arising from powerful emotional and situational forces.
A crucible is also a resilient container used in metallurgy to contain
high-temperature chemical reactions. These definitions describe cli-
ents’ personal experience and the level of intensity at which Crucible
therapy operates.
Unlike other sex and marital therapy approaches, Crucible ther-
apy is rooted in Bowenian differentiation theory (Bowen, 1978). Dif-
ferentiation is the ability to balance attachment in relationships with
self-direction and self-regulation, which boils down to “holding on
to yourself” (keeping your emotional balance) in difficult interac-
tions with others. Crucible therapy differs dramatically from Bowen
therapy in its application of differentiation to intimacy and emotional
relationships, its greater intensity, and its use of collaborative con-
frontation.
According to Crucible therapy, “marriage is a people-growing
machine” driven by differentiation (Schnarch, 1991). The “gears”
of the people-growing processes are described in a lexicon of coined
terms: For example, poorly differentiated partners depend on a
reflected sense of self (acceptance, validation, and empathy from
others) and anxiety regulation through accommodation (regulating
personal anxiety interpersonally through self-presentation and false
agreement) from each other. They extract this through other-validated
intimacy (partners are expected to accept and validate each other’s
disclosures). However, dependence on other-validated intimacy leads
to emotional gridlock (impasse situations), which pushes partners to
shift to self-validated intimacy (validating one’s own disclosures with-
out expecting acceptance from the partner) and become more dif-
ferentiated through their struggles to do this (Schnarch, 1991, 1997,
46   TREATING SEXUAL DESIRE DISORDERS

2002, 2009). Intimacy & Desire details couples’ inevitable struggles

over intimacy, sex, and desire, and ties them to the processes of intrap-
ersonal and interpersonal differentiation woven throughout monoga-
mous love relationships.
Crucible therapy is also identifiable by what it does not do. It
rejects (1) the diagnostic framework of “hypoactive” or “inhibited”
sexual desire (ISD); (2) Kaplan’s (1979) biological drive perspec-
tive and treatment approach; (3) the paradigm of “sex and desire
are natural functions”; (4) “desire-phase disorders,” a concept that
emphasizes initiatory receptivity and assertiveness; and (5) the patho-
logical view of people with low sexual desire enshrined in contem-
porary treatment and the DSM and ICDM diagnostic frameworks
(Schnarch, 2000).
Instead, this therapy posits a completely different paradigm:

1. It approaches desire as a capacity that can be developed, rather

than an inhibited drive.
2. It focuses on personal and relational growth (becoming more
differentiated) rather than removing “blockages.”
3. It focuses on desire for one’s partner and desire during sex,
rather than desire for sex, per se.

Most important for this chapter:

4. It approaches desire as a systemic relationship process, rather

than a personal characteristic and individual diagnosis.
5. It steps outside the common linguistic and conceptual frame-
work of “the identified patient and the asymptomatic part-
ner.”

Crucible Principles about Desire Problems

Basic principles of Crucible therapy include the following:

• Principle 1: One of the strongest determinants of human sex-

ual desire (if not the strongest) is the process of developing and main-
taining a phenomenological self. At some point in human evolution,
the human self emerged and sexual desire was irrevocably changed.
About 1.6 million years ago, the struggles of emerging selfhood grad-
ually began to outweigh biological imperatives, gene distribution
 Using Crucible Therapy for Sexual Desire Disorders   47

strategies, or hormonal drives in determining sexual desire and sexual

behavior.
• Principle 2: Normal healthy people in good relationships have
sexual desire problems. Intimacy & Desire provides the first cohe-
sive explanation for why, sooner or later, normal couples have sexual
desire problems: it’s due to the natural processes of differentiation.
Couples arrive at this point from many different paths. When couples
are emotionally gridlocked over intimacy (described above), desire
fades. Principle 5 (below) states that normal interpersonal dynam-
ics surrounding sexual desire create emotional gridlock and sexual
desire problems, in and of themselves. Poorly differentiated couples
develop emotional gridlock more quickly, more intensely, and more
pervasively, and this holds true for sexual desire problems too. Being
poorly differentiated is a nonpathological, normal state for individu-
als and couples.
• Principle 3: “Low-desire partner” and “high-desire partner”
are positions in a relationship system and are not reducible to individ-
ual characteristics (like biological drive, genetics, sexual preferences,
family history, religious training, unconscious processes, or negative
childhood experiences). In contrast to earlier approaches to sexual
desire problems, low-desire partners are not regarded as pathological,
sexually inhibited, or emotionally blocked. They are not presumed
to be more impaired or less differentiated than high-desire partners.
People who have high libido and love sex are frequently shaped into
occupying the “low-desire partner” position in their relationship by
natural differentiation processes and/or their partner’s behavior.
• Principle 4: The low-desire partner and the high-desire part-
ner do not differ in differentiation. Crucible theory says people pick
partners at the same level of differentiation. Moreover, because “low-
desire partner” and “high-desire partner” are positions in a relation-
ship, they do not differ in differentiation. Research indicates there
is no reason to assume the low-desire partner’s lower desire results
from being less differentiated, sexually experienced, or interested, or
likewise, more inhibited, emotionally damaged, or angry and with-
holding (Schnarch & Regas, 2008).
• Principle 5: The low-desire partner always controls sex. The
high-desire partner makes the initiations, and the low-desire partner
decides which ones to accept. This gives the low-desire partner de
facto control of sex (excluding rape, emotional or physical battering,
and places where women do not control their own bodies).
48   TREATING SEXUAL DESIRE DISORDERS

This approach views sexual desire problems as co-constructed

interpersonal sociobiological and neurobiological events. They are
driven by the way human differentiation and human sexuality are
entwined today, and how they became entwined over the course of
human evolution. The human brain and human sexual desire have
co-developed for over a million years, shaping human nature and inti-
mate relationships as our complex phenomenological “self” emerged.
As a result, issues of adult “self” development (differentiation) greatly
shape sexual desire in committed relationships, through develop-
ments like emotional gridlock and other relational processes. One
reason normal healthy couples have sexual desire problems is because
emotional gridlock dampens sexual desire, and emotional gridlock is
virtually inevitable.
The politics of reflected sense of self steer the course of sexual
desire in committed relationships (and extramarital affairs). In the
early stages of relationships, desire is enhanced by partners supporting
each other’s reflected sense of self through other-validated intimacy.
But sexual desire evaporates when couples battle out the predictable
differentiation-driven self-development wars of “Who do I belong to,
me or you?!” and “I want to be with you, but don’t tell me what to
do!” Power and control fights trump estrogen, testosterone, oxytocin,
and libido every time. The same lack of differentiation (reflected sense
of self) that spurs desire early in relationships also kills desire later
on. The normal healthy battles of selfhood, which invariably occur in
love relationships, make sexual desire problems a virtual certainty for
normal healthy couples.
This view that sexual desire problems are normal is borne out by
research conducted on the DatelineNBC.com website in 2006. When
Dateline NBC devoted an hour of national prime-time coverage to
couples undergoing Crucible therapy for sexual desire problems, over
27,500 people completed an online survey within 48 hours. Sixty-
eight percent reported sexual desire problems: “Sex is dead” (13%);
“Sex is comatose and in danger of dying (22%), or “Sex is asleep and
needs a wake-up call” (33%). Only 22% reported, “Sex is alive and
well,” and just 10% said, “Sex is robust, erotic, and passionate.”

Prevalence of Desire Problems

in Clinical Practice

More then half the cases I see involve couples who have sexual desire
problems. Frequently this is not their presenting issue. Not because
 Using Crucible Therapy for Sexual Desire Disorders   49

they are hiding or denying it. It’s because they have other serious rela-
tionship difficulties: Many are on the verge of divorce; some are sepa-
rated. Most have repeated disastrous arguments. Any prior collab-
orative alliance no longer exists. Sometimes sexual desire problems
created this. Other times sexual desire was a casualty of emotional
warfare.
Relationships frequently blow up over sexual desire problems.
It’s not just that sexual desire is so incredibly important to people,
but that couples handle sexual desire problems so poorly. Likewise,
conventional marital therapy wisdom fails when applied to sexual
desire problems: You can’t agree to disagree with your partner about
having sex. And by the time you compromise and negotiate your way
into bed, your desire is gone.
In half the heterosexual cases referred to me, the man is the low-
desire partner. This may indicate men are as likely as women to be the
low-desire partner in severe or difficult cases, since this constitutes
the bulk of my practice. However, for clinical and theoretical reasons,
I believe this is a more accurate picture of sexual desire problems in
general.

Case Example: Mr. and Mrs. Donner

Initial Presentation
At the outset, both Mr. and Mrs. Donner said they were interested in
treatment. Mr. Donner said he thought his desire was lower than that
of most men, and he didn’t want to lose his marriage. Mrs. Donner
hoped treatment would improve their intimacy (in and out of bed) as
well as their sexual frequency.
Mr. Donner (age 38) and Mrs. Donner (age 37) had been together
for 15 years and married for 12. They had two children, ages 11 and
9. He was senior accountant in a large auditing firm. She resumed
teaching high school when the children didn’t need her as much as
they had before.
Mr. Donner said he came from a home with an angry father.
He thought this was why he was afraid of Mrs. Donner’s temper.
She exploded intermittently when they failed for months on end to
have sex. Mrs. Donner said her father was often gone and her mother
was an alcoholic. By her description, she was the classic “parentified
child.” She had several boyfriends in college and enjoyed sex with
them. Mr. Donner rarely dated and had few sexual encounters.
When Mr. and Mrs. Donner first met, he was smitten with her.
50   TREATING SEXUAL DESIRE DISORDERS

Their sex was good and frequent. It tapered off when they moved
in together, but they still had sex four or five times a month. This
declined to once or twice a month by their third year together. Mrs.
Donner attributed the decline to growing tension in their relation-
ship at that time: They got married after Mrs. Donner presented Mr.
Donner with the choice of getting married or breaking up because she
wanted to have children. After their first child was born, sex declined
further. But Mr. Donner seemed eager to have a second child, and
Mrs. Donner agreed. After their second child was born, sex just about
stopped.
Two years later, Mrs. Donner pushed to seek treatment but Mr.
Donner refused. He did, however, agree to work on their problem.
Several years later, the situation was unchanged. At that point, Mrs.
Donner presented Mr. Donner with the choice of therapy or divorce.

Prior Treatment
Mr. and Mrs. Donner sought help from a local therapist who had a
reputation for treating sexual problems. Mrs. Donner had read Pas-
sionate Marriage and wanted the kind of therapy described there.
According to Mr. and Mrs. Donner, the therapist described her
approach as “a combination of marital therapy, Masters and Johnson,
and David Schnarch.” Mr. and Mrs. Donner were prescribed commu-
nication skills, active listening activities, and nongenital and genital
sensate focus exercises. “Dates” and text messaging were encouraged.
Mrs. Donner was allowed to ask for sex, but Mr. Donner retained the
right to refuse if he felt pressured.
Their therapist also directed Mr. and Mrs. Donner to open sepa-
rate bank accounts, and develop separate friends, hobbies, and inter-
ests. With her encouragement, Mr. Donner attended a men’s group for
several months, and Mrs. Donner went on a weekend trip with her
girlfriends. The therapist proposed that these pursuits would reduce
the emotional fusion between them, and the “emotional vacation”
from their daily interactions might stimulate Mr. Donner’s desire.
During this time they “dated” once a week, and in fact, sex improved.
They had sex about once a week during 6 months of therapy. Mrs.
Donner took this as a sign things were improving, and when Mr.
Donner wanted to stop treatment she agreed.
Because the therapist talked about differentiation, couched
interventions in the language of differentiation, and had Mr. Don-
ner read Passionate Marriage, Mr. and Mrs. Donner thought she
 Using Crucible Therapy for Sexual Desire Disorders   51

knew how to do differentiation-based therapy. But the hallmark of

differentiation-based therapy is not discussions, readings, or insights
about the process, it’s harnessing the differentiation process by how
therapy is conducted. In many successful cases, differentiation is
never explicitly mentioned because the therapist’s position in the
therapeutic system drives the process, rather than the introduction
of a concept. For instance, in Crucible therapy the therapist must
maintain a well-differentiated stance. This is lost when “bans” (e.g.,
prohibiting intercourse) and prescriptions are given (e.g., separate
bank accounts, sensate focus exercises, more sex), because these
create unbalanced alliances with partners who have different moti-
vations. Moreover, these activities are no longer self-defining acts
(“differentiating moves”) because clients are doing what they’ve
been told to do.
When therapy ended, Mr. and Mrs. Donner’s old patterns, sexual
and otherwise, quickly reemerged because they had accomplished
little in terms of differentiation. They went back to having sex once a
month because this was all Mr. Donner wanted. Their arguments and
problematic interactions returned, and Mr. and Mrs. Donner were
demoralized.
It’s not hard for treatment to produce pseudodifferentiation
and short-term increments in sexual frequency. Poorly differentiated
people function better when they get a little emotional or physical
distance and/or receive validation and positive reinforcement from
their mate or therapist. Mr. and Mrs. Donner’s prior therapy capital-
ized on this. But the hallmark of solid differentiation is its resilience
across time and circumstance, especially when people and situations
discourage the effort.
Mr. and Mrs. Donner returned to their therapist, who told them
they were too emotionally fused for Mr. Donner to have desire. She
proposed they extend their “emotional vacation” to living sepa-
rately for a while. Mr. and Mrs. Donner refused and terminated with
her shortly thereafter. They returned to their pattern of sex once
every month or two. A year later they sought treatment with me
because Mrs. Donner again presented the ultimatum of treatment or
divorce.

Case Considerations: Treating Prior Treatment Failures

In my experience, sexual desire problems are no more difficult to treat
than common sexual dysfunctions, which are not very difficult at all.
52   TREATING SEXUAL DESIRE DISORDERS

I attribute this to Crucible therapy’s ability to handle (1) conflict, (2)

failure, and (3) demoralization, which invariably surface with sexual
problems. In conventional therapy, conflict interferes with couples
agreeing to do sensate focus and active-listening exercises, and usu-
ally increases treatment failure.
I find couples’ prior failures in treatment seriously complicate
matters, especially when they believe they previously received ade-
quate treatment from a qualified expert. My clients are sensitized to
and demoralized by the conceptual, dynamic, and strategic pitfalls
of conventional sexual desire treatment. The low-desire partner pre-
sumes he or she will be pressured to have more sex. The high-desire
partner anticipates being pressured to accept less frequency or pas-
sion than he or she wants. Both partners expect one of two scenarios:
I’ll align with the high-desire partner and try to instill desire in the
low-desire partner through prescribed activities. Or, I’ll align with the
low-desire partner and put a ban on sex, or put the low-desire part-
ner in control of sexual initiations. In practice I do neither one, but
couples wonder which of these unworkable strategies I’ll employ, and
whose interests I’ll sell out.
Couples who previously failed in treatment are more doubtful
about their choice of partner and the health of their relationship. They
are more anxious in bed and in therapy, their emotions are labile,
and they are depressed. They overreact and lock into (or avoid) argu-
ments. They give up easily when things don’t go smoothly.
Crucible therapy helps clients (1) maintain as more stable (solid)
sense of self, (2) regulate their own anxiety and soothe their own
heart, (3) remain nonreactive (but not indifferent) to their partner’s
anxiety and reactions, and (4) persevere through difficult times to
accomplish their goals. It counteracts demoralization through inter-
ventions that rapidly accelerate treatment.

Treatment Course
Medical evaluation revealed no physiological, hormonal, or phar-
macological cause for Mr. Donner’s low sexual desire. Mr. and Mrs.
Donner attended the Marriage & Family Health Center’s Intensive
Therapy Program located in Evergreen, Colorado, for three “inten-
sives” 6 months apart, plus 3-hour telephone sessions every 3 to 4
weeks between intensives. Each intensive involved 16 to 20 hours
of therapy over a 4-day period. Crucible therapy can be delivered in
hourly weekly sessions, but the Intensive Therapy Program is espe-
 Using Crucible Therapy for Sexual Desire Disorders   53

cially designed for difficult couples who travel a long distance for
treatment.
After their previous therapy ended, Mr. Donner took the position
of “saying no to sex” in the name of becoming more differentiated.
Mr. Donner thought I was going to support his position because he
said this was his attempt to differentiate from his wife. Mrs. Don-
ner said she wouldn’t tolerate it anymore. Mr. Donner wanted me to
extract a commitment from her to “work on their differentiation.”
I told him I was supporting his differentiation by not doing what he
was asking.
Mr. Donner became upset and anxious, feeling that he was faced
with a decisive choice about having sex. He framed his dilemma as
“Should I give in to save my marriage?” I said this was not about
giving in; it was about the best in him standing up to save his mar-
riage. By going over the details of their early sexual relationship, I
developed a revealing picture of both individuals and their relation-
ship (an “elicitation window”, Schnarch, 1991). It emerged that Mr.
Donner “let” Mrs. Donner seduce him, thinking this would soon stop
and their relationship would become platonic. He didn’t inform her
because, according to Mr. Donner, he was enjoying her affections at
that point.
Accordingly, I organized part of Mr. and Mrs. Donner’s therapy
around the approach’s material on two-choice dilemmas (wherein you
want two choices, but you get only one). I told Mr. Donner he wasn’t
getting anywhere because he understated his situation. I described
one of his two-choice dilemmas as “I don’t want to have sex, but I
want to be married to someone who wants sex!” Then I pointed out
another one: “I agreed to monogamy, but now I want to change it to
celibacy!”
Some clients who are avoiding their two-choice dilemmas like
these “interpretations”—but continue to dodge. There’s nothing
magic about telling someone he has a two-choice dilemma. Instead
I had to circumvent Mr. Donner’s attempts to avoid confronting his
situation. I also had to focus treatment on enhancing this couple’s
differentiation as individuals and as partners and reduce their emo-
tional fusion. This, in turn, required constantly maintaining a bal-
anced collaborative alliance with Mr. and Mrs. Donner. In part, I
did this by making “isomorphic” interventions that simultaneously
impacted both partners in ways helpful to each of them. I worked
hard to develop a relationship with each of them as individuals, and
our collaborative alliance helped them hear difficult things from me.
54   TREATING SEXUAL DESIRE DISORDERS

Crucible therapy calls this “working the lead,” the skill and art-
istry of differentiation-based therapy. For instance, Mr. Donner said
he needed more time to decide which way he wanted to resolve his
two-choice dilemmas. I confronted him with the idea that he wanted
more time to not decide. Mr. Donner said he had fears of abandon-
ment from Mrs. Donner’s threat to leave him. I told Mr. Donner he
didn’t form relationships; instead he took prisoners. He didn’t like
what I was saying, or what I was doing by saying it, but he didn’t lose
sight of the fact that I was trying to help him.
I told Mr. Donner he “wanted to be wanted, but didn’t want
to want.” This is my way of stating a common two-choice dilemma
in sexual desire problems (Schnarch, 1991). On the one hand, he
wanted Mrs. Donner to desire and pursue him, because it made him
feel desirable and valued when she did (reflected sense of self), and he
became anxious when she lost interest (anxiety regulation through
accommodation). On the other hand, Mr. Donner wouldn’t tolerate
the vulnerability of wanting Mrs. Donner more than she wanted him,
even though he tried to keep her in this position for years. On top of
this, not only did he lack desire, he wasn’t interested in having more
desire for these and other reasons.
All of this was wrapped up in my single statement, and it hit
Mr. and Mrs. Donner like a ton of bricks, but in different ways. Mr.
Donner was blasé talking about desire, but approaching desire as
wanting changed the playing field. I pointed out that Mr. Donner got
married—and had sex—because he didn’t want to lose Mrs. Donner,
not because he wanted her. His prior strategic straddle position, “I
want my wife, but I don’t want sex,” evaporated. The issue wasn’t
did he want sex, the issue was did he want her?
I also said his “not wanting to want” didn’t start in this mar-
riage. It was in place by the time he went to college. I left open where
this might have come from, and noted aloud I knew nothing about
his childhood or family. I knew I had struck a nerve, but Mr. Don-
ner didn’t pick up on this, and we stayed focused on his two-choice
dilemmas.
My work with Mrs. Donner was equally intense and challeng-
ing, which counterbalanced my interventions with Mr. Donner, and
maintained a balanced collaborative alliance that facilitated differen-
tiation. I confronted Mrs. Donner about her emotional neediness and
how she depended on getting a positive reflected sense of self from her
husband. She was so desperate to be married, she had married a man
who never chose her. She settled for being accepted and needed, but
 Using Crucible Therapy for Sexual Desire Disorders   55

not wanted. Mr. Donner’s misrepresentations that he wanted to have

sexual desire had been enough to keep her in the marriage for years.
Mrs. Donner could see how she lied to herself and sold herself
out. She knew it wasn’t that he had no desire for sex. He had no desire
for her. She hadn’t wanted to admit it to herself, because then she’d
have to deal with it. She also realized she had been “had.” Mr. Don-
ner frequently manipulated her through her need for validation.
When Mrs. Donner confronted herself, she told Mr. Donner she
wouldn’t settle for not being wanted. If he really didn’t want her, then
she wanted a divorce. This was not like her previous attempts to get
him to validate her, or force him to have sex. This was not an infan-
tile woman feeling hurt by not getting a positive reflected sense of
self. Mrs. Donner was shifting from a reflected sense of self to a solid
sense of self, triggered by acute and painful self-confrontation. Now
she was willing to see the truth; she’d decide for herself whether he
wanted her or not. At this point, Mr. and Mrs. Donner finally reached
critical mass (Schnarch, 1991).

Treatment Outcome
Mr. Donner tried to keep his marriage going the way he wanted for as
long as he could. Only when he realized he couldn’t do this any longer
did he begin to really deal with his situation. Mr. and Mrs. Donner
both went through a “dark night of the soul.” When Mr. Donner
tried to slide by or sell out, I confronted him on it. Mrs. Donner didn’t
need much confrontation. This alone could have unbalanced my alli-
ance with them. However, Mr. Donner took my moves as collabora-
tive rather than adversarial because of our preceding therapy. The
same interventions in a different (less-differentiated) therapy would
have had different impacts.
I didn’t permit a “just do it” approach. That would have allowed
Mr. Donner to avoid his not wanting to want, and interfered with
Mrs. Donner validating herself enough to think she was worth want-
ing. Instead I helped them both go through their crucible and face
their two-choice dilemmas.
Mr. Donner finally confronted himself about never choosing Mrs.
Donner. He had been too insecure to choose. He feared the control
she would have in his life, and he couldn’t handle the vulnerability,
tension, and self-denial involved in loving someone. He accepted the
idea this came from his growing up, but our focus stayed on the pres-
ent situation and necessary decisions, rather than talking about his
56   TREATING SEXUAL DESIRE DISORDERS

feelings and disappointments with his parents. This maintained their

crucible and kept the differentiation process alive. When we repro-
cessed Mr. Donner’s childhood later in therapy, his account of his life
story changed.
Mr. Donner “took the hit” and acknowledged he had never cho-
sen Mrs. Donner. He also said he didn’t find her sexually attractive
anymore. He acknowledged not respecting her because she sold herself
out to get people—him, her mother, and friends—to like her. Rather
than getting “wounded,” Mrs. Donner stepped up and acknowledged
this was true. Their unsettling interchanges in uncharted territory cre-
ated the most intense intimacy Mr. and Mrs. Donner ever experi-
enced. The more Mr. Donner experienced his wife as a separate per-
son who could hold on to herself with him, the more he found her
sexually interesting. Their growing self-respect and respect for each
other led to new sexual initiations and longer foreplay, which grew
out of the more solid self and greater self-regulation they developed
through the therapy.
When Mr. Donner started initiating, Mrs. Donner was hyper-
vigilant to detect if he was trying to buy her off or contain the situa-
tion. But their relaxed emotional connection from doing hugging till
relaxed and heads on pillows began to deepen (Schnarch, 1991, 1997,
2002, 2009). Hugging till relaxed is a multipurpose long-duration
hug focused on enhancing differentiation and intimacy, rather than
making one’s partner feel soothed and secure. It involves standing on
your own two feet and soothing yourself down while being physi-
cally and emotionally engaged with your partner. Heads on pillows
uses nonsexual long-duration eye gazing to accomplish similar goals,
in an “in bed” context couples associate with sex, anxiety, and con-
flict. Although I am known for creating both tools, I didn’t lose my
well-differentiated stance by prescribing them. Mr. Donner and Mrs.
Donner read about them in Passionate Marriage, and when Mr. Don-
ner asked if I thought he should do them, I told him to make up his
own mind. I framed this as his needing to decide who he wanted to
be and become it—and he wasn’t going to do that by following my
instructions.
When Mr. Donner suggested doing heads on pillows several days
later, he and Mrs. Donner knew this was on his own initiative. Look-
ing into his eyes, she could see more openness and availability. Their
sex became more meaningful, more relaxing, and less anxious. They
got along better and they looked better. Mr. and Mrs. Donner showed
 Using Crucible Therapy for Sexual Desire Disorders   57

more sexual desire before and during sex. Their individual function-
ing improved, as did their sexual frequency and relationship satisfac-
tion. Intimacy increased in and out of bed.
I remained cautious about Mr. Donner’s progress until it became
clear he was involved and benefiting from therapy. The couple engaged
in hugging till relaxed and heads on pillows for increasing periods,
eventually settling into a pattern of 20 minutes three or four times
a week. They reported deep relaxation in an intimate context. They
learned to regulate their emotions and keep their reactivity under
control when things didn’t go well. They developed greater ability to
function autonomously and be closer together, physically and emo-
tionally.
Mr. and Mrs. Donner increased their differentiation and reduced
their emotional fusion. In the process, they simultaneously activated
multiple levels of brain function (e.g., sensory, motor, emotions,
cognitions) in a densely layered, powerfully positive, high-meaning
framework that involved their minds, bodies, and relationship with
each other. These qualities of interaction are thought to contribute
to brain plasticity and interpersonal neurobiological reorganization
(Cozolino, 2002).
I knew they were progressing when I saw evidence of brightening,
a softening of facial features and an appearance of aliveness, vitality,
energy, and healthy countenance. Women look like they’ve had a face
lift, and men look softer and more handsome. It’s no mystery why
couples resume having sex: they feel and look more attractive, and
they are more attracted to each other. People who display brighten-
ing find their own eyes look clearer and brighter, their mental acu-
ity is sharper, and their general and emotional intelligence increases.
Brightening is identifiable by untrained observers. Other people find
them more attractive and approachable too.
It is my belief that brightening reflects shifts in brain function.
It happens too quickly and too pervasively to be simply learning.
Couples who show brightening think differently and handle their
emotions better. Their marriages become more stable and less anxi-
ety driven. Partners become more relaxed, more considerate, and
more direct with each other. Relationships with children, parents,
or friends become richer, deeper, and more resilient. Parents report
positive changes in their children. Clients’ changes are relatively
resilient under stress, as one might expect if their brains are func-
tioning differently.
58   TREATING SEXUAL DESIRE DISORDERS

Commentary

Emotionally fused couples have to reach critical mass to take sig-

nificant steps in personal development. That’s the level of anxiety
and pressure necessary to create fundamental change in people and
systems (e.g., marriage, families, organizations). The lower one’s dif-
ferentiation, the greater the anxiety and pressure required to reach
critical mass. Intense levels of emotion, anxiety, and conflict are not a
problem for Crucible therapy. Holding on to yourself in the midst of
this is the therapy. Conflict in love relationships is how human beings
naturally grow. Therapies that don’t handle conflict well are therapies
at odds with the way relationships operate.
The therapist’s personal differentiation sets the upper limit of his
or her effectiveness in treating sexual desire problems (or any psycho-
therapy, whether differentiation based or not): Couples whose level
of anxiety and pressure required to reach critical mass exceeds their
therapist’s level of differentiation cannot significantly reduce their
emotional fusion with that therapist.
Differentiation-based therapy is not as simple as applying the
concept of differentiation. Raising people’s differentiation doesn’t
occur by giving interpretations or prescribing situational changes. It is
an arduous and intense process. Therapists’ practical ability to facili-
tate clients’ differentiation requires theoretical and clinical accuracy,
as well as the ability to operate under pressure.
Bowen himself doubted people could raise their differentiation,
especially without extreme effort. He didn’t think bibliotherapy, com-
munication, and empathy skills training or psychodynamic, insight-
oriented, or emotion-based cathartic psychotherapy could do it. From
years of doing “extreme effort” therapy, I am more optimistic than
Bowen.
The impact of an intervention is co-created by clients and thera-
pists. Much of that stems from the therapist’s differentiation and his
or her position in the interpersonal dynamics of treatment at that
moment. Simply copying interventions described here will not pro-
duce differentiation-enhancing therapy. That’s because (1) the cli-
ent often gets around the therapist, (2) the therapist can’t steer the
intervention and keep it on track, (3) the therapist leads the client
too much when making the move (“snare-trap therapy”), or (4) the
therapist loses a differentiated clinical stance. My interventions came
out of caring enough to confront people with their lives, rather than
combatively trying to “beat clients at their own game” or “get them.”
 Using Crucible Therapy for Sexual Desire Disorders   59

Moreover, their impact was greatly determined by the meaning frame

and momentum I co-developed with these clients in preceding interac-
tions.
Discussing differentiation and helping clients become more dif-
ferentiated are two different things. The latter requires working the
differentiation process in real time. Crucible therapy harnesses this
process, sometimes without ever naming it explicitly.
Effectively treating sexual desire problems involves more than
making the problems go away. It involves resolving them in ways that
enhance both partners’ personal development. I’ve come to believe
this is why Nature ordained that the low-desire partner always con-
trols sex and normal couples shall have sexual desire problems. Good
treatment approaches this inevitable development in ways that fulfill
its “purpose.” This requires believing that marriage is a people-grow-
ing machine.
Working with differentiation doesn’t complicate treatment, but
makes it easier and more effective. It’s much easier to resolve sexual
desire problems when treatment lines up with how differentiation
permeates sexual desire, sex, and intimacy in emotionally committed
relationships. Sexual desire, differentiation, and our mind and brain
are inextricably linked. Perhaps the question is no longer “Can sexual
desire problems be treated effectively?” It is how effectively can sex-
ual desire treatment create pervasive nonsexual changes?

References

Bowen, M. (1978). Family therapy in clinical practice. New York: Jason

Aronson.
Cozolino, L. (2002). The neuroscience of psychotherapy: Building and
rebuilding the human brain. New York: Norton.
Kaplan, H. S. (1979). Disorders of sexual desire and other new concepts and
techniques in sex therapy. New York: Brunner/Mazel.
Schnarch, D. M. (1991). Constructing the sexual crucible: An integration of
sexual and marital therapy. New York: Norton.
Schnarch, D. M. (1997). Passionate marriage: Sex, love, & intimacy in emo-
tionally committed relationships. New York: Norton.
Schnarch, D. M. (2000). Sexual desire: A systemic perspective. In S. R.
Leiblum & R. C. Rosen (Eds.), Principles and practices of sex therapy
(3rd ed.). New York: Guilford Press.
Schnarch, D. M. (2002). Resurrecting sex: Resolving sexual problems and
rejuvenating your relationship. New York: HarperCollins.
60   TREATING SEXUAL DESIRE DISORDERS

Schnarch, D. M. (2009). Intimacy & desire: Awaken the passion in your

relationship. New York: Beaufort Books.
Schnarch, D. M., & Regas, S. (2008). Relationship between sexual satisfac-
tion, sexual functioning and level of differentiation. Paper presented at
the annual conference of the American Association for Marriage and
Family Therapy, Memphis, TN.
 Chapter 4

The Canary in the Coal Mine

Reviving Sexual Desire
in Long-Term Relationships

Kathryn Hall

Kathryn Hall aptly observes that desire is the wish for something that one
doesn’t have. This may explain why sexual passion burns more brightly in
forbidden relationships or those marked by obstacle or objection. Obliga-
tory sex stifles desire.
In the case that follows, the client’s explanation for her lack of desire
is ascribed to her incestuous experiences as a child. It is true that sexual
abuse is often a factor in complaints regarding sexual apathy or aversion.
But equally significant are the erroneous beliefs regarding sexual desire
and the client’s internal voice forbidding her to decline sex for fear of los-
ing her relationship. By receiving permission to say no to obligatory sex,
Andrea is able to attend to, and be curious about, her own nascent sexual
feelings. Therapy is not focused on increasing desire but rather on helping
Andrea understand and appreciate her unique sexuality.
Unlike many of the cases described in this book, individual rather than
couple therapy is provided. Individual therapy is sometimes quite effec-
tive, especially where there are long-standing issues that have not been
resolved, such as a past history of sexual abuse or domestic violence.
Hall’s major take-home message is that the therapist must not want
the client to have sex more often than the client herself wants it. To impose
an expectation that more frequent sex is the desirable outcome in cases
involving sexual apathy is simply to reinforce an unacceptable standard.

61
62   TREATING SEXUAL DESIRE DISORDERS

Kathryn Hall, PhD, is in private practice in Princeton, New Jersey, and

the author of a popular book on sexuality entitled Reclaiming Your Sexual
Self: How You Can Bring Desire Back into Your Life.

“I wish I wanted to have sex, but I just don’t.” Problems with

sexual desire are the most frequent complaint of women coming to
my sex therapy practice, and yet sexual desire itself is probably the
most misunderstood facet of sexual responding. Most women (and
most of my clients complaining of sexual desire problems are women)
believe that the problem resides within them. They believe that there
is something wrong with them if they do not regularly experience
spontaneous sexual desire for their partner, otherwise known as lust
or feeling “horny.” Most women report that they did at one time
experience such feelings. The fact that they now do not is often trou-
bling and distressing not only to them, but also to their partners: “I
want to feel wanted too—I want to know that she desires me” is a
frequent grievance. Because my clinical experience tells me that loss
of sexual desire is different for men and women in both etiology and
treatment, this chapter will be directed at sexual desire problems in
women.
A common misconception is that men and women’s sexuality is
essentially the same, which leads to the belief that the experience of
sexual desire should also be identical across gender. While the major-
ity of men experience spontaneous sexual desire and think about sex
a lot, most women do not, especially as they age and once they are
in a long-term relationship. This change should not be diagnosed as
a sexual dysfunction, although the couple’s distress and difficulty
adjusting to the change may be a focus of treatment. Loss of desire
in romantic relationships is very stressful for Western couples, who
tend to equate love with sexual desire. Couples in other cultures that
distinguish between lust and love and do not rely on the former for
initiating sexual activity do not frequently complain of low desire.
A linear model of sexual responding, wherein sexual desire is a
necessary first step preceding sexual activity, does not reflect the real-
ity of most women’s experience. A pattern of responding that I have
called the desire–arousal feedback loop (Hall, 2004) and Rosemary
Basson (2007) has more eloquently described in her circular model of
the sexual response cycle reflects the fact that sexual desire in women
is often responsive rather than spontaneous. Sexual desire is not expe-
rienced only prior to sex, rather it is the wish, the motivation, and
 Reviving Sexual Desire in Long-Term Relationships   63

the physical urge to engage in sex (or more sex) that is often sparked
by sexual arousal and that hopefully continues throughout a sexual
encounter. Many women erroneously believe that they have a sexual
desire disorder because they do not feel physically turned on prior to
sex. Many women do report that they experience desire for sex once
they are having sex. In other words, once they are aroused, often by
direct touch, they want more sexual stimulation and when sex is over,
they often wonder why they don’t have sex more often. In these cases,
one of the goals of treatment is to help women identify what could
prompt their interest in having sex prior to arousal.
Desire is the wish for something that one doesn’t have. This is why
sexual desire remains high in relationships in which sex is either for-
bidden (premarital or extramarital relationships) or optional (dating,
casual relationships) or where there is an obstacle such as distance,
differing religious faiths, or familial objections. When sex is expected
it often feels obligatory and then one can lose sight of desire, of want-
ing. It is difficult to experience want for something you already have,
or indeed, must have. This is why sexual desire becomes problematic
in many marriages and committed relationships.
Sexual desire is often like the proverbial canary in the coal mine,
with the loss of desire being an early indication of trouble in a rela-
tionship. Because sexual desire is about connection, of all the sexual
responses it will be especially sensitive to a disconnection in the cou-
ple bond. Sometimes, the loss of sexual passion is recognized as an
indication of problems in the relationship. However, the usual course
of desire disorders follows roughly the same story line: The person
who first experiences the drop in sexual interest denies to herself that
it is a problem. Once she can no longer deny it, she tries to deal with it
on her own. She may try to hide it from her partner, often relying on a
calendar for initiating or responding to sex. This calendar is based on
avoiding her partner’s anger rather than on sexual interest or desire:
“If we don’t have sex for a week, 2 weeks, 3 days . . . my partner will
be angry.” The reason for the drop in desire is either unknown to the
woman or is one that she will have trouble resolving on her own or
with her partner. For example, while she may be aware that her lack
of desire has to do with her feelings about the status of her relation-
ship or her feelings about her partner, she may be unable or unwilling
to discuss this with him or her. On the other hand, she may believe
that her lack of desire has something to do with her own personal
issues. She may believe that she is out of love with her partner, that
she has intimacy problems, or that she has issues with sex. These
64   TREATING SEXUAL DESIRE DISORDERS

self-statements are more likely if she has experienced a loss of desire

in other relationships in the past. Once the lack of desire has become
apparent in the relationship, it has likely been occurring for some
time. Attempts to rectify the problem may result in additional disrup-
tion for the couple. It is not uncommon for a low-desiring woman to
engage in sex solely to please or pacify her partner and therefore rush
through sex and/or focus on her partner’s pleasure at the expense of
her own. This pattern will reinforce her belief that she does not desire
and even really enjoy sex. When all else fails, a therapist may be con-
sulted. As therapists, we are lucky when men or women or couples
consult us at the first sign of trouble. But more often than not, we are
the last resort.
Women with low sexual desire often hope that the problem may
be hormonal. While many women reject this notion, they nonethe-
less feel a tremendous societal as well as interpersonal pressure to
feel something (lust) that may not be realistic. So while they may
not believe that the problem is hormonally based, they may want
the solution to be. As an explanation a hormone imbalance alleviates
the shame low-desiring women feel and reduces blaming within the
relationship. The promise of a quick fix that does not require change
in oneself or the relationship is almost irresistible. But this is why
hormonal treatment will ultimately fail as a panacea for low sexual
desire. While an initial rise in sexual activity often occurs with hor-
mone therapy, much of this activity can be attributed to an improve-
ment in the relationship and in one’s outlook because of the attention
being paid to the problem. Hence the large placebo effect evident in
drug trials for sexual disorders (Bradford & Meston, 2007). Increased
sexual activity may also occur in the beginning stages of sex therapy.
Most often, however, clients wait anxiously to hear what is wrong
with them or with their relationship. This negative anticipation pre-
cludes increased sexual interest and activity.
In heterosexual relationships it is usually the woman who loses
sexual desire. It is often assumed that men’s sexual desire, fueled by
higher levels of testosterone, is stronger and therefore more resilient to
a downturn in the emotional tone of the relationship. Men also tend
to view sex as a way to reconnect with their partners; they see it as a
route to intimacy, whereas women tend to view sex as an outcome of
emotional closeness—or at least this seems to hold true in the major-
ity of long-term relationships. The situation is more complicated in
same-sex relationships. Why one member of a couple manifests the
couple’s distress through a lack of desire is often unclear. While this
 Reviving Sexual Desire in Long-Term Relationships   65

may simply be related to differences in innate levels of sexual drive

that the individuals have, the loss of desire in one partner, and the
couple’s reaction to that loss, may shed real light on the inner work-
ings of the relationship, in a way that it does not in heterosexual rela-
tionships. The couple that I have chosen to discuss will be instructive
for both heterosexual and lesbian relationships.
Individuals and couples with low sexual desire are among the
most challenging of our cases. Other sexual problems involve improv-
ing, changing, or enhancing sexual responses to sexual stimulation—
not so in situations involving low desire. In these cases, individuals
or couples expect to feel something in the absence of any direct or
physical stimulation. Managing unrealistic expectations and dealing
with the often acute shame one experiences for not being sexual are
hurdles to treatment progress.

Case Example: Andrea and Cricket

The first thing I noticed about Andrea was her beauty, and I initially
thought it likely that she was more accustomed to being an object
rather than an agent of desire. At age 46, she was tall, slim, and
graceful. Her face was youthful and she had large blue eyes that gave
her the look of a deer in the headlights. Her style of dress was best
described as understated and she wore little makeup or jewelry. By
the end of our first session it was obvious to me that Andrea had no
awareness of herself as beautiful or sexual.
Andrea came to see me at the urging of her partner, Christine.
Christine, affectionately called Cricket, was unhappy about the lack
of sex in the relationship. Cricket and Andrea had been living together
for about 7 years, but sex had been infrequent after the first year and
had further diminished in frequency over the last 2 years. Andrea
and Cricket had sex approximately once every 6 to 8 weeks. A huge
fight and the threat of breaking up prompted Andrea to make an
appointment for therapy. It is important to note that Andrea was not
unhappy about the lack of sex but she was unhappy about the status
of the relationship. “If I never had sex again, it would be okay with
me. I just don’t want to keep fighting about it. I know Cricket is right.
I know that sex is an important part of a relationship, and I wish I felt
that way about her. She deserves it, she really does.”
Andrea and Cricket often fought about the lack of sex but now
the arguing was becoming more frequent and more intense and
66   TREATING SEXUAL DESIRE DISORDERS

Cricket was threatening to end the relationship. Cricket, a psycho-

therapist herself, always wanted to “talk about the relationship.” But
to Andrea, the talking was tantamount to a recitation of the things
that were wrong with her and she was tired of hearing about them.
The reasons—or in Cricket’s opinion, the excuses—regarding the lack
of sexual activity were getting old. They were no longer working to
assuage Cricket’s hurt feelings or to convince her that Andrea truly
loved her. Cricket had asked Andrea many times to go to therapy with
her, but Andrea always refused. She did not want to feel “ganged up
on by two therapists.” Andrea finally called for an appointment with
me after Cricket spent the preceding two nights on the living room
couch.
The story Andrea told about her lack of desire could be summa-
rized as follows: It is my own problem; it has nothing to do with my
partner. I don’t want to have sex now because I was sexually abused
as a child.
Although infrequent, the sex that Andrea and Cricket had was
routine and predictable. The two mutually agreed that sex could never
occur before a workday and it could not happen late at night and it
had to start and end in the bedroom. So sex was relegated to Satur-
day mornings. Cricket always initiated sex and insisted that she plea-
sure Andrea first. Routinely, sex ended when Andrea experienced an
orgasm. When Andrea would attempt to reciprocate, Cricket would
frequently assure her that it was “okay.” This furthered Andrea’s feel-
ing that she was beholden to Cricket, in other words, the sexual expe-
rience increased her feeling of obligation rather than lessening it.
In terms of the sexual abuse, Andrea stated the following facts:
She was abused when she was between the ages of 9 and 11 years
by her father. Andrea’s parents slept in separate rooms; her mother
slept on the main floor as she had lupus and found climbing stairs
tiring, and her father slept in the master bedroom next to Andrea’s
room. On many occasions Andrea went to snuggle in bed with her
father, whom she identified as the more emotionally available par-
ent. The first memory she had of the abuse was when she was about
9 years old and in bed with her father. He stroked her genitals under
her nightgown and the touch felt good to Andrea—until she came to
understand what it meant. Andrea reported that she then felt very
guilty that she never did anything to stop it. “The truth is I didn’t
want him to stop. It felt good.” The abuse ended when Andrea no
longer went to sleep in her father’s room; nonetheless, the guilt that
she felt for her “participation” was very strong.
 Reviving Sexual Desire in Long-Term Relationships   67

Unaware of her sexual orientation or indeed any sexual feelings,

Andrea dated several boys in high school. She found it easy to resist
the sexual advances of her boyfriends and she prided herself on being
a “good girl.” In college, however, she found the rules for being a
“good girl” changed. Her virginity was now seen as a liability and she
was eager to “get rid of it.” She had several boyfriends in college but
never really enjoyed sex. It wasn’t until she was a junior that she had
an inkling she was sexually attracted to women. After a few furtive
and alcohol-aided sexual encounters with “a friend,” Andrea realized
that she was a lesbian.
Andrea’s loss of desire was a pattern in her lesbian relationships.
While she had no desire for sex in her past heterosexual relationships,
the beginnings of her relationships with women were characterized
by strong sexual interest and frequent sexual activity. Initially, Andrea
experienced sex as pleasurable and engaged in a variety of activities
including caressing, oral sex, and vaginal penetration with fingers,
dildos, and vibrators. As her desire waned, Andrea would begin to
restrict sexual activity, preferring a “let’s just get it over with” attitude
to a pleasure-oriented approach. Over time sex would become less
varied, more infrequent, and less fun. As her desire for sex with her
partner waned, Andrea would take on more of the household respon-
sibilities and often found herself doing the majority of the cooking,
cleaning, and home maintenance. During the evaluation she recog-
nized that she was trying to “prove my worth or maybe express my
love and interest” through avenues other than sex. Andrea believed
that her lack of sexual interest was responsible for the breakup of her
previous relationships.
Andrea was in a 10-year relationship that ended just before she
met Cricket. This relationship was sexless for the last 4 years, which
Andrea believed was by mutual consent. When her partner told her
that she had been having an affair during that time, Andrea was dev-
astated. Andrea met Cricket shortly thereafter and was charmed by
her easygoing manner (as evidenced by her nickname) and they soon
moved in together.
Andrea was not attracted to other women; she masturbated infre-
quently and felt guilty about it when she did, as if she were cheating
her partner of her sexual energy. Because this same pattern of losing
desire had happened in previous relationships at much younger ages,
it did not appear to be a physical issue. As a health-conscious indi-
vidual, Andrea had regular physical exams, Pap smears, and mam-
mograms.
68   TREATING SEXUAL DESIRE DISORDERS

Treatment lasted almost 1 full year. Andrea was seen for 24 ses-
sions on a weekly basis, then 2 sessions on a monthly basis and a
follow-up session 3 months later. This last session was about 1 year
after the initial evaluation.
The outcome of this case was very successful. Andrea experi-
enced sexual desire for her partner; the relationship between the two
women improved and Andrea felt increased self-esteem and overall
satisfaction with her life. Cases of low sexual desire are not always
resolved so well or so quickly (although many would not consider a
year of therapy quick). Often the relationship improves and there is
greater acceptance of the lack of desire. This case is instructive for
what went well.

Case Formulation
Andrea was disconnected from her sexual desire and it was a problem
for her in terms of maintaining intimate relationships. She viewed sex
as something she needed to do to be in a relationship, to make her
partner happy. It was not something she did for the pleasure of it.
Given this, it was understandable that Andrea often acted as though
she could trade off one duty for another—she could make up for the
lack of sex by doing an extra few loads of laundry or mopping the
kitchen floor. Andrea’s lack of sexual desire for Cricket was likely
facilitated by the following several factors:

1. The guilt that she felt regarding the incest. Andrea’s under-
standing of the sexual abuse was that it was her fault—after all she
had been the one to go into her father’s bed, she had enjoyed the
touching, and when she no longer sought her father out at night, the
abuse stopped. It was easy for her as a child to assume that the sexual
abuse was in her control and something that happened because she
wanted it to. It is likely that Andrea suppressed her sexual feelings
as an adolescent and as an adult because of the guilt associated with
being a sexual agent.
2. Sociocultural pressures to conform to a model of the “good
girl.” While many women of Andrea’s generation were subjected
to the same societal pressures to regulate the sexual activities they
engaged in with boys, Andrea may have been especially vulnerable
to this pressure given her history of abuse, as well as having an ill
mother and an emotionally needy father (which heightened her sense
of responsibility). The fact that Andrea was unaware of her sexual
 Reviving Sexual Desire in Long-Term Relationships   69

orientation meant that she had no sexually arousing experiences in

adolescence, which further reduced her awareness of sexual arousal
and desire.
3. Relationship dynamics. Although we know about the rela-
tionship only from Andrea’s perspective, this does give us an impor-
tant glimpse into the way that she experiences the relationship. From
Andrea’s description, it seemed that Cricket did not want sex for the
sheer pleasure of it. Andrea was unable to give any indication of what
Cricket’s sexual interests were, apart from wanting to please Andrea.
It was my working hypothesis that, as with many partners of low-
desiring women, Cricket wanted to be wanted, but like many women,
she was settling for being needed. However, Cricket was unwittingly
playing into a dynamic that was inherent in Andrea’s incest—an emo-
tionally or sexually needy person being gratified by Andrea’s sexual
arousal and orgasm. In addition to a replay of the incest dynamic,
the sexual experiences of Andrea and Cricket only served to increase
Andrea’s sense of obligation regarding sex—and the experience of
sexual obligation is most often the death of desire.

Evaluation and Treatment

Treatment of sexual problems actually begins during the evalua-
tion. In addition to a thorough assessment of the sexual complaint
(including an individual sexual history and an examination of the
couple dynamic) this is a good time for sex education. Explaining that
women’s sexual desire is often responsive rather than spontaneous
alleviates the shame and blame that are often part of the presenting
complaint. In Andrea’s case, she clearly blamed herself for the sexual
problems in the relationship. She attributed her low desire to her his-
tory of incest but this just made her feel damaged and helpless to
change the situation. An important point in therapy happened during
the initial evaluation when Andrea realized that she did experience
sexual desire during sex. My questions regarding Cricket and why she
did not want to receive sexual pleasure from Andrea allowed Andrea
to question her original assumption that she was the only one in the
couple with sexual issues.
Some of the critical issues that were addressed in therapy are
discussed below. It is important to note that once raised, these issues
were often discussed many times during the course of therapy. Andrea
was seen individually, as this was her strong preference. I did not
press to see Cricket even once during the evaluation because Andrea
70   TREATING SEXUAL DESIRE DISORDERS

was very sensitive to feeling that Cricket knew how to be in a rela-

tionship and she did not. In other words, Andrea needed the time and
space in therapy to discover her own feelings and desires (sexual and
otherwise) regarding her self in relationship. Given that Cricket was a
psychotherapist, the risk of Andrea feeling judged by two profession-
als was high. It is also my belief that one can work systemically with
only one member of a couple. If one person changes, the nature of the
dyad must necessarily change as a result. As therapy progressed and
progressed well there was never a pressing need to invite Cricket in to
therapy, nor did Cricket ever make her participation an issue.
Early on in therapy I shared with Andrea my clinical impressions
from our initial sessions. I told Andrea that her lack of sexual desire
appeared to be a reasonable response to her situation. Her relation-
ship with Cricket was following a similar pattern of duty and obliga-
tion to that which began in her family of origin and continued in her
subsequent romantic relationships. Duty and obligation understand-
ably conflicted with her ability to experience desire. Reframing her
lack of desire as an understandable response was a pivotal moment
in therapy. It was not as she feared, that either there was something
wrong with her, or worse, that she did not love Cricket. Understand-
ing her lack of desire did not bring Andrea’s desire back. What the
reframing did was to eliminate Andrea’s defensiveness and redirect
the process of therapy with an eager and willing participant. Andrea
came to therapy out of fear of losing her relationship with Cricket.
She continued to come to therapy for her own growth.
In the initial evaluation, Andrea disclosed the sexual abuse, going
into specific details when guided by my questions. It was essential for
Andrea to disclose details to assure herself that I understood all that
had occurred when we discussed the impact of the sexual abuse on
her present sexuality. Helping Andrea comprehend how the abuse,
and her understandable reaction to it, worked with other factors in
her life to contribute to her current desire problems was a crucial
part of therapy. This allowed Andrea to move from a position of
helplessness and hopelessness—“I am damaged and there is nothing I
can do about it”—to feeling hopeful and energized: “I learned about
unhealthy sexuality, now I can learn and experience healthy adult
sexuality. I can learn about my own sexual feelings and I can trust
and enjoy them.”
In the subsequent 2 weeks Andrea and Cricket had frequent
(twice weekly) sex, without any increase in Andrea’s desire or moti-
vation other than to prove to Cricket that she was working in therapy.
 Reviving Sexual Desire in Long-Term Relationships   71

I continued to affirm Andrea’s right to say no to sex and we continued

to explore her lack of desire in the context of the issues raised in the
evaluation. It should be noted that when couples rush quickly back
into having sex without making real changes in the relationship, they
are often just engaging in another variation of obligatory sex (we are
in therapy and so we should be doing something about sex). Indeed,
the brief increase in sexual activity did not last.
As I continued to align with Andrea’s right and inclination to say
no to sex, I gave her the freedom to explore and discover her right
and inclination to say yes. After several months of therapy, Andrea
no longer felt defensive or hopeless and she was in a good position
to explore her nascent interest in and/or motivation for sex. The fact
that Andrea did feel desire during sex was a baseline as I encour-
aged Andrea to be curious about what else might elicit sexual inter-
est, arousal, or desire. Curiosity reverses the avoidance of all things
sexual that usually occurs in women with low desire. I utilized some
of the techniques that are outlined in the book Reclaiming Your
Sexual Self (Hall, 2004). The movie critique technique was one that
worked well with Andrea, as she was an avid moviegoer. In this exer-
cise, Andrea thought about several romantic films that she really liked
and answered questions about them, including ones that instructed
her to explore what it was about the relationship between the lovers
that she found compelling as well as what happened during any sex
scene that she found erotic. It did not matter to Andrea that most if
not all of the movies involved heterosexual relationships; she still felt
an interest in the key dynamics of the major players. In particular, she
loved the old movies involving Spencer Tracy and Katharine Hepburn
and she found their verbal sparring exciting, especially the fact that
they didn’t always have to give in and see each other’s viewpoint.
She was also drawn to the smart and sexy characters in the television
series The L Word. In addition to personality factors, she noticed the
women’s bodies and their lingerie, their casual attitude toward sex,
and the element of play that was often apparent. I was careful not to
encourage or suggest to Andrea that she “try this at home.” Therapy
was an opportunity for Andrea to be curious without being commit-
ted to action. She did ask for suggestions on books and websites and
I recommended two websites (www.goodvibes.com and www.babe-
land.com) as well as the book The Guide to Getting It On (Joannides,
2008). After reading through parts of the book, Andrea masturbated
for the first time in many years, a practice she continued throughout
therapy. Andrea reported feeling sexy but realized that in her relation-
72   TREATING SEXUAL DESIRE DISORDERS

ship with Cricket she was not acting like a smart, sexy woman who
was an equal with her partner. In therapy, Andrea and I role-played
several interactions she had had in the past, or anticipated having in
the future, with Cricket. Andrea practiced relating to her lover in a
more confident and assertive way. Soon when Cricket wanted to talk,
Andrea was either able to participate in a discussion representing her
own point of view or she was able to say she did not want to talk at
the moment. Andrea was also able to leave a conversation “agreeing
to disagree.” While she experimented and had support in therapy for
making changes in the way she related to Cricket, she also became
curious and began to experiment in the way she related sexually to
Cricket. Andrea initiated sex on a few occasions, and during sex she
began to be more assertive about what she wanted (and often this
involved pleasuring Cricket). We also talked about slowing down the
pace of sexual activity so that Andrea could attend to sexual feelings
and desires as they arose during sex. We discussed both the concept
and the techniques involved in building desire rather than sating sex-
ual arousal with a quick orgasm.
When Andrea began to initiate sex, she found that contrary to
her expectations, Cricket was not always ready or willing to have
sex with her. This was a relief to Andrea and was instructive as well.
Now that Andrea was sharing the initiation of sex, Cricket began to
share the limit setting. Contrary to Andrea’s fears, Cricket did not
always want to have sex. At this point, I did some coaching with
Andrea so she could begin to decipher and then to ask and check out
her assumptions about what made Cricket want to have sex with
her. Andrea realized that various emotional factors were responsible
for Cricket wanting sex. Some of these emotions similarly motivated
Andrea to seek out sex, among them a desire for intimacy, reconnect-
ing after an absence or an argument, wanting to express love or to
relax and be playful. Lust or spontaneous sexual desire was a rare
occurrence for both Cricket and Andrea, a fact that was both new
and reassuring to Andrea.
Toward the end of therapy, Andrea reported that other people
had begun to take notice of her and she found herself the object of
sexual attention from both men and women. Men (assuming she was
single) asked her out and other lesbians flirted with her. This was a
strong sign that Andrea had begun to integrate her sexuality into her
life and personality in a meaningful and lasting way.
As Andrea explored and experimented with sex, I maintained a
supportive but neutral stance. The therapist should at no time want
 Reviving Sexual Desire in Long-Term Relationships   73

the client to have sex more than the client herself wants it. This would
simply replay the obligation dynamic with different characters. Build-
ing on the work Andrea did in identifying the various emotional rea-
sons for having sex, she was able to say no to sex more directly (with
less avoidance of Cricket) but also in a kinder and more sympathetic
way. It was at this point that our sessions were spaced with longer
intervals between appointments. Andrea used therapy to further
explore what she liked and didn’t like sexually as her new awareness
of herself as a sexual being was reinforced.

Commentary

The lesson of Andrea’s therapy concerns the vital importance of space.

As a sex therapist I often find myself in the role of advocate or cheer-
leader for good or great or sometimes just adequate sex. Women who
come to therapy complaining of low desire don’t need a cheerleader
for sex. They don’t need encouragement to have more or better sex.
They do not need to feel that they must live up to the rather masculine
ideal of lustful sex. They need a supportive therapeutic relationship in
which they can explore their sexual feelings and discover what works
(or doesn’t) for them in their lives and in their relationships. At times
I had to hold myself back from cheering Andrea on, nudging her for-
ward, extolling the virtues of a happy sex life. I had to tell myself
that I couldn’t want her to have sex more than she wants it. I had to
remind myself that it was okay if she decided that she did not want to
have a sexual relationship with her partner or anyone else.
In the space of therapy, Andrea was able to sort out messages
from her past and confront the shame she felt for the abuse she expe-
rienced. She grew to be curious about sex. With permission not to
have sex or be sexual, she ultimately found a place for sex in her life.
Low sexual desire is a sexual disorder without a clear definition. In
essence what constitutes low desire is defined by the client and her
partner. The resolution must similarly be defined within the couple.
Therapy needs to provide a space in which clients can find their own
level of desire.
Sex therapy may be victim to its success and popularity as a brief
symptom focused approach to sexual problems. Even though this case
had a successful outcome, it took approximately 1 year to reach that
point. Andrea had a patient and sympathetic partner who shared her
interest in having sex be an expression of love and who, as a psycho-
74   TREATING SEXUAL DESIRE DISORDERS

therapist, understood that therapy often takes time. Many male part-
ners feel more hurt and upset at the lack of sex. They desperately want
to feel wanted and have difficulty tolerating a slow pace of therapy.
Many times male partners have wondered whether I, as a woman,
can really understand their perspective on sex, their need or desire to
be wanted sexually. What I learned from Andrea and Cricket’s case
was that managing expectations is an important part of therapy. I
now tell couples at the outset that therapy is a long process. I share
with them both the traditional or male model of sexual desire as well
as Basson’s model of female sexual desire during the evaluation. I
demonstrate throughout therapy an understanding of their divergent
perspectives on sex, but I remain resolutely neutral regarding how
they will ultimately negotiate their differences. Therapy should give
the individual or couple space in which to explore what will inspire
their sexual relationship. In cases of low desire, I do not encourage
couples to make dates for sex. What I do encourage are dates that
give the couple time and space in which sexual desire, interest, or
willingness might occur.
Perhaps one of the most important lessons from Andrea’s therapy
is that given time and space, women will discover the source of their
passion. The key in therapy is to facilitate this process while the chal-
lenge may be to help the partner provide and maintain that space
within the relationship.
Obligation kills desire. Pressure, be it from oneself, one’s partner,
or one’s therapist, will not lead to passion. What does lead to passion
will differ across genders and individual clients. It is up to the client
to discover it. It is up to the therapist to support the client, and often
her partner, through this process.

References

Basson, R. (2007). Sexual arousal/desire disorders in women. In S. R. Leiblum

(Ed.), Principles and practice of sex therapy (4th ed., pp. 25–53). New
York: Guilford Press.
Bradford, A., & Meston, C. (2007). Correlates of placebo response in the
treatment of sexual dysfunction in women: A preliminary report. Jour-
nal of Sexual Medicine, 4, 1345–1351.
Hall, K. S. (2004). Reclaiming your sexual self: How you can bring desire
back into your life. Hoboken, NJ: Wiley.
Joannides, P. (2008). The guide to getting it on (6th ed.). Waldport, OR:
Goofy Foot Press.
 Chapter 5

Confronting Male Hypoactive

Sexual Desire Disorder
Secrets, Variant Arousal,
and Good-Enough Sex

Barry McCarthy
Alisa Breetz

In this thoughtful chapter, Barry McCarthy and Alisa Breetz observe that
dysfunctional, conflictual, or absent sex plays an inordinately negative role
in couple intimacy, and that often it is the male partner who decides uni-
laterally to stop being sexual. Often, the man’s lack of desire is secondary
to erectile difficulties but at times it is related to undisclosed secrets and
shame.
Operating within a cognitive-behavioral framework, McCarthy and
Breetz present the case of a man who is avoiding sexual intimacy with
his new wife because of an undisclosed sexual fetish—a 20-year history
of masturbating to images of women wearing mid-calf boots. The man’s
reliance on Internet boot fetish sites to arouse and stimulate him is playing
havoc with his current marriage to a 37-year-old woman who is eager to
become pregnant and greatly distressed about the lack of sexuality in her
life.
McCarthy and Breetz discuss their “good-enough sex” approach and
use of structured exercises to help recapture desire as well as provide a
host of suggestions for relapse prevention.

75
76   TREATING SEXUAL DESIRE DISORDERS

Barry McCarthy, PhD, is Professor of Psychology at American Uni-

versity and a certified sex and marital therapist who practices individual,
couple, and sex therapy at the Washington Psychological Center.
Alisa Breetz, MA, is a graduate student in the clinical psychology doc-
toral program at American University and has collaborated with Dr. McCa-
rthy on various articles focused on sexual functioning, couple therapy, and
sexual trauma.

Clinicians are increasingly reporting that the sexual problem

that most subverts couple satisfaction and brings couples to therapy
is conflict about sexual desire and extreme sexual avoidance (McCa-
rthy & McCarthy, 2003). Although lay public and media emphasis
is on the man’s role of pursuing sex and the woman’s role of with-
holding sex, the reality is that when couples stop being sexual (i.e.,
having sex less than 10 times a year), it is usually the man’s deci-
sion, made unilaterally and conveyed nonverbally. In understand-
ing, assessing, and treating the problem of male hypoactive sexual
desire disorder (HSDD) we advocate a comprehensive, integrative,
psychobiosocial approach to male and couple sexuality. In addition,
we strongly suggest adopting the “good-enough sex” model, which
focuses on valuing a variable, flexible approach to sharing intimacy,
pleasure, and eroticism rather than clinging to the traditional male
criterion of autonomous erections and perfect intercourse perfor-
mance.
To date, the greatest attention has been paid to HSDD in women.
Basson (2007) has introduced and developed the concept of “respon-
sive sexual desire.” This breakthrough therapeutic intervention has
destigmatized HSDD and allowed many women to accept the obser-
vation that their desire may be more variable and flexible than that
of males. Female desire is simply different, neither better nor worse.
If sexual desire is defined by the traditional youthful male standard—
easy, predictable erections with a focus on sexual frequency and per-
formance—the woman is stuck in the “one down” position. In the
traditional model, sexual desire and arousal is a race, and she is the
loser.
The comprehensive, integrative, psychobiosocial approach to
couple sexuality presents a very different model. We believe that each
person is responsible for his or her own desire, arousal, and orgasm.
The challenge for couples is to develop their unique couple sexual
style and to integrate intimacy and eroticism into their relationship.
 Confronting Male Hypoactive Sexual Desire   77

The traditional male expectation of easy, predictable erections, total

sexual control, and perfect intercourse performance must be con-
fronted as self-defeating.
Traditionally, a man believes that sexual response is autonomous:
he can experience desire, arousal, and orgasm without needing any-
thing from his partner. Although this might be characteristic in new
relationships, it subverts mature couple sexuality, especially after the
ages of 40–50. The new psychobiosocial model views sex as an inter-
personal process, not an autonomous one, with the ultimate goal of
enhancing relationship satisfaction (Metz & McCarthy, 2007).
The basic paradox in couple sexuality is that sex plays a greater
role in overall well-being when it is unhealthy than when it is healthy.
Healthy couple sexuality enhances feelings of personal and couple
psychological well-being. The paradox is that dysfunctional, conflict-
ual, or nonexistent sexuality has an inordinately powerful negative
role, robbing the relationship of intimacy and threatening relation-
ship viability.

Male Hypoactive Sexual Desire Disorder

The majority of men who lack desire are reacting to erectile dys-
function (ED) and/or ejaculatory inhibition (EI). In secondary male
HSDD, the man has lost his confidence regarding erections, inter-
course, and orgasm. Rather than the healthy cycle of positive antici-
pation, pleasure-oriented sex, and a regular rhythm of sexual expe-
riences, an unhealthy cycle of anticipatory anxiety, tense, pass–fail
intercourse performance, and frustration, embarrassment, and even-
tually sexual avoidance becomes dominant. Often, sex has become a
fearful, embarrassing experience to be avoided. The decision to stop
sex is typically made unilaterally by the man and conveyed nonver-
bally. He thinks, “I don’t want to start something I can’t finish,” and
so avoids sensual and sexual touch. By the age of 65, one in three
couples has a nonsexual relationship, which increases to two in three
couples by age 75 (McKinlay & Feldman, 1994). The cessation of
touching and sexuality contributes significantly to a man’s view of
aging as a loss.
Although pro-erection medications have been viewed as the
answer to erection and desire problems, often medical interventions
result in a nonsexual relationship because of unrealistic sexual perfor-
mance expectations.
78   TREATING SEXUAL DESIRE DISORDERS

A less common but more challenging problem is primary male

HSDD. Although men with primary HSDD may be sexually func-
tional in a new relationship, the reality is that they often cannot sus-
tain or do not value intimate, interactive couple sex. Typically, the
core problem is a sexual secret that they feel must be kept hidden.
These secrets may be a variant arousal pattern, a preference for mas-
turbatory sex rather than couple sex (especially using Internet porn), a
poorly processed history of sexual trauma that has not been disclosed
to the partner, or unverbalized conflict about sexual orientation. This
combination of eroticism, secrecy, and shame creates a poisonous and
very controlling sexual scenario. Often, the man blames the woman
for the sexual problem. She feels confused, frustrated, and rejected,
leading to anger and alienation.

Case Example: Nick and Dora

Nick, age 33, initiated the request for consultation because of

increasing marital distress with his second wife, Dora, age 37. She
was threatening to leave Nick because their 18-month-old marriage
was nonsexual, and had been since before they wed. Dora wanted
children and felt great stress about her “biological clock.” Nick was
extremely distressed at the possibility of being twice divorced before
age 35.
Nick’s initial request was for individual therapy, but our preferred
treatment approach is couple therapy with a four session assessment
model. Both partners are seen in the first session, then an individual
session is scheduled with each partner to obtain a psychological/rela-
tional/sexual history, and finally a couple feedback session for the
couple to discuss a therapeutic plan.
The first couple session was quite stressful—clearly, the marriage
was in crisis. Dora was extremely confused and agitated about living
in a nonsexual marriage. Dora had met Nick at a picnic arranged by
married friends who assured her that Nick was committed to both
marriage and children. Now Dora felt that Nick had pulled a “bait
and switch,” and she felt betrayed. Unless their sexual pattern was
quickly resolved, Dora threatened to leave the marriage so she could
remarry and try to have a child.
Nick presented as the rational, conciliatory spouse who promised
this would all work out. His explanation of their problems focused
 Confronting Male Hypoactive Sexual Desire   79

on the stress caused by conflicts about wedding planning, which he

blamed primarily on Dora’s mother, especially conflicts about reli-
gious symbols involved in the wedding ceremony. Nick said he felt
badly about the nonsexual state of their marriage, but reassured
Dora of his commitment to her and to having children. Nick said that
Dora’s 15-pound weight gain, pressure to have sex, and accusations
that he was a latent homosexual or having an affair were the main
barriers to their sexual intimacy.
Their individual sessions were scheduled for the same week, with
Nick’s session first. The clinician begins the history with the following
introduction:

“I want to understand your psychological, relational, and sexual

history both before this marriage and during the marriage. I want
to hear both strengths and vulnerabilities. I appreciate your being
as forthcoming and blunt as possible. At the end, I’ll ask if there
is any sensitive or secret material that you do not want shared
with your spouse. I will not share it without your permission, but
I need to know as much as possible so I can be of help to you in
understanding and resolving these problems.”

Nick reported beginning masturbation at age 12, and by age 13 he

had developed a narrow, controlling fetish pattern involving mid-calf
boots. Although he felt shameful about the fetish and compulsive
masturbation and had tried multiple times to abstain, the mid-calf
boot fetish had dominated his sexuality for the past 20 years. Nick
experienced 20–35 orgasms a month, the vast majority involving
two Internet boot fetish sites where he charged approximately $700
a month to his credit card. This was a powerful sexual secret he had
not shared with Dora or any other woman (including his ex-wife).
Nick said that early in a relationship he would be sexually desir-
ous and functional, but within weeks or months he would develop
ejaculatory inhibition. With increased frustration for him and his
partner, Nick would avoid intercourse and would revert to masturba-
tory sex using the fetish site. The clinician labeled Nick the “master
of masturbation,” which he smilingly acknowledged.
When Nick met Dora he was enthusiastic and hopeful that his
pattern would change. He saw Dora as a very attractive and sexually
positive woman and he found the first 5 months of his relationship
with her sexually rewarding. The cycle ended when Dora insisted on
80   TREATING SEXUAL DESIRE DISORDERS

remaining on the birth control pill until they were actually married.
Nick wanted a child and felt stymied at what he viewed as Dora’s con-
servatism. He blamed it on her mother, who was a practicing Roman
Catholic. Nick had been raised in a nondenominational Christian
church but religion played a minimal role in his life.
Once the “magic” of romantic love/passionate sex/idealization
was broken, Nick withdrew from Dora sexually and resumed daily
masturbation using the mid-calf boot site. They attempted intercourse
three times during the honeymoon but Nick was self-conscious, moved
to intercourse quickly, and tried to force ejaculation. He focused on his
boot fetish fantasies. Dora found the prolonged intercourse physically
and emotionally irritating. Nick would “run out of gas” and would
either lose his erection or end the sexual encounter. Nick felt frustrated
and humiliated and avoided talking with Dora about sex. Outside of
sex, however, he continued to value their affectionate relationship.

Past History: Nick

Nick’s siblings had established successful marriages and families,
although Nick never discussed sexual issues with them. He was emo-
tionally closer to his mother, who had struggled financially following
the divorce from Nick’s father. His father had a history of extramari-
tal affairs, and a year after the divorce he married the woman with
whom he was having an affair. However within 2 years his father was
divorced again. Nick prided himself on not having affairs and was
shocked by the clinician’s question of whether he viewed the fetish as
a type of affair. Nick had never thought of the fetish as a secret sexual
life, equivalent to an affair.
As he talked about Dora and his fear that she would leave him,
it was clear that Nick was in great distress. While Nick desperately
wanted a successful marriage and family, he felt controlled by his
secret sexual life. Nick wanted Dora’s love and acceptance, but was
afraid to share his sexual dilemma with her.
Typically, at the conclusion of the individual history, several
open-ended questions are asked:

1. “What else should I know about you psychologically, rela-

tionally, or sexually?”
2. “As you look back on your entire life, what was the most
negative, confusing, guilt-inducing, or traumatic thing that
ever happened to you?”
 Confronting Male Hypoactive Sexual Desire   81

3. “Is there anything you want to red-flag and not have me share
with your spouse?”
4. “Is there anything you want to ask or check out with me?”

Nick said that he really wanted to remain married and have chil-
dren with Dora. His secret (and expensive) fetish was the major nega-
tive reality of his life, but he was afraid to share it because of Dora’s
possible reaction. The clinician actively lobbied Nick to disclose his
secret since the best time to share sensitive material is during the
couple feedback session. The clinician repeated the 12-step program
mantra: “You are only as sick as your secrets.”
Nick also agreed to attend his first meeting of the 12-step fel-
lowship Sex Addicts Anonymous (SAA). Receiving acceptance and
support from group members, especially through a relationship with
a sponsor, is of great value in reducing stigma and shame as well as
improving accountability with respect to compulsive/addictive behav-
ior.

Past History: Dora

Earlier in her life, Dora saw herself as a smart, attractive woman who
liked men and sex, but the stress of dating had truly worn her down.
She had initially felt optimistic about Nick, but her disappointment in
the lack of sex was profound and her fears of never having a family
overwhelming. Dora felt unattractive and nonsexual and for the first
time in her adult life had ceased masturbating. Men flirted with her
and she reported two invitations to have an affair but decided not to
act on these invitations unless she was officially separated. However,
awareness of these opportunities made the option of a separation
more compelling.
Dora believed that Nick had a sexual secret—either that he was
homosexual or having an affair with another woman. She felt pres-
sured from her individual therapist to move on with her life since she
was 37. The worst obstacle in Dora’s life was the pattern of being
disappointed and let down by men—her father, boyfriends, and now
Nick. Dora felt depressed and was herself experiencing low desire.

Couple Feedback Session

The 90-minute couple feedback session is the core intervention in this
therapeutic model. As with the vast majority of couples, the clinician
82   TREATING SEXUAL DESIRE DISORDERS

had received permission to share sensitive and secret material in a

therapeutic manner.
The feedback session has three goals: (1) to develop a genuinely
new individual and couple narrative regarding intimacy and sexuality,
(2) to agree on a therapeutic plan and contract, and (3) to assign a
psychosexual skill exercise to begin to address desire issues.
The feedback started with enumerating Nick’s personal and sex-
ual strengths: He was a competent, well-intentioned male who loved
Dora and wanted a successful marriage and family; he could experi-
ence desire, arousal, and orgasm; he was finally willing to face dif-
ficult sexual issues; he was an empathic problem solver.
Clearly, Nick’s greatest vulnerability was the secret, shameful
boot fetish. Its power was demonstrated by normally frugal Nick
spending a great deal of money on Internet sex, by his reluctance to
enlist Dora as his intimate ally (instead further alienating her by rais-
ing false issues about her weight and the mother-in-law’s role), and by
his lack of comfort and confidence with intimate, interactive sex.
The clinician gave Nick a chance to change, edit, or add to the
narrative, but Nick said it was “spot on.” The clinician asked Dora
whether she needed to clarify any information or perceptions about
Nick’s sexual narrative. Dora wanted to be sure she had the whole
story and that there was not an affair or any other emotional or sex-
ual secret which would be revealed later. Throughout this feedback
session an important therapeutic strategy was to avoid strong nega-
tive emotions.
The same process was repeated for Dora’s narrative with Nick
listening. Dora was surprised at the accuracy of her narrative, espe-
cially how rejected and demoralized she felt. Dora felt validated by
the recital of her personal, relational, and sexual strengths. Nick com-
mented on how sad he felt about Dora’s feelings of depression, sexual
rejection, and diminished desire.
The second phase of the feedback session involves outlining the
therapeutic focus and contract—a 6-month good-faith effort to build
a new couple sexual style, to confront the sexual poison of a secret
fetish life, and to affirm marital vitality by having a planned, wanted
child. It was clear to the clinician that this would be a daunting task
but, if Nick and Dora stayed focused and motivated, a realizable
one.
The third phase was a psychosexual trust exercise, which focused
on developing a “trust position.” The couple are presented with sev-
 Confronting Male Hypoactive Sexual Desire   83

eral examples of physical positions (e.g., she puts her head on his
chest and listens to his heartbeat; they lie together in a spoon position
and verbally acknowledged feeling cared for and secure). In the pri-
vacy of their home, they try out and find one position where they feel
comfortable, connected, and safe. In the case of Nick and Dora, we
started with trust because it addressed a core issue and was likely to
be successfully implemented. In addition, Nick agreed to find some-
one from the SAA group who was able to put a “block” on the fetish
sites.
At the beginning of the weekly couple sex therapy session, Dora
reported that the trust exercise had been powerfully energizing for her
in physically reconnecting with Nick for the first time since their mar-
riage. The computer blocking program had been successfully installed
and Dora held the code. Nick joked that money would be better spent
on therapy than compulsive cybersex.
The next psychosexual skill technique involved a comfort exer-
cise to share pleasure and intimate feelings and heighten the erotic
experience. The exercise is done in the privacy of their home. They
experiment with touching inside and outside the bedroom; clothed,
semiclothed, or nude; being silent or mixing talking and touch-
ing; taking turns or doing mutual touch to establish receptivity and
responsivity to touch scenarios and techniques. As part of the com-
fort exercise there was a prohibition on Nick trying to force orgasm
and turning away from Dora when he failed. Not surprisingly, Dora
found the experience more fulfilling than Nick. Dora transitioned to
the trust position after less than 5 minutes of intercourse when she
sensed that sexual intercourse was no longer pleasurable or involving
for Nick. He affirmed her perception, and this helped him see Dora
as his intimate sexual friend rather than someone to perform for so
she wouldn’t abandon him. In that same week, Dora asked Nick to
hold her while she pleasured herself to orgasm. This was very sexually
arousing for Nick, who was aroused by her arousal and experienced
her sexual response as a good thing rather than as pressure to match
her response.
During the next therapy session, they had an emotional discus-
sion over the importance of Nick sharing his struggles with sexual
compulsivity. The hardest thing for Nick to accept was that couple
sex could not have the extreme intensity of fetish sex, although it
could be more genuine and satisfying.
The next psychosexual skill exercise was an “attraction” exercise
84   TREATING SEXUAL DESIRE DISORDERS

to identify what Nick genuinely found attractive (physically, emotion-

ally, sexually, and interpersonally) about Dora. This exercise had a
powerful energizing effect on Dora and helped to undue the damage
his defensive attacks on her weight and attractiveness had caused.
Nick also requested that (1) Dora be open to his erotic stimulation
because her arousal was arousing for him, (2) they shop together at
Victoria’s Secret for sexy clothing, (3) she engage in multiple stimula-
tion during intercourse (e.g., being open to receiving breast stimu-
lation and giving testicle stimulation). In addition, Nick’s requests
assured Dora that he wanted and needed her as his erotic partner.
Building bridges to desire is a couple task. Most helpful for Nick
and Dora was to have “his,” “hers,” and “our” bridges to sexual
desire. Dora needed to regain her “sexual voice” and to be recep-
tive and responsive to both partner-interaction and self-entrancement
arousal. This in turn facilitated Nick’s sexual desire and response.
Dora’s openness to engaging in multiple stimulation during inter-
course was particularly valuable. In addition, Dora accepted Nick
using self-stimulation during erotic, nonintercourse sex. Her use of
sexy clothing (a variation of role enactment arousal) was not a sub-
stitute for the mid-calf boot fetish, but a different bridge to desire
and an erotic stimulus. Dora’s enthusiasm in pleasuring and eroti-
cism allowed Nick to “piggy-back” his arousal on hers. The clinician
emphasized the importance of being both intimate and erotic friends
rather than competitors for ease and rapidity of sexual response.

Confronting Variant Arousal

Addressing Nick’s variant arousal pattern was challenging. Although
some clinicians advocate the woman accepting the man’s variant
arousal and integrating it into their couple sexual style, we believe
that this is not a genuine option for the majority of men with a secret
sexual life. The narrowness and rigidity of fetish sex is such that it
does not integrate into couple intimacy and eroticism. The analogy
that Nick found most helpful was that the mid-calf boot fetish was
like “sexual heroin.” The erotic charge from the fetish was extraor-
dinarily powerful and had been reinforced by tens of thousands
of Internet/masturbatory orgasms. The combination of eroticism,
secrecy, and shame was as compelling as heroin and ultimately just
as destructive to Nick’s life, especially his marriage and hope for a
family. Nick’s commitment to totally abstaining from the fetish was
not caused by moralistic reasoning, but by the understanding that
 Confronting Male Hypoactive Sexual Desire   85

it would control and poison not only his life but their couple rela-
tionship as well. Good intentions were not enough. Nick needed to
use all his resources, including regular attendance at SAA meetings, a
relationship with a sponsor, maintaining the computer block on fetish
sites, developing an intimate and erotic couple sexual style, couple sex
therapy, and checking in monthly with Dora to ensure there was no
regression to a secret sexual life (i.e., maintaining transparency).
Variant arousal is truly an intimacy disorder. While couple sexu-
ality is necessary, it is not sufficient for overcoming a long-standing
variant arousal pattern. Both Dora and Nick needed to be aware that
even the healthiest couple sexuality would not be enough to break the
cycle of sexual compulsivity.
In subsequent couple sessions at least 10 minutes were devoted to
discussing Nick’s compulsive sexual behavior. For most men, sexually
compulsive behavior is a chronic issue. For a minority of men, the
fetish loses its power once the secrecy is confronted and awareness
of the harmful effects of compulsive sex become clear. Unfortunately,
Nick needed to consistently monitor the fetish to prevent a relapse
into his secret world. Nick struggled with his “sexual demon.” The
strength of his sexual urges to act out the fetish arousal was quite dis-
tinct from marital and sexual satisfaction. Originally, Dora hoped that
love, a renewed marital commitment, and a satisfying sex life would
be enough to change the variant arousal pattern. It was a sobering
realization for both Nick and Dora to accept that this was a separate
issue that required vigilance and monitoring.

Sexual Desire and Conception

Perhaps the most difficult, but crucial, discussion occurred during the
ninth therapy session. Nick and Dora had resumed intercourse, and
Dora was not using birth control. The question was whether they felt
confident enough of their marital and sexual commitment to have a
planned, wanted baby.
The issue for Dora was whether a baby would cement their mari-
tal bond or destabilize marital sex and reignite Nick’s sexual com-
pulsivity. As they discussed these complex issues, the clinician took
the role of facilitater, helping the couple make a wise decision, rather
than being the decision maker. It was crucial that Dora believe Nick
had her best interests in mind and that he would not do anything to
intentionally undermine her or their marital bond. Nick was able to
make that commitment. Although there could be “lapses”—incidents
86   TREATING SEXUAL DESIRE DISORDERS

of masturbating to images of the boot fetish or even using Internet

stimuli—Nick was committed to transparency, to enhancing marital
sexuality, and to not allowing his lapse to become a relapse to a secret
sexual life.
Nick assured Dora he would not let her become pregnant and
then abandon the marriage. She assured him of her love and of the
value she placed on both marriage and family. Nick’s other major
concern was that Dora would never truly forgive him for his past
behavior. Dora wanted a marriage with Nick where they maintained
a secure attachment through good and bad times, including couple
sexual issues and compulsive sexuality.
Intercourse with the hope and intention of becoming pregnant is
an aphrodisiac for most couples. It certainly was for Nick and Dora.
They committed to having intercourse two to three times during the
week with the greatest probability of fertility. Much to Nick’s sur-
prise, the impetus of pregnancy enhanced his sexual desire. Initiating
intercourse only at high levels of arousal and using multiple stimula-
tion and erotic fantasies (but not the boot fetish) as an orgasm trig-
ger resulted in pleasurable, functional intercourse and intravaginal
ejaculation. Much to Dora’s surprise she became pregnant within 3
months.
Sessions were now scheduled biweekly in order to maintain the
gains they had made. On the weeks when we did not meet, Nick and
Dora were encouraged to preserve the time for themselves in order to
talk, have a sexual date, go for a walk, have lunch, engage in a psy-
chosexual skill exercise, or simply be with each other. An advantage
of couple time is that it facilitates being together without the distrac-
tions of work, chores, and other agendas.
The more variable and flexible couple sexuality is, the less likeli-
hood of relapse. Nick and Dora needed to refine their initiation pat-
terns, maintain affectionate touch both inside and outside of the bed-
room (while recognizing that not all touch could or should lead to
intercourse), develop and refine erotic scenarios and techniques, view
intercourse as a natural continuation of the pleasuring/eroticism pro-
cess (rather than as a pass–fail performance test), integrate afterplay
scenarios and techniques that promote bonding and satisfaction, and
accept the varied roles and meanings of couple sexuality (as a shared
pleasure, a means of expressing loving feelings, a tension reducer to
alleviate stress, a “port in the storm,” one-way sex to soothe a disap-
pointment, couple sex to breach an argument or feelings of alienation,
a way to reaffirm attraction and vitality).
 Confronting Male Hypoactive Sexual Desire   87

An Individualized Relapse Prevention Plan

In an individualized relapse prevention plan it is crucial that the cou-
ple realize that sexual desire must be consistently nurtured. Other-
wise, a high rate of relapse is likely. Individually and together the
couple needs to build anticipation and bridges to desire, and integrate
intimacy and eroticism into their lives and marriage. Just as impor-
tant, they need to monitor “traps” that can subvert and “poisons”
that can kill desire.
Before formal treatment was terminated, Nick and Dora received
a handout of 10 relapse prevention strategies/techniques (Metz &
McCarthy, 2004), which can be found in Table 5.1. They were asked
to choose 2 to 4 that were personally relevant. Since they were expect-
ing a baby, one technique was an agreement that at least one weekend
a year they would go away as a couple without the baby. Fortunately,
Dora’s parents and sister indicated they would be pleased to babysit
for a night, weekend, or even a week.
The other major relapse prevention technique agreed upon was
to plan a sexual date with a prohibition on intercourse once every 6
weeks. This was particularly important for Dora, who strongly val-
ued the role of playfulness in couple sexuality. Dora found it easier
than Nick to accept that intimate, interactive couple sex was not as
erotically powerful as the old fetish pattern. As the clinician said,
“Don’t compare apples and oranges,” but instead realize that your
new sexual style fits your life and marriage.
There were two important structural factors in their relapse pre-
vention program. First, they scheduled 6-month follow-up sessions
over a 2-year period. At each session, the couple checked in on the
state of intimacy and sexuality, reviewed progress on reaching the
goal for the previous 6 months, and set an enhancement goal for the
next 6 months. The goal could be something small, such as trying a
new sensual lotion or a different sequence of pleasuring/eroticism, or
something big, such as experimenting with a role enactment scenario
or going away for the weekend to enhance their intimate and erotic
connection.
A second major structural factor in relapse prevention is the use
of a “booster session.” If they had gone 2 weeks without a significant
sexual encounter, the higher-desire partner (in this case, Dora) agreed
to initiate sex. If that was not successful, on the third week the other
partner (Nick) agreed to initiate. If they had gone a month without a
significant sexual encounter, they called for a booster therapy session.
88   TREATING SEXUAL DESIRE DISORDERS

TABLE 5.1. Relapse Prevention Strategies and Guidelines

1. Set aside quality couple time and discuss what you need to do individually and
as a couple to maintain a satisfying, intimate relationship.
2. Every 6 months have a formal follow-up meeting either by yourselves or with a
therapist to ensure that you remain aware and do not slip back into unhealthy
sexual attitudes, behaviors, or feelings. Set individual and couple goals for the
next 6 months.
3. Every 4–8 weeks plan a sensual pleasuring session or a playful erotic session
where you have a prohibition on intercourse. This allows you to experiment
with new sensual stimuli (alternative pleasuring position, body lotion, or new
setting) or a playful, erotic scenario (being sexual in the shower, a different oral
sex position or sequence, one-way rather than mutual sex). This reminds you
to value sharing pleasure rather than intercourse performance and to develop a
broad-based, flexible sexual relationship.
4. Five to 15% of sexual experiences are dissatisfying or dysfunctional. That is
normal, not a reason to panic or feel like a failure. Maintaining positive, realistic
expectations about marital sexuality is a major resource.
5. Accept occasional lapses, but do not allow a lapse to become a relapse. Treat a
dysfunctional sexual experience as a normal variation, a mistake to learn from.
You are a sexual couple, not a perfectly functioning sex machine. Whether
once every 10 times, once a month, or once a year, you will have a lapse
(dysfunctional or dissatisfying sex). You can laugh or shrug off the experience
and make a date in the next 1 to 3 days when you have the time and energy
for an intimate, pleasurable, erotic experience. The importance of setting
aside quality time, especially intimacy dates and a weekend away without
children, cannot be emphasized enough. Couples report better sex on vacations,
validating the importance of getting away, even if only for an afternoon.
6. There is not “one right way” to be sexual. Each couple develops their
own unique style of initiation, pleasuring, erotic scenarios and techniques,
intercourse, and afterplay. Rather than treating your couple sexual style with
benign neglect, be open to modifying or adding something new or special each
year.
7. “Good-enough sex” has a range from disappointing to great. The single most
important technique in relapse prevention is to accept and not overreact to
experiences which are mediocre, dissatisfying, or dysfunctional. Take pride in
having an accepting and resilient couple sexual style.
8. Develop a range of intimate, pleasurable, and erotic ways to connect, reconnect,
and maintain connection. These include five “gears” (dimensions) of touch:
a. Affectionate touch (clothes on): kissing, hand-holding, hugs
b. Nongenital sensual touch (clothed, semiclothed, or nude): massage
(excluding genitals), cuddling on the couch, touching before going to
sleep or on awakening
c. Playful touch (semiclothed or nude): mixing nongenital and genital
touch, dancing together, touching while showering or bathing, “making
out” on the couch
d. Erotic, nonintercourse touch: using manual, oral, rubbing, or vibrator
stimulation to high arousal and/or orgasm for one or both partners
e. Intercourse: sensuality, playfulness, eroticism naturally flow into
intercourse. The more ways to maintain an intimate sexual connection,
the easier to avoid relapse.
 Confronting Male Hypoactive Sexual Desire   89

TABLE 5.1. (continued)

9. Saturate each other with multidimensional touch.
10. Keep your sexual relationship vital. Continue to make sexual requests and
be open to exploring erotic scenarios. The importance of maintaining a
sexual relationship that serves a 15–20% role of energizing your marital
bond and facilitating special feelings of desirability and satisfaction cannot be
overemphasized. Couples who share intimacy, nondemand pleasuring, erotic
scenarios and techniques, and planned as well as spontaneous sexual encounters
have a variable, flexible sexual relationship. This is a major antidote to relapse.

The focus of the session was to identify the “message” behind the
sexual avoidance and to problem-solve how to break the avoidance
cycle. Although we value supportive, clothes-on affectionate touch
(holding hands, hugging, kissing) as a safe, secure form of connec-
tion, this is not sexual touch. Sensual, playful, erotic, nonintercourse,
as well as intercourse, are all dimensions of healthy couple sexuality.
The challenge for Nick and Dora was to use variable, flexible sensual
and sexual touch to stay connected. In addition, they learned to value
a “good-enough sex” approach to couple sexuality rather than cling
to the pass–fail criterion of perfect intercourse performance.

Commentary

Nick and Dora successfully confronted two poisons—a nonsexual

marriage and Nick’s secret fetish world. Formal treatment involved
nine weekly sessions, eight biweekly sessions, one booster session,
and three 6-month follow-up sessions. At the last follow-up, they
were busy parenting a 19-month-old son and Dora was 2 months
pregnant with their second child.
Nick continued his involvement with the SAA fellowship,
attending weekly meetings, and continued the monthly check-in
process with Dora. Both rated marital satisfaction in the A– range;
Dora rated sexual satisfaction in the B+ range, while Nick rated it
as a B. Nick’s task was to accept himself and commitment to marital
and sexual intimacy as the very best he could do and be. Nick felt
accepted and loved by Dora, but also felt somewhat frustrated with
the fact that sex with Dora was not more erotically fulfilling. Nick
wanted to be an especially good sexual educator for his son so that
he did not have to go through the pain of harboring a secret, variant
arousal pattern.
90   TREATING SEXUAL DESIRE DISORDERS

Couple sex therapy for low desire is an excellent example of

the need for an integrative, comprehensive, psychobiosocial model
for assessment, treatment, and relapse prevention. The clinician as
well as each individual and the couple are urged to use all relevant
resources to address the complex, multidimensional issues character-
istic of HSDD.
Psychologically, the keys to desire are positive anticipation and a
sense of deserving. Biologically, it is crucial to address hormonal and
medical deficits, as well as illness, the side effects of medications, and
poor health habits. Medical resources are not stand-alone interven-
tions, but rather must be integrated into the couple style of intimacy,
pleasuring, and eroticism. Relationally, the partner is viewed as an
intimate and erotic friend.
The role of psychosexual skills is of particular importance in
developing and maintaining sexual desire. Our cultural view of
desire and sexual performance holds that it is simple and “natural.”
In reality, the challenge for both individuals and couples is to inte-
grate intimacy and eroticism into their ongoing relationship after
the initial charge of romantic love/passionate sex/idealization has
dissipated. This requires that the woman value her “sexual voice”
and that the man learn to value intimacy and nondemand plea-
suring. Both partners need to integrate these into their sexual life
together.
Finally, couples must have positive, realistic sexual expecta-
tions. Accepting that couple sexuality is inherently variable and
flexible can be empowering rather than anxiety provoking or dis-
couraging. Sexual desire can be facilitated and enhanced or it can
be subverted and poisoned. The “good-enough sex” model pro-
motes sexual desire for men, women, and couples (McCarthy &
Metz, 2008).

References

Basson, R. (2007). Sexual desire/arousal disorder in women. In S. Leiblum

(Ed.). Principles and practice of sex therapy (4th ed., pp 25–53). New
York: Guilford Press.
McCarthy, B., & McCarthy, E. (2003). Rekindling desire: A step-by-step
program to help low-sex and no-sex marriages. New York: Brunner/
Routledge.
McCarthy, B., & Metz, M. (2008). Men’s sexual health: Fitness for satisfying
sex. New York: Routledge.
 Confronting Male Hypoactive Sexual Desire   91

McKinlay, J., & Feldman, H. (1994). Age-related variation in sexual activity

and interest in normal men. In A. Rossi (Ed.), Sexuality across the life
course (pp. 261–285). Chicago: University of Chicago Press.
Metz, M., & McCarthy, B. (2004). Coping with erectile dysfunction: How to
regain confidence and enjoy great sex. Oakland, CA: New Harbinger.
Metz, M., & McCarthy, B. (2007). The good-enough sex model for couple
sexual satisfaction. Sexual and Relationship Therapy, 22(3), 351–362.
 Chapter 6

“Desire Disorders”
or Opportunities
for Optimal Erotic Intimacy?
Peggy J. Kleinplatz

Aim at heaven and you will get Earth thrown in. Aim at
Earth and you get neither.
                 —C. S. Lewis

In this chapter, Peggy J. Kleinplatz artfully illustrates how Experiential Psy-

chotherapy and her own unique views of the opportunities afforded by sex-
uality are used to deal with desire complaints. She observes that although
her clinical approach emphasizes personality growth and discovery (in the
presence of the partner), sexual problems are usually resolved as well.
One of the significant aspects of therapy is the focus on achieving erotic
intimacy or what Kleinplatz describes as the “inter-penetration of the part-
ners, including their wishes, hopes, desires, fantasies, dreams, and fears
via sexuality” so that each may have an entry into their partner’s inner world.
Optimal sexuality—what makes sexuality memorable—involves being fully
present, authentic, vulnerable, intensely connected with the partner, and
emotionally willing to take risks during sex. It is this subjective and erotic
experience that is valued as a therapeutic goal over any objective indice of
“normative” sexuality, such as increasing sexual frequency.
In her clinical illustration, Kleinplatz describes several palpable
moments when Mrs. Carter identifies a powerful, often painful emotion
associated with a past event and gives expression both to the feeling and a

92
 “Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   93

more empowered, assertive response. By translating this response to her

everyday world and interactions, Mrs. Carter is able to access and experi-
ence sex that is worth desiring. Although the therapy is relatively brief, the
impact is long-lasting.
Peggy J. Kleinplatz, PhD, is Associate Professor in the Faculty of
Medicine and Clinical Professor in the School of Psychology, University of
Ottawa, in Ottawa, Canada. Her clinical and research work focuses on opti-
mal sexuality, eroticism, and transformation, with a particular interest in the
elderly, sexual minorities, and other marginalized populations.

Overview of Problems of Sexual Desire

Desire problems are the most common sexual problems seen in my

practice. Some months they comprise a higher proportion of the cases
than all other sexual problems combined. Often I think that almost
all sexual problems are based in conflict over too much sex, too little
sex, or the “wrong” kinds of sex. The frequent comment “If I never
had sex again I wouldn’t miss it” inevitably leads me to question why
this individual is in my office and why now.
Frequently, individuals with low desire say that they have never
had sexual desire or at least not much desire. However, a little prob-
ing often reveals that if they do not recall having desire for “sex” as
they have come to define it, they may recall incidents of very high
arousal and excitement and desire in the past. However, what they
have come to label as “sex” now is not worth wanting.
Complaints typically come from the higher-desire partner. Even
when the lower desire client reports freely, “I’m the one who needs
treatment. I’ve come across this before. It’s me. It’s why my other
relationships have ended and I don’t want this one (or the next one) to
end because of my problem, too” I am not clear as to the nature of the
problem. Sometimes low desire is only evidence of good judgment.
Two types of considerations/conceptualization govern my work
with clients referred for treatment of sexual desire disorders: One
comes from the experiential model of personality and psychotherapy
(Mahrer, 1978, 1996, 2002; Mahrer & Boulet, 2001); the other comes
from sexology and in particular, my own approach to eroticism and
optimal sexuality (Kleinplatz, 1992, 1996, 2004, 2006; Kleinplatz
& Krippner, 2005; Kleinplatz & Ménard, 2007). The methods and
goals that emerge from these ways of thinking meld nicely in dealing
with low desire (and other sexual concerns) in therapy. Both ways of
94   TREATING SEXUAL DESIRE DISORDERS

thinking lead me to focus less on the nature of desire disorders and to

concentrate instead on how the individuals involved might grow and
how their sex lives might be closer to optimal.
Experiential Psychotherapy* (Mahrer, 1996) is unique, brings
about fundamental change relatively quickly, and may seem intimi-
dating to those unfamiliar with this approach. The goal of therapy is
not to ameliorate the symptom but to use the presenting problem as
an opportunity for growth. Change is brought about by going within
rather than attempting to achieve some externally imposed set of
goals, whether from the therapist or the higher-desire spouse. Work-
ing with moments of peak experiencing helps to bring about sub-
stantive personality change. Thus, in Experiential Psychotherapy one
never sets out to treat (the symptoms of) sexual (or other) disorders.
However, often the personality changes that occur during the course
of therapy are so substantial that sexual disorders seem to be “cured”
nonetheless (Kleinplatz, 1998, 1999, 2004, 2007).
The methods of Experiential Psychotherapy differ markedly from
those of conventional sex therapy. Each session includes four steps
(Mahrer 1996): The initial step involves entering into a moment of
strong feeling in order to find and access some deeper way of being
within the individual. During the second step, the client welcomes
this new experiencing by beginning to identify it and receive it, for
example, by attending to the bodily sensations that accompany the
emerging way of being. During the third step, the client returns to
earlier life events during which this inner experiencing could have and
should have been present, although it has not generally been avail-
able in many years. The client returns to the past and lives as the
newly accessed deeper experiencing, giving voice and expression to
the way of being that he or she might have been and can now choose
to become. In the final step, the client, still in the office, tries out and
rehearses the newly revived inner way of being in prospective new
opportunities in the “real” postsession world. Homework is usually
generated by the “new” client, who plans to carry on being the person
he or she might have been after conclusion of the session.
Although Experiential Psychotherapy was designed to be used
in individual therapy, it offers a particular advantage in dealing with
sexual problems in couple therapy (Kleinplatz, 1999, 2007). It is a

*Experiential Psychotherapy as described by Mahrer (1996) is usually capitalized to

distinguish this model of psychotherapy from the rather large family of other experi-
ential approaches to psychotherapy.
 “Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   95

truism in couple therapy that changes to one of the individuals creates

a threat to the couple system. One advantage of this method is that
the partner’s presence helps make change safer for the couple—being
a witness to the therapy process may increase respect for the partner’s
courage, thereby enhancing relationship intimacy. The Experiential
models of personality change and psychotherapy emphasize optimal
ways of being and behaving (Mahrer, 1996, 2008a, 2008b). There
is something profoundly exciting for both parties when they begin
to envision a relationship that is more than merely free of problems
but one in which sex begins to soar—or more correctly, when the
participants begin to glimpse how it might feel to be utterly alive
and engaged in each other’s embrace. Perhaps most fundamentally,
Experiential Psychotherapy places a primacy on subjective experience
over objective indices of behavior, such as sexual functioning, perfor-
mance, and frequency.
Similarly, a focus on optimal sexuality and eroticism in sex
therapy shifts the emphasis from how often couples engage in sex to
whether or not the sex they habitually engage in is worth wanting.
The assumption here is that a lot of cases of low desire stem from
unfulfilling sex. The conflation of frequency counts with assessments
of pleasure, joy, and delight makes it too easy to get sidetracked into
recording progress in terms of how often the couple has sex, which
can eclipse attention to the quality of the sex.
From this vantage point, the definition of “sex” offered by many
people referred for treatment of low desire is so narrow as to preclude
desire. The definition tends to feature tension relief, intercourse, and
orgasm. If “sex” is to be a few perfunctory moments of “foreplay”
followed by penetration so as to get “sex” over with as quickly as
possible, it is hard to imagine why anyone would want it, not to men-
tion why anyone would put up with such uninspired, bland, lacklus-
ter, and, indeed, undesirable sex. Even worse, if the chief motive for
going through the motions is to be able to count this event as having
“done it” in order to prevent interpersonal conflict—as in, “if I don’t
‘do it’ he [or she] gets grumpy”—then sex is bound to be empty, if not
outright laden with resentment. It is even more disturbing that either
partner would choose to endure such a chore in the name of peace or,
more accurately, to buy some temporary relational détente.
In this clinical approach, the focus is not on acts or techniques
or performance but on erotic intimacy. By erotic intimacy, I am refer-
ring to the knowing interpenetration of the partners, including their
wishes, hopes, desires, fantasies, dreams, and fears, via sexuality.
96   TREATING SEXUAL DESIRE DISORDERS

Eroticism is about the intent to arouse and to heighten that arousal

for the sheer joy of it and for the sake of having an entry point into
the partner’s inner world (Kleinplatz, 1992, 1996, 2006). It is about
allowing the vulnerability that one or both partners experience in this
endeavor to be exposed in the hope that whatever is discovered will be
accepted, valued, cherished, and regarded as precious. Eroticism can
potentially go beyond the sensory and may involve the entire range of
intrapsychic and interpersonal elements (Kleinplatz, 1992, 1996). In
an erotic encounter, the lover feels valued knowing that his/her part-
ner is interested enough in him or her as an erotic being to enjoy the
process of attempting to provide erotic fulfilment rather than merely
aiming for orgasm. The passion of eroticism may perhaps be most
profound when both partners sense they are touching one another’s
deeper, inner, hidden selves, rather than only their bodies.The sense
of intimacy that comes from this sort of carnal knowledge, used here
deliberately as a descriptor of a profound, shared state rather than as
a euphemism for “having sex,” is the essence of eroticism.
Recently my research team has been investigating empirically
the phenomenon of optimal sexuality among key informants, that
is, individuals who have experienced optimal sexuality, primarily
in relationships of 25 years or more. Our findings have shown that,
indeed, there are aspects of extraordinary sex reported almost uni-
versally among individuals despite different educational and socio-
economic backgrounds and diverse sexual histories. These qualities
include being fully present, authentic, vulnerable, intensely connected
with the partner, and taking emotional risks during sex (Kleinplatz &
Ménard, 2007; Kleinplatz et al., 2009).
Putting the clinical and research pieces together, whatever kind of
sex works for two (or more) individuals will be more enticing if the
partners are alive, embodied and integrated within themselves and
absorbed in and engaged with one another in the moment. The par-
ticulars will be unique to each individual; in fact, that is what makes
sex so erotic—that each encounter involves two sets of sexual arousal
patterns and accompanying meanings, each as distinctive as finger-
prints. However, the commonality is that the individuals choose to
go outside the boundaries of conventional sex scripts and knowingly
reveal themselves, being emotionally naked together with awareness
of the risks engendered in this endeavor.
In summary, where these complementary approaches meet is in
privileging subjective experience over objective indices of behavior and
individual uniqueness over normative sexuality and in the assumption
 “Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   97

that in order for “sex” (whatever that entails) to be desirable, it will

have to be deeply engaging to the individuals in question.
Here is where this approach to thinking about people and change
in psychotherapy intertwines with the role of eroticism in dealing with
low desire: The goals of therapy from the vantage points of Experien-
tial Psychotherapy and promoting optimal sexuality involve making
the relationship just safe enough for the partners to be vulnerable,
authentic, and engaged together. Sharing in erotic intimacy presup-
poses two individuals capable of being and choosing to be alive in
their skin together.

Challenging Conventional Assumptions

The challenges in cases of low desire or sexual desire discrepancy are

posed primarily by the unspoken assumptions about sexuality held
by the general public (and sometimes within the field of sex therapy)
and reinforced by the media. These assumptions include the follow-
ing: the problem is the quantity of sex rather than the quality; sex
is equated with intercourse (in heterosexual couples); low desire is
viewed as a problem to be treated rather than a message calling for
attention to something deeper in the individual and/or the couple, or
an opportunity for growth; and the goal of treatment is to increase
sexual frequency.
Hollywood images set couples up for the bizarre belief that every-
one should want “sex” whenever it is available regardless of mean-
ing and context. Patients are thus often in the position of choosing
to compromise between what looks easy on the screen but is unat-
tainable and what they have known as arduous and dull but should
implicitly be wanted and engaged in for the sake of the relationship.
In addition, gender role norms work to everyone’s disadvantage;
the notion that men and women are essentially and fundamentally
different leads to an awful lot of condescension and resentment. Feel-
ings of being unwanted are often buried or are expressed as anger
rather than sorrow or hurt.

Case Example: Karen and Mark Carter

The case illustration presented here is a representative and relatively

ordinary case, similar to the ones I see routinely in my practice.
Karen Carter had been in therapy previously for treatment of
98   TREATING SEXUAL DESIRE DISORDERS

depression, low self-esteem, and body-image problems and was

referred to me for treatment of low desire. Previous therapy 2 years
before seemed to manage the symptoms of depression but did not
result in broader change. She had been using oral contraceptives for
12 years except when trying to conceive. Mrs. Carter is in good health
and not on any medications. An IUD is used for birth control.
There were a total of seven therapy sessions in addition to one
follow-up session 6 months later and a final session at the 18-month
mark. The first session involved meeting with Mrs. Carter alone, and
all the subsequent sessions included Mr. and Mrs. Carter in couple
therapy. No matter who the identified patient is, whoever is bothered
by the problem really ought to be present if therapy is to be most
effective.
Mr. and Mrs. Carter have been together since their late teens
and have never had sexual partners other than each other. “We were
so young and so nervous when we started.” They married almost 20
years ago and are now in their early 40s. They have three children
ranging in age from 9 to 17 years old. They report having “a really
good relationship” with “much love.” However, Mrs. Carter feels
no desire for sex: “It’s not as if I feel a void. I don’t think about it.
I don’t dream about it. It’s not that I’m not attracted to him. I find
him very attractive. I just have no desire. It’s been this way for many
years . . . almost from the beginning . . . from when we started hav-
ing sex.”
The couple had been having sex once a month for at least 10
years. Prior to that, sex occurred roughly once per week. Since their
marriage, there had never been enough sexual activity for Mr. Carter,
but at least during the years when they were trying to have children,
Mrs. Carter put in her fair share of the effort and would initiate occa-
sionally. After their youngest daughter was born, the decrease in sex-
ual frequency was gradual but noticeable over time. Mr. Carter com-
mented, “This is very hard because I find her extremely attractive.”
Mrs. Carter responded, “Well, you know I try for a few weeks at a
time . . . and then I slip.” Mr. Carter replied, “It makes me feel that I’m
not a priority for her . . . I care very much about her satisfaction. I try
to be a good lover. I wish she enjoyed it is much as I do, so she’d look
forward to it . . . I’m seeking more than physical fulfillment.”
Over the years Mr. Carter had coped by retreating from all physi-
cal contact, then in moments of desperation would return to initiat-
ing sex with Mrs. Carter. When he observed her “giving in” with a
marked lack of enthusiasm, he would retreat again, with increasingly
 “Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   99

longer intervals without sexual or other physical intimacy. Mr. Carter

no longer initiates because he knows his wife will say “yes” but “for
[what he considers] the wrong reasons.”
Mrs. Carter has no desire to initiate. “But I get emotional fulfill-
ment from making him happy.” He counters, “I get turned off by
not having her want sex per se. I perceive her as feeling it’s more of a
‘have to.’ ”
When I inquired as to what brought them into therapy at this
time, Mr. Carter reported that he had been in a serious car accident 1
year earlier and had been unable to engage in intercourse temporar-
ily. This scare had been a wake-up call for him and created a sense of
urgency about a future without sex. Finally, Mr. Carter had reached
the point where one day a few months earlier he had simply stopped
in mid-thrust and rolled away from his wife. “I just stopped and con-
fronted her that I couldn’t go on this way.” Thereafter he became
nonresponsive and nonaffectionate and “that led to our finally dis-
cussing the problem.”
In using the Experiential approach, formal history taking is rare.
However, enough data about the past, present, and especially the
future emerge nonetheless.

Past History
Mrs. Carter’s parents separated when she was 6 years old. After her
father left, she had no further contact with him until adulthood. In
previous therapy she had identified abandonment issues but dealt with
them with limited success. Her mother did not have the resources,
financially or emotionally, to raise her alone, so she was raised by
both her mother and her grandmother in a home with many rules
(e.g., eat this, do not wear that) and few boundaries (e.g., no pri-
vacy in bedrooms or the bathroom). “My grandmother would walk
in while I was in the shower to hurry me up until I was 15.” She
had little ownership of her body in that environment, although she
did try: “I would get caught breaking every single rule.” There was
no history of sexual abuse. Messages about sexuality were mixed. “I
hit puberty early and was teased a lot. I became very self-conscious.
Mom would always say, ‘If you’ve got it flaunt it’ but I never did.
My mother did and I thought it was gross.” Indeed, Karen’s result-
ing, lifelong self-consciousness and inhibitions about her voluptuous
figure would later become an issue in therapy. Mrs. Carter began self-
stimulating at 12 or 13 and was “caught” by her grandmother who
100   TREATING SEXUAL DESIRE DISORDERS

told the rest of the family: “They found it funny. Nothing was sacred
in that house. Nothing was private . . . .so I stopped.”
Mr. Carter grew up in a traditional nuclear family with two lov-
ing but overprotective parents. They never spoke about sex and he
learned considerably from their silence. He was taught to always be
a gentleman, but could only surmise what this meant in a highly sex-
negative environment. He tried to be respectful of women but was
not clear on the extent to which his reticence was in deference to their
delicate sensibilities versus his own need to play it safe and be inof-
fensive.
When Mark and Karen began dating, he waited almost a year
to first initiate intercourse. “I went very slowly with her. I wanted to
make her feel comfortable.” Mrs. Carter added, “There was a lot of
making out and [to her surprise] several months before we had oral
sex.” As he said, “I wanted it to come from her. I had never pressured
her. ” Over the following months their sexual contact was very enjoy-
able, fun and spontaneous, although the progression of their relation-
ship was strikingly slow, at least according to Mrs. Carter. Eventually,
she surprised him by saying she was on the pill and had had enough
of waiting.
The first attempt at intercourse was painful and clumsy. Over the
course of 20 years, their sex life had deteriorated gradually. At first,
it was Mrs. Carter who initiated sex. Mrs. Carter said she loved hav-
ing sex to make her husband happy. She had orgasms but no delight.
Mr. Carter had never felt comfortable or been effective at making
his wishes known. They both tended to follow all the rules they had
somehow assimilated while growing up, including don’t start any-
thing you can’t finish; any touch could lead to sex; sex should be all
or nothing; sex must be natural and spontaneous; and talking ruins
the mood.

Therapy Process
I requested a detailed description of “sex” and their feelings during
sex. Their account is utterly dispassionate: Historically, about three-
quarters of the time he says, “Let’s go upstairs.” She adds, “We go
upstairs pretty well. I’ve never refused him. It’s not an issue. The kids
are asleep. It’s at night. Then I’d change in the bathroom and put on
a nightgown. He’d be in bed, waiting. I’d get in and we’d touch and
kiss.” For how long? She answers, “For 1 to 3 minutes. If I wasn’t
really in the mood, than it would be more like 1 minute. After 1 to
“Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   101

3 minutes, we would initiate intercourse. I still get sore when he first

starts to penetrate . . . but penetration is slow.” “How slow is it?” I
ask. They both agree: “About 10 seconds.” Intercourse begins in the
missionary position or with her on top for 2 minutes. Then he ejacu-
lates. “Or if I try but it hurts too much when he starts to penetrate, I
usually masturbate him.” Mr. Carter adds, “Or I’ll touch her breasts
and make love with her breasts . . . or she’ll give me oral sex. I’ll offer
to give her oral sex and she’ll say ‘don’t.’ Then we talk for a minute
or two and clean up. At one time it was exciting and I’d feel turned
on. Not so much anymore.” Mrs. Carter states, “Now it’s less excit-
ing but still loving because I know I’m making him happy . . . but now
there are more and more times where I feel nothing.” Upon further
inquiry, she adds, “I’m very uptight. I have a hard time relaxing and
letting go. I need control. The only thing I can control is my body.”
Fortunately the ideal they both aspire toward is similar: They
seek sex that is “Fun, easygoing . . . feeling close and together, so in
love!” I agreed to help them replace dread with anticipation, but I
could not assure them of what that sex might look like or what pre-
cisely they might come to anticipate. I did, however, note the absence
of the erotic dimension in their description of their sex life and gave
feedback accordingly, saying that I was not sure I’d want to have sex
if I had their sex life, either. (It usually comes as a great relief to clients
to hear this sentiment expressed.)
At the next session, Mrs. Carter commented that the initial meet-
ing had been helpful. “We’re talking more and differently . . . We feel
like a team.” They seemed less blaming and accusatory. I asked Mrs.
Carter to describe the best sex of her life. She recounted times in
her late teens when she and Mr. Carter were dating. She recalled the
stirrings she felt as the two sat in the backseat of his car, listening to
the radio and “making out.” These vague memories led us to look
for moments of more intense arousal during those encounters. She
recalls, “It made me feel really powerful that I turned him on.” We
identified a series of incidents in which she felt suffused with excite-
ment and power at recognizing her capacity to arouse her boyfriend,
to make him melt, and to turn him into the proverbial putty in her
hands. These feelings were accompanied by a rush of heart-pounding
energy, a sense of glee and delight at her own, long-forgotten abil-
ity to call the shots and make him want more—in fact, to make him
want her more. As she lived in these moments, all of her senses were
engaged. She particularly reveled in stroking him to the beat of the
background music, switching her rhythm as dictated by the next song
102   TREATING SEXUAL DESIRE DISORDERS

on the radio, and smelling him sweat with desire and anticipation
during the lull between songs.
Homework in this approach typically originates from the cli-
ent, who will try out new ways of being and behaving outside the
office that had been recovered during the therapy session, Alternately,
whatever homework assignments I might recommend—in contrast to
those that come from the client—are always designed to elicit strong
feeling.
The “homework” for the following session was dictated by the
seductive young woman now sitting in my office toward the end of
the session rather than by me, the therapist, or even by Mrs. Carter
as she had been for most of her adult life. Mr. and Mrs. Carter were
to take the car out to their favorite teen “make-out” spot, the woods
alongside the Ottawa River Parkway, to put their compilation of 80s
hits on the car stereo, and to play and explore sexually just as they
had done in their teens.
At the next session, Mrs. Carter reported that they had aimed to
“make out” for an hour. Mr. Carter said, “I enjoyed knowing there
was no sex planned and only mutual exploration for its own sake.”
Mrs. Carter reported, “Yes, I get to sensual but not to sexual. An hour
seems like forever . . . All that’s been on my mind is trying to fix this.
What if I go through all of this and it still doesn’t work in the end?”
Clearly, Mrs. Carter had turned the homework she had designed her-
self into an evaluation of performance. “There’s been no progress
although our communication and interaction are better.” Mr. Carter
commented that her assessment of progress revealed a great deal
about her definitions of sex and success. She complained that it was
hard to know how to proceed. “I don’t know what I like.”
In the weeks that followed, Mr. and Mrs. Carter spent consider-
able time trying to discover what they liked. I told them to spend
some time, perhaps 15 minutes each, asking for all the pleasure they
could take and then attempt to actually receive it. This seems like a
relatively simple bit of “homework” but it is deceptively difficult. For
20 years or so I have had clients experiment with this exercise, and it
is a rare couple indeed who can stay with their feelings in their first
effort for more than 15 minutes, as they encounter barriers within,
interpersonally, and in the environment. The reports of their endeav-
ors, of course, provide useful clinical material for developing embodi-
ment, that is, the ability to be fully alive, present, and engaged in
one’s body (Kleinplatz & Ménard, 2007). It was quite illuminating
for Mr. and Mrs. Carter. Their first attempt had brought home to
“Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   103

them immediately the extent to which they aim to follow unspoken

expectations rather than actually paying attention to what might
prove pleasurable. Mrs. Carter had instructed him to do whatever
he wanted, thereby revealing how she subverts her own attempts to
discover what pleases her. As she put it, “Sex for me has been divided
into, first I have 10 minutes of pleasure and then he has 10 minutes of
sex.” She added, “Touching him over the last weeks has been loving
and sad. I felt badly that we had gotten so distant over the years. We
had had a very ‘TV image’ of sex that said a woman needs touching
and then a man needs an orgasm.”
For Mr. Carter, “it was very sensual being touched.” However, he
was beginning to be confronted with his own inhibitions: “I’m reluc-
tant to make myself vulnerable by having to ask . . . for anything.”
In the weeks that followed, Mr. and Mrs. Carter continued to
experiment with asking for what gave them maximal pleasure, each
time coming up against their own barriers to seeking out what they
wanted most. These included fears of being selfish, being perceived
as demanding or greedy, fears of being exposed, rejected, or losing
control, and body image concerns. Over the course of the next four
sessions we would work with whichever of these issues seemed to be
most salient, evoking the most intense feelings during their explora-
tions in bed and, especially, right then and there during the session.
At the outset of the fourth session, Mrs. Carter stated, “I don’t
believe him when he says he finds me extremely attractive. He’s the
perfect guy.” Mr. Carter declared again his strong attraction for her.
She discounted that, but more important her focus moved in another
direction: “My worst fear is that he’d do the same thing as all the
other people in my life and just leave, just like my dad.” Her husband
interrupts in a well-meaning attempt to offer reassurance. Nonethe-
less, she gives expression to her mounting fears of abandonment, of
being seen as inadequate and left alone. “That’s why it’s so important
to me to fulfill you sexually.” Mr. Carter responded, “I’ve given you
no indication ever that I’d ever leave.” But she continued, becoming
tearful, oblivious to his words, “No one has ever stuck around. I’m
always afraid that I’ll do one thing wrong and he’ll leave.”
I ask her to take me to the moments in her life when the fears she
is now describing seemed most intense and threatening. We return to
high school, which was replete with moments of rejection and aban-
donment. “I liked guys but it wasn’t reciprocated, or not for long,
because I wouldn’t ‘put out.’ I liked this boy Jason for over a year.
We finally went out and then he stopped talking to me. He had a
104   TREATING SEXUAL DESIRE DISORDERS

huge crush on my best friend. I found out later he was going out
with her, Beverly the perfect.” As we explore these moments, speak-
ing directly to the unavailable objects of her desire, we first come
upon her pain, her feelings of being devastated and utterly crushed.
Her chest is tight, heavy, and her heart is beating too fast. As we
stay with these moments and delve deeper, something new begins to
surface. We discover her unknown capacity to simply let go, to walk
away unscathed, unharmed, to be separate, unique, distinct, and per-
haps somewhat above her phalanx of false friends. Being apart from
Jason—or her father—was beginning to feel like a relief. Staying with
her husband suddenly felt like a choice made freely rather than an act
of desperation to ward off the dread of being alone. As she turned
to her husband, wondering what he had made of such intense self-
revelation, he responded, “I’m not going anywhere. I was never going
anywhere. I’ve been here for 20 years. When am I off probation? I
don’t want to go anywhere else and that’s not going to change.” Each
of them relaxed, sighing audibly. As Mrs. Carter said, “That’s good
because I’ve decided you’re a keeper. [Laughing] That helped quite a
bit. The tightness is gone. I need to pay more attention to my body.”
They hugged just before they left the room.
Over the next month they continued to experiment with ask-
ing for all the pleasure they could take, but the exercise became
more playful and the allotted time seemed to pass quickly so they
increased their playtime. They began spending more time together
and found different ways of being intimate, for example, going for
walks, touching on the couch, and showering. In addition, they both
noticed that they had forgone sexual intercourse but were spending
a lot of time in mutual oral sex. The “rules” they had lived by began
to disappear, especially the idea that sex and sexual arousal were all
or nothing. As Mr. Carter said, “So it’s not an ‘on-or-off switch’—
it’s a dimmer.”
In couples with sexual desire discrepancy, both initially tend to
define one of them, (i.e., “the identified patient”) as having low desire,
as being defective and in need of fixing. Both tend to define the other
partner as having a robust, healthy sexual appetite and as being ever
ready, willing, and able to have sex if not for the obstacle of the reluc-
tant partner. This ubiquitous pattern tends to maintain the status quo
by keeping the couple polarized and each individual entrenched in a
role that is really more of a caricature. For as long as these roles they
have co-constructed remain unchallenged, neither one has to look too
carefully at the purpose of the apparent “symptom”—it is much sim-
“Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   105

pler to seek out the causes of psychopathology than to acknowledge

the purpose of these polarized roles. When they begin to shift, there
is often a sense of giddy disbelief and accompanying lightness and
freedom that is quite palpable in the therapy room.
In this case, it was Mrs. Carter who had been constructed as
the sole obstacle to sexual paradise. However, as soon as she began
to change, it became increasingly obvious that Mr. Carter had been
standing in his own way. His patiently waiting months for Mrs.
Carter to be “ready” when they were still virgins was explained at
the time as him having been a gentleman. His reluctance to initiate
in the years that followed was attributed to his fear of being rebuffed
by his beloved wife. It was only when she began to know what she
wanted that it became apparent that Mr. Carter had been all too com-
fortable in the role of long-suffering and loyal husband who would
never pressure his wife for sex. It was now time for him to take some
chances, if he dared. Although this prospect initially seemed daunting
to Mr. Carter, he quickly began to relish transcending his self-imposed
boundaries and risking his own sexual self-expression.
One particularly important turning point occurred during one of
Mr. Carter’s turns to ask for pleasure. Mrs. Carter had been expect-
ing instruction to give him manual or oral penile stimulation and was
shocked when all he wanted was for her to caress his forearm. She
kept preparing to reach for his penis and he would return her hand
back to his forearm. He wanted a gentle, feathery touch, so light as
to be barely discernible but just enough to make her presence known.
As he later described it, “I finally got the idea that it was impor-
tant to take responsibility for my own pleasure. I showed her what I
wanted and it was a surprise . . . ” “To both of us!” She interjected.
He continued, “I found it very arousing. I was trying different things
but wanting her to touch me just so and saying so. I felt present and
free. Afterward, she said she’d never felt closer to me.” She added, “I
felt warm, safe, loved, connected. I wanted to do this, even though it
seemed a little weird until I got into it.” Mr. Carter said, “Later, I felt
at peace, calm . . . really great. Nothing else mattered.” Mrs. Carter
commented, “Knowing that it’s possible took the pressure off.” Both
finally felt they deserved whatever pleasure they wanted.
The fifth session marked the major turning point in therapy. In
previous sessions, Mrs. Carter had mentioned her self-consciousness
about her body without much feeling. In contrast, in the fifth ses-
sion, as she begins to describe how she needs everyone to like the
way she looks, “to have everyone accept me and like me, at my own
106   TREATING SEXUAL DESIRE DISORDERS

expense,” something more seems to be stirring. We begin the first step

of this Experiential session: As I ask her to take us to a moment when
these feelings seemed to be stronger, more pronounced, she describes
her relationship with her friend Jennifer. “She was aggressive, closed-
minded, and would cut you off. I organized their baby shower at her
home and not one nice word from her. Only criticisms. I was shak-
ing, I was so angry.” At the time, Karen had been frozen and silent.
The most palpable feeling at this point in the session is of her being
passive in her habitual “people pleaser” mode that verges on martyr-
dom. She feels hurt, used, and unappreciated. However, during this
session, we return to the baby shower and Karen confronts Jennifer,
giving expression to her feelings at that time. She is saying, “I don’t
like the way you treat me. You don’t do that if you have a real friend-
ship. Everything always had to be the way you wanted. You are just
miserable to be with. Why did I ever care?” As she says these words,
something is beginning to emerge. She continues as the feelings inten-
sify and peak: “I made huge changes in my life. Jennifer, I think you’re
jealous.” The tight, frozen constricted feelings are dissolving: “I feel
good. It’s in my stomach. I’m feeling heard. What a relief! I used to
think it was me.” The heavy constricted feeling is gone and although
it did not seem particularly difficult before, breathing now comes eas-
ier. There is a pleasant feeling of lightness and emptiness.
Here, in the key moment of the first step, we have found some-
thing in Mrs. Carter that is not normally accessible, but it is palpable
and present in the course of the session. In the second step, Mrs.
Carter takes a few more moments to identify and welcome this new
potential. It is the sense of assertiveness, taking charge and entitle-
ment accompanied by a freedom and expansiveness uncommon in
her life.
During the third step of this session, we look for and locate other
moments earlier in Mrs. Carter’s life when such feelings occurred or
should have occurred. We return to them with the intent to live in
them fully and allow whatever was deeper within Mrs. Carter to sur-
face. Mrs. Carter finds a whole series of painful events in her relation-
ship with her mother. We enter into each one, looking for those most
fraught with the newly available ways of being, whether or not they
were accessible at the time. She recalls, “When I was a child, I was not
allowed to snack. I was to eat what she served when she served it—
never more and never less. One day in grade five I had a sleepover at
a friend’s house and we had blueberry pancakes for breakfast. When
I got home I was nauseated but I was mostly afraid. Eventually, I had
“Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   107

to tell her the truth because I knew I wasn’t up to going to church.

She never believed anything I said. She was going to send me anyhow
until I started vomiting blueberries. She always lied so she assumed I
did, too. I sat there on the bathroom floor, sick to my stomach while
she yelled at me. I was such a mess.” As we reenter this moment of
cowering on the bathroom floor, she is emboldened even as she feels
nauseated. This time, she literally stands up to her mother and starts
hurling all over her mother’s Sunday best. Little Karen Carter is feel-
ing taller by the minute as she yells, “I’ve had enough of you. I’ll eat
what I want, when I want, where I want, and I’m not going to put
up with your rules ever again. Do you hear me, Ethel? No, don’t you
dare hit me because you know I’ll hit you back.”
From there we are suddenly transported to grade 12 when
Karen Carter was invited to visit Parliament Hill for fireworks on
Canada Day. Karen was never permitted to have friends over but her
home was the closest to the fireworks. When her friends dropped by
to use the bathroom, “Mom came in. She slapped me in front of my
friends at the age of 17! I was horrified. She actually smacked me in
front of all those people, hard enough to leave hand prints. I spoke
my mind. And then she did it again! She slapped me in the face for
talking back! I learned early not to express my feelings. For the first
time in my life, I thought I was actually going to hit her. I cannot
believe that this is happening to me. This is what it’s been like my
whole life.”
Only this time, as we go further in what might have been that
day, Karen is looking at her mother and shouting back: “How can
you do this to me, again?” They are right in each other’s face. “You’ve
never been a parent. I don’t know what you are. You are a stupid, stu-
pid woman. I don’t think you really know how much damage you’ve
done. I need my husband and friends to love me in the way you never
did, and you still don’t. I deserved better. I always did and I still do.
You never cared about me. You should have adored me! Any other
mother would have been proud to have me as her daughter . . . would
have treasured me!” As she says these words, she is full of assertive-
ness and entitlement, but her voice has taken on a new tone, of feeling
worthy, attractive, maybe even valuable. As if she is commenting to
an imaginary audience, Mrs. Carter pronounces, “I never felt entitled
to the things I have. But not anymore!”
During the fourth step, as Mrs. Carter begins to imagine how
her life might be different if she treated herself as the special, valu-
able woman now unfolding in my office, a whole slew of possibilities
108   TREATING SEXUAL DESIRE DISORDERS

bursts forth: “I could buy new clothes, get a gym membership, or go

on more trips to the tropics. I could take a day and go to a spa for a
massage, get a facial, a manicure, and get my hair all done pretty for
no reason at all. Then I could get a nice dress and go out for dinner.
I could go shopping for a really expensive pair of red high-heeled,
open-toed pumps at the mall.” She contemplated also writing a letter
to her mother, “telling Mom what I felt all those years with an item-
ized invoice—I don’t have to send it, but I might!” “I could go crazy
in bed . . . I could take charge, know what I want, pure pleasure and
purely selfish; I could stand up for myself at work with that arrogant
boss and coworker Mary. I’m doing a hell of a standup job. Feels
good to actually say it.” Indeed she felt a loosening in her chest and
stomach. Mrs. Carter continued triumphantly, “No more trying to
please people who don’t deserve to be pleased!”
Before leaving my office, Mrs. Carter committed to actually
enacting at least two of the possibilities she had imagined, thereby
making it more likely that the new person who had appeared dur-
ing the session would continue to live and breathe in Mrs. Carter’s
“real” world. Mrs. Carter did, in fact, buy that pair of sexy new
pumps later that day at the shoe boutique and did seek out pure
pleasure in bed that night with a sense of joyous entitlement to sex-
ual delight.
At our sixth session, Mr. and Mrs. Carter stated that they had
made time alone together a priority and were having a lot of fun.
“It was like being kids again. We’ve been playing strip poker.” They
had been exploring one another’s bodies and had enjoyed touch-
ing and nibbling passionately. Mr. Carter commented, “It was so
completely stress free, relaxed, and so connected.” Mrs. Carter said,
“I liked kissing his back . . . and cuddling later. It was me who initi-
ated ‘bringing it to the next level’ with no expectation or pressure.”
They giggled as they searched for the words to describe their new
pastime, “ . . . Dry humping . . . It worked very well. We both had
orgasms. It felt natural, intimate, in flow, in tune, in the moment
. . . it felt right.” Mr. Carter said, “I felt really connected and close
to you.” Mrs. Carter responded, “There was no pressure and no
mental clouding. When we’re there in that moment, that’s where
we’re supposed to be. Just a complete focus on each other.” And as
Mr. Carter added, “There’s no pressure as to how soon we’ll do it
again next.”
Obviously, both were now enjoying their sex life and noted that
although they were having sex more frequently, their idea of “prog-
“Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   109

ress” had been redefined. Mrs. Carter noted, “It’s changed dramati-
cally . . . the new concept is of no expectation.” Mr. Carter responded,
“There are no more clouds . . . instead we have a sense of optimism.”
Both were bubbling over with enthusiasm as Mrs. Carter said, “I feel
much more desire than before. I’d like it to be higher still and that
will come. I’m much more positive.” They announced that they were
ready to stop seeing me and agreed to a follow-up session 6 months
later and another at the 18-month mark.

Therapy Outcome
Six months later, Mr. and Mrs. Carter were continuing to relate more
and more openly and were touching more, both in and out of bed.
Their frequent neck rubs in the living room had seemed so inviting
that their youngest daughter had jumped in, wanting to participate.
This in turn had led them to begin talking more openly with their
children about sexuality, “sex education,” and the role of sex in rela-
tionships. Reflecting back on her “progression” from youthful explo-
ration to sexual intercourse, Mrs. Carter pointed out, “I realize now
that once we began having ‘sex’ we cut back on pleasure.” She wanted
her children to have every option—not merely those prescribed by
social norms.
They had arranged a weekend away and Mr. Carter had bought
some lingerie that Mrs. Carter had worn for an evening out, build-
ing anticipation. “She looked hot!” Mr. Carter exclaimed and she
responded, “Yeah, I really felt sexy there!” Mrs. Carter’s body image
and safety issues had now fully dissipated. She was now not only
more comfortable in her own body but also more confident at work
and with her mother. “I feel more often that I am likable, worth lov-
ing, and can be assertive without worrying.” As they came to uncover
each other more nakedly, they had begun to share fantasies and, in
turn, as they ventured further, encountered more limits. For example,
Mr. Carter noted, “I’m also coming up against my own inhibitions
regarding initiation. I’m trying to seduce you, even though I prefer to
be passive.” One and one-half years later, the couple was continuing
to blossom. They had entered a dialectical process in which each new
discovery led to new erotic challenges to play with and overcome, if
they so chose (Kleinplatz, 1992, 1996). Both reported focusing more
fully, “no longer jumping ahead,” “noticing more of what was going
on,” and “staying in the moment more.” As Mr. Carter said in con-
clusion, “Our intimacy has become an oasis.”
110   TREATING SEXUAL DESIRE DISORDERS

Commentary

The outcome of this case was quite satisfying. It is characteristic of

most of the cases I deal with in terms of the presenting problem, the
histories of the couple, both as individuals and together, the nature,
extent, and duration of their sexual desire discrepancy, the therapy
provided, the goals achieved, and the couple’s satisfaction with the
results of therapy.
Two threads of interwoven factors contributed to the success
of this case. The first is that the personal growth of these two indi-
viduals, particularly Mrs. Carter, allowed her to be more the kind
of person she was meant to be. In Mrs. Carter’s case, this entailed
becoming more assertive and powerful, standing up for herself, and
feeling valuable, worthy, and even desirable in her life in general and
therefore in her sexuality as well. The nature of the sexual encounters
shifted, because the people involved in them had changed in ways
that were not specific to sex but encompassed sex. The second is that
Mr. and Mrs. Carter redefined, expanded, and increased what they
expected of sexuality. They stopped counting sexual events and began
to engage in the kinds of sexual intimacy that were worthy of their
efforts and were fulfilling.
Therapy allowed Mrs. Carter to access the experiencing within; to
identify and welcome those ways of being; to live fully in the moments
when that experiencing could have and should have surfaced; to be
the person during the session she might have been all along; and to
anticipate with glee the possibility of being this person in bed with
Mr. Carter as well as in other contexts in the future. In addition, Mrs.
Carter glimpsed how delightful it might be to actually live in this
fashion during the sessions vividly enough so that she was enabled to
carry this out in her everyday life. This led to changes in her relation-
ship with her body and with Mr. Carter, (sexually and otherwise), as
well as with other people, including her mother and her coworker.
These changes, in turn, spurred Mr. Carter to see some opportunities
for his own development, and the process looked so appealing that
he, too, chose to grow.
Although it has been noted often in the literature that cases of
low desire or sexual desire discrepancy are difficult to deal with effec-
tively, that has not been my experience. Most of the men and women
in my practice are seen for an average of 6 to 10 sessions. The changes
occurring over the course of these sessions tend to be enduring, as
seen at 18-month follow-up.
“Desire Disorders” or Opportunities for Optimal Erotic Intimacy?   111

I wonder sometimes if the reason that cases of low desire are

reported to be challenging is because the target of therapy a priori
is increasing sexual frequency. First, to the extent that therapists are
aiming to ameliorate a sexual behavior, in an area so central to iden-
tity and fraught with meaning, the resulting changes may be fleet-
ing. However, the magnitude of change may be circumscribed by the
limitations of the goals per se. On the other hand, when the goal of
therapy is substantive personality change and presenting complaints
are used as an entry point into the client’s inner world, much broader,
deeper, and enduring changes are possible (Mahrer, 1996). This case
illustrates the value of an alternative approach: because Mrs. Carter
made some fundamental changes in her personality, many things
shifted; her sexuality and her sexual relations were only the icing on
the cake.
Aside from the particular new ways of being unique to these indi-
viduals, a consequence of the therapy process is that the persons hav-
ing the sex were more authentic, embodied, and alive and thus able
to be more present, open, and free in their sexual and other relations.
To the extent that therapy succeeds in helping individuals in relation-
ships to fulfill their own potentials, should they choose to be sexual
together that sex will become more optimal.
Second, this case illustrates the value of acknowledging the sorry
state of the couple’s sex life and the therapist’s supporting them in
refusing to settle for sexual drudgery. When individuals lose interest
in sex, or at least in the caliber of sex they are currently rejecting,
there is likely a good reason. Rather than helping patients to increase
sexual frequency with minimal attention to the quality of their sexual
relations, we might instead encourage clients not to have sex unless
and until they know what they want, can ask for it, and feel flooded
with erotic desire (Kleinplatz, 1992, 2006). One reason clients are
reluctant to have “sex” is because they have an inkling from some-
where within or—for the lucky ones—some memories of what they
really want.
I suppose one might argue that the changes in Mr. and Mrs. Cart-
ers sex life could be attributed to a change in their sexual script and
therefore their sexual practices, allowing them to be more inclusive
and to focus on sexual pleasure rather than sexual performance. I
could appreciate this way of conceiving of the changes effected
through therapy and would not quite argue with this characteriza-
tion. However, this characterization does not address the more fun-
damental level at which change occurred. This couple did not replace
112   TREATING SEXUAL DESIRE DISORDERS

their narrow and constricting notions of sex with others coming from
the therapist; rather, because they changed as individuals and as a
couple, new, more fulfilling options sprang from within and led to
more optimal sexual intimacy. Although the majority of clients with
low desire whom I see in therapy ultimately end up having more opti-
mal sex, sex that is more authentic, uninhibited, erotically intimate,
and intensely connected, the particulars remain unique to each indi-
vidual or couple.

References

Kleinplatz, P. J. (1992). The erotic experience and the intent to arouse. Cana-
dian Journal of Human Sexuality, 1(3), 133–139.
Kleinplatz, P. J. (1996). The erotic encounter. Journal of Humanistic Psychol-
ogy, 36(3), 105–123.
Kleinplatz, P. J. (1998). Sex therapy for vaginismus: A review, critique and
humanistic alternative. Journal of Humanistic Psychology, 38(2),
51–81.
Kleinplatz, P. J. (1999). Infertility, “Experientially Oriented” couples ther-
apy and subsequent pregnancy. Journal of Couples Therapy, 8(2),
17–35.
Kleinplatz, P. J. (2004). Beyond sexual mechanics and hydraulics: Human-
izing the discourse surrounding erectile dysfunction. Journal of Human-
istic Psychology, 44(2), 215–242.
Kleinplatz, P. J. (2006). Learning from extraordinary lovers: Lessons from
the edge. Journal of Homosexuality, 50(3/4), 325–348.
Kleinplatz, P. J. (2007). Coming out of the sex therapy closet: Using expe-
riential psychotherapy with sexual problems and concerns. American
Journal of Psychotherapy, 61(3), 333–348.
Kleinplatz, P. J., & Krippner, S. (2005). Spirituality and sexuality: Celebrat-
ing erotic transcendence and spiritual embodiment. In S. G. Mijares &
G. S. Khalsa (Eds.), The psychospiritual clinician’s handbook: Alter-
native methods for understanding and treating mental disorders (pp.
301–318). Binghamton, NY: Haworth.
Kleinplatz, P. J., & Ménard, A. D. (2007). Building blocks towards optimal
sexuality: Constructing a conceptual model. The Family Journal: Coun-
seling and Therapy for Couples and Families, 15(1), 72–78.
Kleinplatz, P. J., Ménard, A. D., Paquet, M.-P., Paradís, N., Campbell, M.
Zuccarini, D., & Mehak, L. (2009). The components of optimal sexual-
ity: A portrait of “great sex.” Canadian Journal of Human Sexuality,
18(1-2), 1–13.
Mahrer, A. R. (1978). Experiencing: A humanistic theory of psychology and
psychiatry. New York: Brunner/Mazel.
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Mahrer, A. R. (1996). The complete guide to Experiential Psychotherapy.

Boulder, CO: Bull Publishing.
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Philadelphia: Brunner-Routledge.
 Chapter 7

A Skeptical View of Desire

Norms and Disorders
Promotes Clinical Success
Leonore Tiefer
Marny Hall

In this chapter, Leonore Tiefer and Marny Hall illustrate the possibilities
of treating sexual desire complaints from a nonpathological model. Rather
than using the DSM-IV-TR criteria as a tool for diagnosing sexual desire
problems, they rely on the New View classification, which considers sexual
complaints within a cultural context and serves as a guide for assessment
and treatment.
Because these authors regard sexual desire as culturally determined
and socially scripted, they avoid using the language of “sex drive.” They
believe that this term reinforces the mistaken belief that sexual desire is
intrinsic, internal, and biologically based. Rather they see sex as a learned,
scripted, and socially “normed” behavior. They suggest that a sex thera-
pist can function as a coach who facilitates sensual, recreational, emo-
tional, and attitudinal learning and growth. In fact, they assert that an ethical
therapist should refrain from allying with cultural norms regarding sexuality
but rather help couples sort out the kind of sensual and romantic life that
works best for them, even if it completely omits traditional “coupling.” Finally,
they avoid endorsing any one path to clinical success, believing that each
case must be assessed and treated uniquely without preconceived goals
or interventions.

114
 A Skeptical View of Desire Norms Promotes Success   115

These authors illustrate the various ways in which the New View classi-
fication may guide treatment by presenting three short cases, one involving
a lesbian couple, another a traditional heterosexual couple, and the third a
couple struggling with personality and recreational differences. The three
cases have different outcomes, and actual changes in sexual frequency
are modest or absent altogether. Nevertheless, it would be difficult to argue
that these are not successful outcomes. Instead of linking assessments of
success (or failure) solely to sexual performance and frequency, the New
View—by naming and challenging conventional standards of sexual suc-
cess and failure—invites clinicians to use richer and more nuanced ways of
assessing outcome in sex therapy.
Leonore Tiefer, PhD, is Clinical Associate Professor (Psychiatry) at
New York University School of Medicine. She is the author, among other
works, of Sex Is Not a Natural Act (2nd ed.) and founded the Campaign
for a New View of Women’s Sexual Problems (newviewcampaign.org) in
2000.
Marny Hall, PhD, LCSW, is a sex therapist in the San Francisco Bay
area. Her books include The Lavender Couch, Sexualities, The Lesbian
Love Companion, and, with Kimeron Hardin, Queer Blues.

Introduction: There Can Be No Valid

Diagnostic Scheme, but There Can Be
Useful Classification Systems

There have been rules and recommendations regarding sexual desire

and sexual activity throughout recorded history (Nye, 1999). Some
proclaim the dangers of indulgence, some the perils of restraint.
Depending on the author and his or her occupation and cultural
background, standards have been more or less based on gender and
race, written in Latin or the vernacular, promoted from pulpits or
through broadsides.
Twentieth-century Western science entered the arena of sexual
norms in the form of official postwar medical classification schemes
such as that proposed by the American Psychiatric Association in
1952 and repeatedly revised thereafter (American Psychiatric Asso-
ciation, 1994). At first largely ignored outside psychiatry, sexual func-
tion nomenclature has drawn increasing attention in the past decade
in research and at conferences supported by a new global industry
devoted to medical function treatment.
A plethora of new science-focused sexuality texts use the language
116   TREATING SEXUAL DESIRE DISORDERS

of health and the rhetoric of “evidence-based” to draw lines between

acceptable and problematic forms of sexual desire and expression.
Despite the technical jargon, however, there is no more consensus
on how much or little interest in sex is normal or healthy than there
was in “prescientific” eras on how much or little sexual interest was
chaste, undisciplined, pious, or dishonorable.
We believe that there can never be a successful way to define
good/normal/healthy/correct sexual desire outside of cultural stan-
dards for the simple reason that sexual desire is a product of human
psychobiological development and expression permanently con-
trolled, contained, and constructed by cultural context. Current
official scientific formulations draw on a mythical universal model
of sexual response, locating the desire for sexual expression in an
alleged and romanticized model of species-specific and species-wide
biological/hormonal/genetic origins. But any examination of the
innumerable permutations of sexual meaning, social priority, and
expressive form, especially one grounded in a knowledge of the his-
tory of human sexuality, pulls the rug out from under this mythical
“human sexual response.”

People Look for Guidelines

and Media Inflate Insecurity

Nevertheless, although there can be no objective or universal

answer to the question of what type or amount of sexual expres-
sion is normal, the “proper” performance of sexual activity is
highly valued in many cultures as a sign of individual maturity
and gender adequacy. Satisfaction with sex is widely viewed as an
indispensible element in relationship success and longevity. Mass
media, most people’s source of sexuality education, endlessly cel-
ebrates proper sexual performance in print, film, and on the Web.
Knowing and conforming to age- and gender-appropriate stan-
dards is of widespread interest and personal concern. Although
many websites now inclusively advise that “everybody’s different
and everybody’s normal when it comes to sex and sexuality” (e.g.,
sexualityandu.ca, 2008) and magazines advertise “helpful tips”
from their colorful covers, paradoxically the attention to sexual
performance, even when it is supposed to reassure, often gener-
ates and escalates insecurity.
 A Skeptical View of Desire Norms Promotes Success   117

The New View Approach

and Classification Scheme

Noticing the increasing public attention to sexual norms and con-

cerned that medical professionals and an ambitious pharmaceutical
industry were promoting false standards and exploiting the public’s
insecurities, a group of feminist social scientists and health profes-
sionals met in 2000 to analyze the situation and develop an approach
to classification that could be used to guide sex education and treat-
ment without imposing norms. The resulting New View manifesto
has been widely published and its classification system has been pre-
sented in workshops and educational venues (Working Group for a
New View of Women’s Sexual Problems, 2000; newviewcampaign.
org) (Table 7.1). Originally developed to apply to women, the system
was reworked slightly in 2006 to be useful for educating and treating
men as well (Tiefer, 2006).
One of the two crucial elements of the New View approach is its
definition of sexual problems. The classification guidelines state (see
Table 7.1), “Sexual problems are defined by the Working Group as
discontent or dissatisfaction with any emotional, physical, or rela-
tional aspect of sexual experience” (emphasis added). The New View
approach allows people to define their own problems, assuming, in
the absence of universal norms, that discontent or dissatisfaction is
a matter of wide individual and couple variation. This is to be con-
trasted with the definition in the American Psychiatric Association’s
manual that specifies sexual problems as disturbances in hypothesized
norms, that is, “the [sic] sexual response cycle.” “The sexual dysfunc-
tions are characterized by disturbance in sexual desire and in the psy-
chophysiological changes that characterize the sexual response cycle
and cause marked distress and interpersonal difficulty” (American
Psychiatric Association, 1994, p. 493).
For the clinician using the New View approach, the absence of
norms for sexual desire offers some important therapeutic advantages:

• A secure position from which to construe differences in sexual

interest between sexual partners as discrepancies like other
relational discrepancies (e.g., whether to spend holidays with
one set of in-laws or the other; whether to have children now,
later, or not at all).
• A starting point for analysis and behavioral modification that
118   TREATING SEXUAL DESIRE DISORDERS

TABLE 7.1. The New View Classification System

Sexual problems are defined by the Working Group as discontent or dissatisfaction
with any emotional, physical, or relational aspect of sexual experience. They may
arise in one or more of the following four interrelated dimensions of people’s sexual
lives.

I. Sexual problems due to sociocultural, political, or economic factors

A. Ignorance or anxiety due to inadequate sex education, lack of access to
health services, or other social constraints including:
1. Lack of vocabulary to describe subjective or physical experience.
2. Lack of information about human sexual biology and life-stage changes.
3. Lack of information about how gender roles and cultural norms
influence men’s and women’s sexual expectations, beliefs, and behaviors.
4. Inadequate access to information and services for contraception and
abortion, STD prevention and treatment, sexual trauma, and domestic
violence.
B. Sexual avoidance, distress, or lack of pleasure due to perceived inability to
meet cultural norms regarding correct or ideal sexuality, including:
1. Anxiety or shame about one’s body, sexual attractiveness, or sexual
responses.
2. Confusion or shame about one’s sexual orientation or identity, or about
sexual fantasies, desires, and preferences.
3. Fear of judgment or punishment by cultural, community, or religious
institutions.
C. Inhibitions due to conflict between the sexual norms of one’s subculture or
culture of origin and those of the dominant culture.
D. Lack of interest, fatigue, or lack of time due to family, work, or other
obligations.

II. Sexual problems due to partner and relationship factors

A. Inhibition, avoidance, or distress arising from:
1. Betrayal, dislike, fear, or resentment of partner, abuse or exploitation by
partner, or partners’ unequal power status.
2. Discrepancies in desire for frequency or nature of sexual activity.
3 Inability to communicate effectively about preferences for initiation,
pacing, or shaping of sexual activities.
4. Disagreements, spoken or assumed, about the terms of the relationship,
the degree or meaning of commitment, or the desire for monogamy or
non-monogamy.
B. Loss of sexual interest and reciprocity as a result of ongoing conflicts over
commonplace issues such as money, schedules, or relatives, or resulting
from traumatic experiences, such as infertility or the death of a child.
C. Inhibitions in arousal or spontaneity in response to partner’s health status
or sexual problems.

III. Sexual problems due to psychological factors

A. Experienced or perceived lack of choice in sexual behaviors or attitudes,
ranging from aversion toward or ambivalence about sexual pleasure to
sexual obsessions or compulsive behaviors.
B. Consequences of past negative sexual, physical, or emotional experiences.
 A Skeptical View of Desire Norms Promotes Success   119

TABLE 7.1. (continued)

C. Guilt or shame about sexual desires or fantasies.
D. Effects of depression or anxiety.
E. General personality problems with attachment, rejection, cooperation, or
entitlement.
F. Sexual inhibition due to possible negative consequences (e.g., pain during
sex, pregnancy, sexually transmitted disease, loss of reputation, rejection, or
abandonment by partner).
G. Deeply held negative beliefs about one’s self-worth or desirability.
H. Not accepting age-related life changes.

IV. Sexual problems due to physiological or medical factors

Pain or lack of physical sensation or response during sexual activity despite a
supportive and safe interpersonal situation, adequate sexual knowledge, and
positive sexual attitudes. Such problems may arise from:

A. Local or systemic medical conditions affecting neurological, vascular,

circulatory, endocrine, musculoskeletal, or other systems of the body.
B. Pregnancy, fertility treatments, sexually transmitted diseases, or other sex or
reproductive conditions.
C. Side effects of drugs, medications, or medical treatments.
D. Overuse or dependence on alcohol or other recreational or prescribed drugs
or other substances.
Note. Based on Tiefer (2006); unified language for both men and women.

minimizes partners’ name-calling and interrupts efforts to ally

with the “sexually normal” therapist.
• An immediate focus on cultural influences that can be used
throughout treatment.
• An immediate focus on sexual habits and preferences as learned
that can be used throughout treatment.

The other crucial element of the New View approach is its exten-
sive listing of factors contributing to sexual distress and dissatisfac-
tion, grouped into four categories (see Table 7.1):

• Sexual problems due to sociocultural, political, or economic

factors
• Sexual problems due to partner and relationship factors
• Sexual problems due to psychological factors
• Sexual problems due to physiological or medical factors
120   TREATING SEXUAL DESIRE DISORDERS

The expansive lists of elements within each category draw the thera-
pist’s attention to the assorted and multifarious ways that cultural
factors can contribute to sexual problems, offering opportunities for
bibliotherapy, directions for focused sexual history taking, and ideas
for clinical interventions and homework assignments.
In order to demonstrate how the New View approach guides
the treatment of couples presenting with complaints involving sexual
desire, three illustrative cases are presented. All were seen and treated
by Marny Hall.

Case Example 1: Kenji and Marsha—

Post-Honeymoon Blues

Kenji grew up in Taiwan. After her announcement that she was a

lesbian created a hornet’s nest of family protest, she fled to North-
ern California. Just 21 when she arrived in San Francisco, Kenji
got a job as a taxi driver and plunged wholeheartedly into the
gay scene. It was exhilarating to be free of family obligations and
constraints. The oldest of three sisters, Kenji had—for as long as
she could remember—felt responsible for her family’s well-being.
Her mother—ill and depressed—stayed in her bedroom for days
at a time. Her father rarely came home. When Kenji was 10, she
found out that his “business trips” had simply been weeklong gam-
bling binges. By contrast, her new “chosen” San Francisco family
of queer playmates was always supportive and available. Her new
friends and lovers were also, for the most part, heavy drinkers and
recreational drug users. It wasn’t uncommon for Kenji to party all
night with them and then segue, without any break, into her day
shift at the cab company. When she was 25, she was pulled over
for erratic driving. Her blood alcohol level was well over the legal
limit. She lost her job and her driver’s license and faced a stiff fine
that the judge promised to waive on the condition that Kenji started
going to AA. Kenji complied.
By the time she was 30, Kenji had been a regular AA member
for 5 years, gotten an administrative job in an international banking
firm, and hooked up with Marsha, another AA member. Like Kenji’s
relatives, Marsha’s Polish Catholic family in Chicago raised a furor
when she came out. She, too, left her home precipitously and headed
for the gay-friendly Bay Area. New teaching credential in hand, she
had no trouble landing a job as a math teacher in an inner city public
 A Skeptical View of Desire Norms Promotes Success   121

school. Before she joined AA, Marsha had also burned the candle at
both ends, working all day and partying hard at night. For her too
this had been a welcome emancipation from family-of-origin travails.
Marsha’s father had been an alcoholic unable to keep a job. His pre-
mature death when Marsha was a teen left the family’s fortunes even
more precarious. Marsha’s mother had to shuttle between two jobs to
keep the family intact. Preoccupied with survival issues, she had little
time or energy for Marsha or her four siblings. But, Marsha reported,
the kids pulled together and nurtured each other in myriad ways.
After they had recovered from the coming-out rupture, Marsha’s fam-
ily members were once again very close.
When they came for sex therapy, Kenji and Marsha were in their
mid-30s and had been together for 6 years. They reported that, aside
from their sexual impasse, they got along well together. They rarely
disagreed and when they did have a conflict, they resolved the dispute
easily. Marsha’s gift for dissolving tension was apparent early in ther-
apy. In the first session, they disagreed—somewhat heatedly—about
who had made the first move toward a romantic connection. “Yes,”
Marsha said slyly, “you first asked me out for coffee but I had been
vibing you for months before that—slinging it like this.” Marsha then
demonstrated her wiles by puckering her lips and batting her lashes
at Kenji. At this, Kenji giggled and shrugged. The argument was over.
When I commented on her conciliation talents, Marsha said that, as
the middle child in a family of five, it had been her role to make peace
between the older and younger kids.

Presenting Problem and History

During the initial session, Marsha and Kenji reported that their stren-
uous efforts to avoid “lesbian bed death” (LBD) had failed. Neither
had any desire for sex. In their previous relationships with other part-
ners, such a dramatic cessation of desire had presaged the end of the
partnerships, and they were afraid that history would repeat itself and
that they would lose each other.
The specter of LBD had haunted their relationship from its incep-
tion. It was legendary in their AA community. “U-haul lesbians”—
those who moved in together on the second date—were reputed to
be the most susceptible to LBD. According to conventional wisdom,
becoming domesticated too quickly was a sure way to kill romance.
In order to avoid such a fate, Kenji and Marsha had proceeded
cautiously—stretching out their courtship for months. They were
122   TREATING SEXUAL DESIRE DISORDERS

very attracted to one another and reported that lovemaking, when

it finally happened, exceeded all expectations. They were “on cloud
nine” for days afterward. Compelling as the sex was, they continued
to pace their relationship in a deliberate way. Their determination to
manage their relationship carefully, as well as their demanding com-
mitments to work and to their AA programs, kept them apart dur-
ing the week. As a consequence, weekends became much anticipated
and treasured romantic interludes. After 2 years of sustained sexual
passion for one another—certain that they had eluded the dreaded
LBD—they moved in together.
They reported that over the next 2 years their desire faded imper-
ceptibly. Intervals between lovemaking gradually increased from
a few days to a week, to a month. Each reported keeping a secret
tally of “how long it had been.” To acknowledge any lapse in desire
for one another would have confirmed that their efforts to avoid the
dreaded LBD had failed, so they made excuses: they were too tired or
too stressed about work or too avid about a new queer TV series to
make time for lovemaking.
When San Francisco mayor Gavin Newsom legalized gay mar-
riage in 2004, Kenji and Marsha planned their nuptials. They would
go to City Hall, get married, then go to a friend’s cabin for a weekend
honeymoon. Discussion of the honeymoon plan finally broke their
conspiracy of silence. They joked awkwardly about it. What if, once
they got to the cabin, they didn’t feel like sex? What kind of honey-
moon would it be? It was after this mutual acknowledgment that they
decided to pursue sex therapy.

Case Conceptualization and Treatment

A sex therapist applying American Psychiatric Association criteria to
this situation of persistently deficient sexual desire might diagnose
Kenji and Marsha as each suffering from hypoactive sexual desire
disorder (HSDD). After arriving at such a diagnosis, a conventional
sex therapist might prescribe a series of non-goal-oriented sensuality
exercises as homework. According to conventional precepts, such a
regimen would help the couple move toward resuming their previous
erotic intimacy or at least reveal blocks to that intimacy.
In contrast, a New View–oriented practitioner would approach
the problem from another angle, viewing Marsha and Kenji’s sexual
avoidance as based on shame stemming from “perceived inability
to meet cultural norms regarding correct or ideal sexuality” (Table
 A Skeptical View of Desire Norms Promotes Success   123

7.1, I.B). Romance, desire, and passion are not simply the preferred
narratives of the heterosexual culture. Before recent legal moves to
legitimize gay relationships, passionate desire had been the sole crite-
rion for validating lesbian relationships. Without the requisite erotic
credentials, intimate relationships between women become invisible;
cohabiting and committed partners are likely to be perceived as “just
roommates.” In the case of Marsha and Kenji, there is another twist
to the “just roommate” narrative. Growing up, each partner was
most validated in her role as sister, as it was Kenji’s and Marsha’s
siblings—as opposed to parents or other relatives—who had provided
each with affirmation and love. Therefore, for Kenji and Marsha, the
role of sibling—with its associations of comfort, collaboration, and,
not least important, its prohibition of sexuality—had provided the
template for positive relationships.
Simply by virtue of being an authority figure who responds posi-
tively to the couple’s history, the sex therapist is positioned to counter
the shame and the sense of relationship inadequacy so often shared by
partners. I expressed genuine awe about their success at making their
passion last as long as it had. In fact, if anything, their campaign had
perhaps been too successful. Because they had managed to sustain
their erotic intensity for so long, Kenji and Marsha had inadvertently
fused passion and sex. As a result other, less earth-moving inclinations
toward intimacy, too subtle to register on their passion radar, prob-
ably escaped their notice. In other words, because sex between them
had been so memorable, the only conditions salient enough to catch
their attention were passionate desire or its polar opposite—LBD.
However, early in the therapy I observed that the couple’s easy,
low-key intimacy indicated that they often inhabited a middle ground
between passion and LBD. I asked if they would be willing to pay
more attention to this middle ground and proposed that we begin
to look for ways to translate their playful qualities, their humor and
irreverence, and their ease with each other into special forms of eroti-
cism to challenge their narrow sexual paradigm. They were willing
but dubious. They said they had come to therapy hoping to rekindle
their honeymoon passion.
This was perhaps the critical point in therapy—a moment when
I took a strong stand that diverged from cultural norms about sex
and sex therapy. As directed by the New View approach, I explic-
itly challenged the prevailing essentialist model and norms of sex. I
responded that, experienced as I was, I had never been able to help
long-term couples re-create the circumstances that had once gener-
124   TREATING SEXUAL DESIRE DISORDERS

ated intense desire. For most couples, I had observed that passion
sprang from some combination of novelty, uncertainty, and taboo-
breaking—a constellation of elements that, if relationships endured,
was unsustainable. Perhaps the most central aspect of our therapy, I
said, would be expressing sadness about the transience of such ardor.
Nevertheless, I added, even if passionate love was transitory, it none-
theless deserved their continuing homage. If they had never experi-
enced intense desire for other women, they would never have become
lesbians—a hard-won identity each woman valued. Most important,
they never would have gotten together.
As their first homework assignment, I asked them to spend time
together contemplating the shared erotic passion that each declared
had been the most profound experience of her life. I proposed that
they find a special candle—selected for its pleasing size, shape, and
scent—and that they light it for 20 minutes every night for a week.
During this ritual, I asked them to sit together and meditate quietly on
Eros with their minds and hearts or whatever sensing and feeling fac-
ulties they could muster. If Aphrodite were thus honored, I observed
(only half jokingly), she would help Kenji and Marsha make the nec-
essary passage to other sorts of sensuality and pleasure. The point
of this assignment was to counter the shame that Marsha and Kenji
felt about the cessation of passionate desire in their relationship. The
staging of such a ritual announces to the participants that—far from
being over—this chapter in their lives, now enshrined, will continue
to exist in a transcendent way. In the following session, they reported
both grief and relief. They were, they said, receptive to the “middle
ground” sex that I had proposed.
For their next homework assignment, I asked them to continue
the candle-burning ritual. I also gave them two handouts to take
home and discuss: a list of different sorts of love catalogued by the
Greeks (Hall, 1998, p. 84), and Annie Sprinkle’s 101 Uses for Sex—
or Why Sex Is So Important (Sprinkle, 1996, pp. 5–6). Among the
various purposes Sprinkle lists are: “Sex as a sedative . . . Sex as a
reward . . . Sex to make you laugh (it can be hilarious).” In the follow-
ing session, we brainstormed still more counternormative variations
such as maybe-I’ll-feel-like-it-after-we-start sex, let’s-just-do-you sex,
no-big-deal quickies, if-I-don’t-have-to-lift-a-finger sex, orgasm-free
sex, and so on.
I asked them to experiment with their own alternative forms of
intimacy. In the next session, Marsha reported piggybacking on a titil-
lating childhood memory. As a 10-year-old, she had gotten “exams”
 A Skeptical View of Desire Norms Promotes Success   125

from a school pal who had had a toy medical kit. After she remi-
nisced with Kenji, they went to a secondhand medical supply store,
got a nurse’s uniform and some other supplies, and played “naughty
nursey.” This blend of friction and fantasy was a poor substitute for
previous passion, they said, but it had been silly and fun. They were
relieved to break the long dry spell. In the next sessions, we continued
to discuss the loss of their desire and to come up with homework
experiences that developed and reinforced the emerging paradigm.
A few weeks into therapy, following an Easter vacation trip home
to Chicago, Marsha and Kenji reported that Marsha’s mother’s health
was failing. During a family conference, Marsha had decided she had
to move to Chicago to help, and Kenji agreed to the move as her
company had available openings in Chicago. Marsha would have no
trouble getting a teaching job. They planned to leave after the school
year was over.

Therapy Tune-Ups
Kenji and Marsha terminated therapy and moved to Chicago 3 years
ago. Because of continuing connections to the Bay Area, however,
they make regular pilgrimages back to San Francisco, and whenever
they return, they contact me for a “tune-up.” Typically they report
that their erotic momentum persists for a few months following each
appointment with me. They do get turned on by the friction-and-
fantasy formats they have developed, but at a certain point such
postpassionate intimacies begin to feel contrived—too different from
the effortless sex they experienced in their initial years together to be
worth the exertion. I comment that their self-consciousness is a valid
and valuable signal; it means that they are swimming against the cul-
tural current of standardized sex norms that they, like the rest of us,
have internalized as the “truth” of sex. I reemphasize the ubiquitous
presence—in both queer and straight culture—of one-size-fits-all mes-
sages about sex. In the face of such powerful and pervasive influences,
I observe, it is remarkable that they can invent and follow their own
erotic scripts for even 10 seconds. By the end of these tune-up ses-
sions, Kenji and Marsha are again eager to experiment with their own
brand of intimacy. Each time they come back to see me, their own
signature eroticism seems easier and more satisfactory. Both women
are now almost 40, and have been together for almost a decade. Sex
therapy continues to be, perhaps, a two-steps-forward, one-step-back
process.
126   TREATING SEXUAL DESIRE DISORDERS

Case Example 2: Alan and Grace—

The Consolations of Touch
Presenting Problem and History
In their mid-30s, Alan and Grace are transplanted midwesterners from
big farm families. They met at the Silicon Valley company where they
work as software engineers. Both claimed their fall into love was a
plunge, precipitous and thrilling. They married 6 months later. In the
beginning, sex was superb—fueled by mutual passion and biological
urgency. They wanted to start a family. As months, then years, ticked
by and Grace did not get pregnant, they began to feel pressured. Fol-
lowing the regimen recommended by a fertility specialist, they tracked
ovulation. Sex turned into a chore for Grace—a duty to be performed
at appointed times. Still she did not get pregnant. They embarked on
a series of expensive and invasive fertilization-enhancing procedures.
After several setbacks (including two late miscarriages), Grace became
pregnant again. Confined to bed for the second half of her pregnancy
and outfitted with a monitor that would tell her if the baby’s heart
stopped, she successfully carried the baby to term. Without a moment
to recover from months of stress and uncertainty, Alan and Grace
became new parents . . . and sexless partners. Alan was interested in
sex, but no trace of Grace’s early passion survived the protracted and
painful attempts to have a child.
By the time they came to sex therapy, their son, Jordan, was an
amiable and much-loved preschooler. Again, using the DSM crite-
ria of persistently deficient sexual desire and the fact that Alan was
unhappy with the sexless status quo, a sex therapist might diagnose
HSDD (American Psychiatric Association, 1994). Applying tradi-
tional sex therapy, the clinician again might reasonably suggest that
Alan and Grace begin a series of non-goal-oriented massages—exer-
cises designed to rekindle Grace’s presumably dormant desire.

Treatment and Discussion

Rather than assuming that an absence of sexual desire in and of itself
is a problem, in this case the New View would finger relational trauma
(i.e., “Loss of sexual interest and reciprocity as a result of conflicts . . .
resulting from traumatic experiences, e.g., infertility or the death of a
child”; see Table 7.1. Section II, B) as the clinical issue. Acknowledg-
ing grief and stress (the specific vigilance occasioned by the miscar-
riages) was the starting point for sex therapy with this couple.
 A Skeptical View of Desire Norms Promotes Success   127

Grace continued to feel that Jordan’s existence hung in the bal-

ance and, consequently, she monitored him closely. During an initial
session, it was easy to expand this preexisting framework (preoccupa-
tion with the well-being of Jordan) with a piece of conventional wis-
dom: a robust relationship between Jordan’s parents would provide
the most nurturing possible environment for him. To achieve this, Alan
and Grace needed time alone together to recover from the previous
years’ ordeal. Their psychological wounds deserved tending. Carving
out time for healing interludes required our going over the details
of child care. Nuts-and-bolts planning about reliable babysitters—
though far removed from anything remotely erotic—was the key part
of the couple’s “sex” therapy. With a couple of hours cordoned off,
they were instructed to simply spend soothing time together—relax-
ing, napping, spooning, having in-house picnics, reading together, or
pursuing any other intimate activity they chose. After 2 weeks, they
added shared showers and massages to their rest and recreation rou-
tines. Without any prompting, their interludes became erotic in new,
calm, and tender ways.
During therapy, Grace and Alan discussed their surprising ten-
tativeness with each other. They reminisced about their honeymoon
period, as well as the sexual adventures—both positive and negative—
that predated their relationship. Because they had a wide repertoire of
experiences it was easy to segue to a discussion of cultural myths and
messages about one-size-fits-all sex. After 2 months of weekly ther-
apy, Alan and Grace left for a long-scheduled 3-week family vacation.
They spent time with Alan’s extended family at a mountain retreat.
When they returned, they reported that thanks to relatives who were
enthusiastic babysitters they were able to continue their time-outs.
Sex, minus the old bells and whistles, had become a consolation, one
way among many of being close and comforting each other.

Case Example 3: Sean and Eva—

Wizards of Intimacy

Sean, 48, is an energy-saving consultant for large corporations, an

antiwar activist, and a transplant from Ireland. He grew up in an
emotionally arid household, as the middle of five sons in a Dublin
slum. Despite his liberal politics, he described himself as sexually con-
servative. He had had few lovers and liked sex with the lights out,
missionary style. Eva, the only daughter of Jewish union organizers,
128   TREATING SEXUAL DESIRE DISORDERS

grew up in New York City, came to college in Berkeley in the 1980s,

and never left. The director of a nonprofit company that provides
services for newly arriving Latina immigrants, Eva had had many
lovers—both casual encounters and live-in partners.

History
Sean and Eva were housemates before becoming lovers. They lived
in a sprawling Victorian house with a group of like-minded activists.
Over time, they began going to concerts and films together. When
they realized they were attracted to each other, they moved out and
found their own place. At first, sex was equally exciting for both.
But over the next year, a misalignment emerged. Sean felt they didn’t
physically fit in a way that provided enough friction for him to main-
tain an erection or achieve orgasm and he lost interest in sex. After a
long spell of frustration, followed by a stretch of complete abstinence,
Eva insisted they see a sex therapist recommended by a friend. The
therapist enlisted them in a slow-paced program of sensual massage
and mutual masturbation. The goal of these at-home assignments was
to become more familiar with one another’s bodies, preferences, and
pleasures. Eva hoped that Sean would become comfortable substitut-
ing the pleasures of “outercourse” for his preferred but nonworking
intercourse.
Given the standard DSM approach that would label this a case
of lost desire as a consequence of erectile disorder, such techniques
seemed appropriate. Though Sean and Eva found the therapist help-
ful and sensitive, the exercises simply exacerbated their differences.
They became polarized, Sean claiming he was just an old-fashioned
guy and Eva losing her previous self-assurance. The whole area of
sexuality became aversive. They stopped sex therapy and all attempts
to have any kind of sex. A clinician might now diagnose the problem
as a sexual aversion disorder. At Eva’s urging, they agreed to see a
new sex therapist.

Intervention
During their first visit both complained that after 7 years of living
together, their misalignment persisted. They were as sexually incom-
patible as they were socially in sync. As a result of their prodigious
efforts to cure the problem, sex had become an ordeal that they both
avoided. Using the New View to classify the couple’s avoidance not
 A Skeptical View of Desire Norms Promotes Success   129

as a sexual disorder but as a partner issue of discrepant attitudes (spe-

cifically, a discrepancy regarding frequency or nature of sexual activ-
ity; see Table 7.1, II.A.2) removes any implication that the impasse
is pathological and must, therefore, be cured or dissolved. Rather,
such an analysis opens up the possibility of discussing that a couple’s
approach to sex, as to other hobbies and shared activities, exists on a
continuum of compatibility. This discussion explicitly takes the pres-
sure off partners to conform to a one-size-fits-all sexual intimacy.
In therapy, Sean and Eva were encouraged to explore what their
erotic alignment and misalignment meant to each. Such a starting
point stressed diversity rather than some “universal” sexual boiler-
plate. As the discussion proceeded, very diverse attitudes about the
role of sex emerged. For Eva, who defined herself as “a very sexual
person,” sex was the sine qua non of partnership. For Sean, sex was
a “take it or leave it” matter. He rarely masturbated and had been
contentedly celibate for months at a time. As a young man, he had
seriously considered the priesthood.
Once it was permissible to discuss, rather than fear, different
views on sex, not surprisingly other differences could be acknowl-
edged. Sean wanted to join the Peace Corps and live overseas; Eva
was invested in her California job. He loved backpacking; she liked
bicycling. As they had grown older, he had become more solitary,
she more gregarious. It emerged that earlier in their relationship any
mention of such differences had been taboo because of the worst-
case scenario each privately dreaded: if they were incompatible as
lovers, they would have to break up, acrimoniously and irrevocably.
These beliefs, explored in therapy, had a variety of sources: bruising
breakups each had experienced in the past; messages from both Eva’s
and Sean’s parents that couples stick together through thick and thin;
and perhaps most important, the ubiquitous happily-ever-after stories
favored by popular culture.
Rather than their sexual functioning, the New View taxonomy
pinpointed Sean and Eva’s shame about not living up to norms as the
area of clinical intervention. Together we considered the absence of
familial or cultural support for any sort of bond that wasn’t sexual.
To fill in the cultural lacuna, we gave ourselves an assignment. I would
try to find some written accounts of non-erotic but loving cross-sex
bonds. Because they were film buffs, they promised to find films that
featured loving nonsexual bonds between cross-sexed peers. When
we met again, I reported that I was only able to find one book (Brain,
1976) and one magazine article (Chatterjee, 2001). They reported,
130   TREATING SEXUAL DESIRE DISORDERS

laughing, that they too had been struck by how rarely such loving
bonds are considered worthy of cinematic representation. They had
only been able to find one film on the subject: The Wizard of Oz.
With their shame somewhat reduced, Sean and Eva were able to
consider the pros and cons of continuing their live-in relationship.
After long deliberation—much of it painful—they concluded they
were superb friends and decided to move apart. Wrenching as this
separation was, they negotiated it in a nonblaming, mutually sup-
portive way. Six months after they stopped therapy, I bumped into
Sean and Eva in a movie queue in Berkeley. Amused, they told me I’d
caught them in flagrante delicto during one of their weekly film dates.
They continue to be intimate in other ways. Sean has just nursed Eva
through a nasty bout of flu. Eva tells me that she is interviewing can-
didates from an online dating service she has joined. Sean remains
contentedly celibate.

Discussion
If we use the resumption of an erotic connection as the sole measure
of therapeutic success, this case is a therapy failure. Not only was
the therapist unable to facilitate a rekindling of desire in the part-
ners; they ultimately separated. However, positive outcomes—using
the New View approach—are measured within a broader context of
client well-being. In the case of Sean and Eva, shame associated with
their discrepancy in desire had been reinforced by the interventions of
a well-intentioned but traditional sex therapist. Their recovery from
shame, anxiety, and sexual aversion, and their acceptance of their
non-erotic attachment, allowed each to pursue his or her own ver-
sion of personal fulfillment. The couple regarded the treatment as a
success.

Commentary

There are no magic bullets for the cultural, political, psychological,

social, or relational bases of sex problems. Adhering to a medical
model that attempts to classify sexual problems as if they were in any
way similar to medical disorders offers power to those who subscribe
to prevailing cultural norms and disempowers those who see things
differently. In the treatment of couples with sexual complaints, this
can be harmful as well as unjust. Once ethical clinicians recognize
 A Skeptical View of Desire Norms Promotes Success   131

that standards of sexual function and response change with the times,
they then must avoid justifying standards and norms as if these repre-
sented clinical health rather than cultural power.
Arrangements about sexual frequency or passion are foremost
matters of relational negotiation. The sex therapist as therapist
unpacks motives and contributions of the past. Much about sex is
reframed by the therapist as the patients are taught to challenge their
assumptions along with those of the popular media (Tiefer, 2004).
Most patients treated successfully gradually accept the perspective
that beliefs and attitudes about sex are historical, negotiable, and flex-
ible, and realize that such beliefs are asserted for rhetorical purposes
rather than being statements of enduring fact. Without being didactic,
the therapist illuminates the position that “being horny” is all about
norms, in the same way as “dying for some chocolate” or “I have got
to get some fresh air” are. These longings feel embodied and “purely”
somatic and not at all cultural, but viewing them as having some non-
cultural source is not useful to therapy. The language of “sex drive” is
avoided altogether. The sex therapist as coach facilitates sensual, rec-
reational, emotional, and attitudinal learning and growth. The ethical
therapist, mindful of misusing her authority, will not ally herself with
cultural norms that insist sex is important to a successful relationship
or with a mistaken medical model that links sexual conduct to myste-
rious but authoritarian notions of drive or libido. The desire to desire
becomes one of many sociocultural topics under discussion as each
case follows its unique trajectory.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual

of mental disorders (4th ed.). Washington, DC: Author.
Brain, R. (1976). Friends and lovers. New York. Basic Books.
Chatterjee, C. (2001, September/October). Can men and women be friends?
Psychology Today, 34, 61–67. Available at www.psychologytoday.com/
articles/pto-20010901-000031.html.
Hall, M. (1998). Lesbian love companion. New York: HarperCollins.
Nye, R. A. (Ed.). (1999). Sexuality. New York: Oxford University Press.
Sexualityandu.ca. (2008). Life after puberty. Retrieved October 15, 2008,
from www.sexualityandu.ca/teens/life-5.aspx.
Sprinkle, A. (1996). 101 uses for sex—or why sex is so important. Women
and Therapy, 19(5–6). Excerpt on www.anniesprinkle.org/html/writ-
ings/101_uses.html.
132   TREATING SEXUAL DESIRE DISORDERS

Tiefer, L. (2004). Sex is not a natural act and other essays. Boulder, CO:
Westview Press.
Tiefer, L. (2006). The New View approach to men’s sexual problems. Retrieved
October 15, 2008, from www.medscape.com/viewprogram/5737_pnt.
Working Group for a New View of Women’s Sexual Problems. (2000). A
New View of women’s sexual problems. Retrieved October 15, 2008,
from www.newviewcampaign.org/manifesto.asp.
 Chapter 8

Complaints of Low
Sexual Desire
How Therapeutic Assessment
Guides Further Interventions

Rosemary Basson

In this chapter, Rosemary Basson highlights the many factors that contrib-
ute to sexual desire complaints in couples. Her case clearly illustrates the
inherently relational aspects of sexual desire—the role of each partner in
creating and maintaining sexual avoidance. Along with the developmental
experiences and expectations of each partner that serve to subvert desire,
one major precipitant, a husband’s past extramarital affair and its discovery,
seems to have set the stage for sexual avoidance by his wife. As Basson
notes, this case illustrates the common observation that a woman’s feelings
for her partner most generally and especially at the time of sexual engage-
ment, greatly influence sexual receptivity and interest.
Like many of the clinicians in this book, Basson emphasizes the neces-
sity of treating both partners when there is a complaint of sexual dysfunc-
tion in either partner. One of the novel interventions in this case and in the
one presented by her colleague, Lori A. Brotto in Chapter 9, is the inclusion
of mindfulness training along with more traditional cognitive-behavioral and
couple counseling interventions.
Finally, Basson emphasizes the current dilemma facing clinicians
regarding androgen therapy. She clarifies the shortcomings of research
studies that suggest that androgen deficiency underlies women’s sexual
desire/interest disorder and she proposes a more methodologically sound
research approach.

133
134   TREATING SEXUAL DESIRE DISORDERS

Rosemary Basson, MD, is the Director of the Sexual Medicine Clinic

at Vancouver General Hospital, as well as Clinical Professor in the Depart-
ment of Psychiatry and the Department of Obstetrics and Gynecology at
the University of British Columbia. Her reconceptualization of the sexual
response cycle and her emphasis on the importance of arousal and motiva-
tion as critical components of sexual desire has had a major impact on the
theory and treatment of women’s sexual complaints.

The theoretical framework that guides my assessment and man-

agement of complaints of low sexual desire hinges on the concept that
sexual motivation is larger than “desire” (as in drive or lust). The lat-
ter, often depicted as innate or even “spontaneous,” normally lessens
for women more so than it does for men as a relationship lengthens.
The multitude of other reasons men and women engage in satisfying
sex (Meston & Buss, 2007) motivates them to begin a sexual encoun-
ter even if desire is not the primary driving force on a particular occa-
sion (and for some, women especially, on any recent occasion). There
needs to be an expectation that desire will occur during the experience
once pleasure and arousal are felt and the desire for more intense sex-
ual sensation is triggered (see Figure 8.1). The expectation is that the
desire so triggered will be enjoyable and appreciated by the partner.
Motivated, for example, by a need of emotional intimacy,
appraisal of low-key sexual stimuli can lead to a degree of subjec-
tive arousal. If the required stimulation continues and the person
attends to it, views it as both erotic and pleasurable, arousal intensi-
fies, thereby triggering desire. This responsive desire invites stimuli
that are considered by the person to be more intensely sexual: for
instance, more purposeful genital stimulation. Arousal then becomes
even more intense and a yearning for the physical as well as the emo-
tional satisfaction of sex is now present. Orgasm(s) may or may not
occur: for some people they are very important for their own satis-
faction or for their partner’s satisfaction. The subsequent well-being
and emotional closeness that accompanies resolution of sexual sen-
sations provides further motivation for future engagements. There
is now qualitative research confirming the strong clinical impression
that, for both men and women, arousal and desire are frequently not
separable (Graham, Sanders & Milhausen, 2004; Janssen, McBride,
Yarber, Hill, & Butler, 2008).
The sexual response cycle where a person starts from “neutral”
is inherently vulnerable. Many psychological and some biological fac-
 How Assessment Guides Interventions   135

FIGURE 8.1. The sexual response cycle, a circular response cycle of overlapping
phases: Desire may not be present initially but triggered during experience. The
sexual and nonsexual outcome influences future sexual motivation. ANS, auto-
nomic nervous system. Adapted from Basson (2001, Fig. 2). Copyright 2001 by
the American College of Obstetricians and Gynecologists.

tors can limit the effectiveness of sexual stimuli. For women, their
mood, their feelings for their partner generally and at the time of
sexual interaction, and their ability to stay focused are major con-
tributions to their experience of sexual desire and arousal. For men,
these factors have received less research attention, although fear of
performance failure or other negative outcomes appear to be com-
mon distractions (Bancroft & Janssen, 2000; Janssen et al., 2008).
Our clinic, the British Columbia Center for Sexual Medicine,
located at Vancouver Hospital, British Columbia, Canada, receives
relatively few referrals for hyperactive sexual desire other than in the
context of neurological disease where “hypersexuality” must be distin-
guished from loss of inhibition. Other referrals are of men and women
reporting excessive and often risky sexual activity as a means of cop-
ing with mood disturbance. Some ambivalence about giving up the
“hunt” and the thrill of risk can hamper compliance with therapy.
136   TREATING SEXUAL DESIRE DISORDERS

Being a university-associated tertiary clinic, many of our refer-

rals are for complicated erectile dysfunction, anejaculation, sexual
pain, and sequelae of chronic neurological illness. Nevertheless, low
desire is still the most prevalent concern in these and in our physi-
cally well patients. Usually the partner with low desire identifies as
the patient but both partners are assessed and treated. When the
“nonpatient” partner is reluctant or unwilling to attend sessions, the
reason is usually a poor emotional relationship and the prognosis is
also poor.
Challenges are many; frequently the issues are not strictly sexual
despite the sexual symptoms, and in-depth psychotherapy is needed.
For women, we now employ a small-group format for delivering ther-
apy, which is a combination of cognitive-behavioral (CBT) interven-
tions, sex therapy, sex education, and mindfulness techniques. Group
treatment follows the initial assessment of the couple and has proven
to be quite effective (Brotto, Basson, & Luria, 2008). To illustrate
my approach to the treatment of low sexual desire, let me describe a
recent case.

Case Example: Tom and Lucy

Presenting Problem
Lucy and Tom are both 48 years old. Lucy presents saying “I just
have no libido. If it was up to me it would be fine not ever to have
sex again—I know this sounds terrible. It’s not that I don’t love Tom.
I’ve never had much sexual drive but now it’s zero.” Tom adds, “You
know, it isn’t just Lucy. I think I am losing my desire too. We both feel
that this is abnormal and both wish we were sexual more often.”
The couple confirmed their marriage of 22 years was good and
they were very fond of each other. They had many shared interests
and there was no question of alcohol or substance abuse or any major
current stresses at work or within the family. Their two sons were
both doing well in college.
The couple explained that for Lucy’s sake, they had saved inter-
course for marriage, but nonpenetrative sex had been fine during their
engagement of 3 years. Sex was described as rewarding, occurring
perhaps weekly in the first number of years. They mentioned some-
what ruefully that they had never been a couple “who couldn’t wait
to rip each other’s clothes off.” Tom had always been the initiator
but had frequently requested Lucy to do so. When seen privately in
 How Assessment Guides Interventions   137

a subsequent session, Lucy recalled that she had initiated sex on one
occasion but Tom was not interested. She found his refusal devastat-
ing and never tried initiating again.
Of note, until 5 years ago, Tom spent many weeks away from
the home in his job as a mining engineer. When he was interviewed
alone, it was clear that Tom did masturbate. In the past, he engaged in
self-pleasuring some two to three times a week, more recently perhaps
weekly.
He reported no concerns with his erection, ejaculation, or orgasm.
He agreed his motivation to be sexual with Lucy was lessening and
wondered if it was a reflection of her lessened interest and his needing
it to be a mutually enjoyable experience; otherwise he saw no value
in pursuing it.
In her individual interview, Lucy explained that she never had
self-stimulated, being warned against it as a child. She had always
felt awkward and shy about initiating sex. When sexual with Tom,
Lucy was usually aroused and reported the experience to be pleasur-
able. Similarly, she was usually orgasmic with direct clitoral stimula-
tion and reported no pain or discomfort with intercourse. She was
puzzled as to why their sexual infrequency was so marked, given the
frequently rewarding outcome. Often she asked herself, “Why don’t
we do this more often?”
The couple presented as affectionate and respectful. Lucy was
particularly warm and outgoing, speaking very fondly of her partner,
her family, and her work. Formerly a teacher in public schools, she
now co-owns a private tutoring business. On each visit she arrived
early and was perfectly dressed, manicured, and coiffed. Lucy agreed
she liked to have herself and her life predictable and organized. Tom
also came across as warm and generous, noncritical, supportive, and
in no way blaming Lucy for their current predicament.
When seen separately, Tom admitted to an affair 10 years earlier.
He said, “I’m not at all proud, I deeply regret it ever happening, I had
just no idea it would ever be so devastating to Lucy.” Lasting a few
months, “it was pure sex.” Tom had become enamored with a flirta-
tious mutual friend who apparently had very high sexual desire, and
was very fond of initiating sex and very enthusiastic. Tom felt that his
affair was still a relevant factor in their current sexual infrequency.
During Lucy’s solo interview, she too mentioned the affair, describ-
ing how she became aware of the affair. She spoke of the severe shock
it was to her. At the time she had been feeling very confident about
herself. Her sons were then 8 and 10; she had more time for herself,
138   TREATING SEXUAL DESIRE DISORDERS

had been working out, going to the gym, losing weight, and feeling
attractive and confident. She felt she had just begun getting her life
back, reentering the work force by forming a company with a friend
for the private teaching of English as a second language. “Why did I
not know it had been going on?”
Lucy’s distress appeared to as be much about her inability to
detect anything wrong or to be suspicious as about the affair/betrayal
itself. Lucy explained that no particular counseling was given to the
couple at the time. They briefly saw the local Roman Catholic priest,
who said that these things happen rather commonly and that some
good can come out of them. He even suggested that the marriage
sometimes actually improves as a result. Lucy did not feel that the
latter had happened. She explained how she had tried to make the
very best of things and to be forgiving and as warm and affectionate
as ever.
The couple have rarely addressed or spoken about the affair and
its impact in any detail. Wanting to be more attractive to Tom, Lucy
had very quickly found herself a plastic surgeon and received breast
augmentation: she explained that the other woman had particularly
large breasts whereas Lucy “was almost flat.” Unfortunately, this led
to loss of her former pleasurable nipple sexual sensitivity. Also Lucy
was not pleased with the unnatural look and the excessive firmness.
She has never sought revision but regrets her “foolish” decision to
have the augmentation. Lucy spoke of her guilt that she must have
been too preoccupied with the family or her new job, leading Tom to
“stray.”

Medical History
Tom was healthy and not taking any medications. Lucy’s past medi-
cal history included having an imperforate hymen such that she pre-
sented with recurrent abdominal pain between the ages of 11 and
12 and had to be admitted to the hospital on an emergency basis for
buildup of blood inside her uterus and pelvis. Additionally, as the
result of a date rape at the age of 19, Lucy contracted genital her-
pes that was recurrent for a few years. The latter had not recurred
during the pregnancies, to Lucy’s huge relief. Each pregnancy had
been marred by the fear herpes would harm their child. Lucy still saw
herself as responsible for the date rape. At this time, however, Lucy
was healthy with regular menses although she noted increasing mood
lability and depressed thoughts premenstrually.
 How Assessment Guides Interventions   139

Developmental History: Lucy

Lucy reported that her childhood was chaotic. The family was Catho-
lic; her father was an alcoholic and unfaithful to his wife. Lucy had
little relationship with him. She did not fear him since he was not
physically violent, even when drunk, but he was absent as a parent
for her and her four siblings. The family moved many times and pov-
erty was an ongoing problem. Her mother warned her repeatedly that
sex would cause problems and definitely needed to be avoided until
marriage. There were no positive messages about sex, either from
her mother of from her Catholic school, where self-stimulation was
described as sinful regardless of whether a person was single or mar-
ried.

Developmental History: Tom

In describing his family history, Tom reported that his father was
often away on business and Tom feared him when he was around as
he had an unpredictable temper. His mother was described as aggres-
sive and angry. At home, Tom stayed out of trouble by keeping a low
profile, looking after his younger sisters, and being very responsible
for them at a young age.
Tom says he never rebelled like other teen-agers: “that absolutely
was not possible!” Puberty was normal and Tom reports only infre-
quent self-stimulation. He agrees that his sexuality has always been
fairly low key. There were a couple of partners before Lucy and the
sexual experiences were positive, but not particularly memorable or
frequent.

Diagnoses
Tom was not diagnosed with any sexual disorder. Situational hypo-
active sexual desire disorder (HSDD) was considered, but the only
aspect of desire that was reduced was sex with Lucy: not only did
self-stimulation continue, but sexual fantasies remained. His lessen-
ing frequency of self-stimulation was considered to be within normal
limits for his age.
Lucy was diagnosed with DSM-IV HSDD. However, she could
experience arousal and desire once sexually engaged. Therefore, she
did not meet the diagnosis of sexual interest/desire disorder—a defini-
tion recommended by an international consensus committee in 2003
and endorsed by a larger international consensus committee represent-
140   TREATING SEXUAL DESIRE DISORDERS

ing major sexological and urological organizations in 2004 (Basson et

al., 2004; Basson R., Brotto, L. A., Petkau, J., Labrie, F., in press).

Formulation
Part of Lucy’s lack of sexual interest seemed related to the caution and
negative messages she received about sex from her mother. Ironically,
the warning that “sex will cause problems” was in some ways borne
out: her sexual development as a teen was negative in a very dramatic
way with the hematocolpos. In addition, the date rape followed a
few years later, compounded by the distress of recurrent herpes. The
lack of intensity in Tom’s need to be sexual with her was another fac-
tor: although people can move on from the effects of negative themes
about sex through childhood and adolescence, perhaps Tom’s appar-
ent lack of sexual intensity allowed Lucy to remain hesitant and never
quite at peace with the idea of actually wanting sex.
Lucy’s self-image was poor. She blamed herself for Tom’s affair,
for not being able to get over it, for her date rape, for potentially
harming their babies should they have been affected by the herpes.
As well, she claimed to have always been too thin and the breast aug-
mentation had done little to improve her self-image. A major theme
for Lucy was her need to be in control, which obviously served her
well in getting through the chaos of her childhood, but it made the
discovery of Tom’s affair all the more devastating because she realized
she was not in control of her life. Moreover, being in control is the
antithesis of being sexual.
Precipitating factors for Lucy’s lack of sexual desire included her
reaction to Tom’s affair. Although speaking initially of guilt, Lucy
agreed that she had not dealt with her anger, feeling that anger was
wrong. Suppressing her anger led to suppression of other emotions
including sexual desire. Now, at midlife, hormonal changes might be
implicated as well: midlife is associated with declining intracellular
production of androgens. It is possible these changes were allowing
the psychological issues to exert a greater impact.
In addition to the factors that may have precipitated the low
sexual frequency between Tom and Lucy are the factors that main-
tained the status quo. These included Tom’s rather low-key approach
to sex, which is not uncommon in men from families in which self-
assertion was not tolerated. Being assertive and being sexual are
often linked: when one is suppressed, the other is often suppressed
as well.
 How Assessment Guides Interventions   141

Tom agreed that he does not like to impose on others and not
imposing sex on Lucy has been important for him. Sex during the
affair was completely different. It was wonderful to be wanted sexu-
ally, but yet somewhat overwhelming. In retrospect Tom wonders if
he would have eventually found it to be somewhat threatening. Being
away from home so often because of his business may have contrib-
uted to Tom’s reliance on self-stimulation. He acknowledged that
masturbation is very different from partnered sex. The latter involved
multiple reasons to go ahead or not and connected many emotions
other than sexual ones, whereas, he added, “on my own it is very
straightforward and easy and takes care of things.”

Feedback to the Couple

The formulation was shared with the couple by explaining a model of
the sexual response cycle. The composite cycle whereby there may or
may not be desire initially in any one sexual experience, and arousal
preceding and accompanying desire, was presented (see Figure 8.1).
The various factors weakening Lucy’s cycle were then identified.

1. Initiating /accepting invitations to sex. Lucy avoided initiat-

ing sex for reasons other than desire, such as to increase emotional
closeness, due to her fear of rejection. At the beginning of their rela-
tionship, awkwardness, shyness, and even guilt about sex would also
have precluded initiation. Mostly when Tom initiated Lucy accepted:
the issue was that Tom did so infrequently.
2. The sexual context and stimuli were not always optimal. Late
at night when sleep was needed was the usual timing.
3. There were many psychological factors that operated to
decrease Lucy’s arousal on those occasions when the sexual experi-
ence was unrewarding. Lucy’s need to suppress her anger was one. It
is very difficult to suppress just one emotion: all are likely to be sup-
pressed, including sexual emotions. Low self-image was another, as
was her discomfort with letting go of control.
4. Biological factors were not obvious. At age 48 Lucy may have
up to 40% reduction of total testosterone production, but the rel-
evance of this is quite unclear.
5. Although the outcome of being sexual together was frequently
positive, it appeared not to motivate the couple to have a repeat expe-
rience. Lucy’s fear of rejection and Tom’s resentment that Lucy never
142   TREATING SEXUAL DESIRE DISORDERS

initiated prevailed. Also the times Lucy was not aroused left her with
even less motivation to repeat the experience.

Treatment
Treatment involved a variety of interventions, including psychoedu-
cation, CBT, sex therapy, and an introduction to mindfulness. Lucy
declined a referral to a therapist in order to address her anger although
she acknowledged that it was present.

Psychoeducation
The presentation and discussion of what was causing and maintaining
their difficulty was itself therapeutic. Both partners expressed relief at
having some understanding of why each was sexually hesitant. They
especially appreciated learning how each partner enabled the other to
stay the same.

Cognitive-Behavioral Therapy
Having briefly discussed the various reasons men and women have
sex, the couple filled out forms checking reasons they might or might
not initiate or agree to sex. Lucy found this difficult because, as she
said, “I never initiate,” but she was able to see the value in identifying
some of the items that hold her back from making a sexual overture
to Tom. She was encouraged to make thought records of some of
these misgivings and discovered many of them were overstated if not
catastrophic. More balanced evidence-based thoughts were encour-
aged.
Tom realized that in addition to holding back because he resented
Lucy’s failure to initiate sex, he needed to see Lucy’s enjoyment
and sexual excitement. Without Lucy’s excitement his own arousal
required total absorption in his own sexual fantasies. Were he to do
this when making love to Lucy he felt that he would be unfaithful all
over again. He was encouraged to consider whether he truly believed
his fantasizing was equivalent to being unfaithful.
Behavioral interventions included making several practical
changes, such as the use of low lighting so that Tom could see Lucy
during sex, as well as beginning sexual engagements earlier in the day
so as to avoid the battle between fatigue and arousal.
 How Assessment Guides Interventions   143

Small-Group Therapy for Lucy

In addition to the interventions described, Lucy attended four 2-hour
small-group sessions held 2 weeks apart and led by two therapists.
Sexual response cycles were discussed, clarifying that most women
in long-term relationships have sex for reasons other than desire, at
least at the outset. Also emphasized was the importance of context—
interpersonal and environmental, as well as cultural contexts, were
also outlined. That women frequently have difficulty staying focused
and being present in the moment was acknowledged and led directly
into discussion of the technique of mindfulness. In their sessions the
group discussed and practiced cultivating a state of “relaxed wakeful-
ness” whereby the goal is to remain in the moment and ultimately to
observe distracting thoughts but not follow them. Daily practice of
mindfulness was encouraged.
The cognitive work included identifying inaccurate and cata-
strophic thoughts about sexuality, attractiveness, and worthiness.
Thought records were described and encouraged. Lucy and the
other women completed assignments between the sessions that
involved both the cognitive work and the mindfulness practice. Fur-
ther assignments involved encouraging communication and listen-
ing skills.

Therapy for Tom

Tom said he had been intrigued by the possible connection between
his coping skills in childhood and his low-key sexuality as an adult.
He was interested in becoming more assertive in appropriate circum-
stances outside of the bedroom. It was suggested that being flexible
might be more helpful than always being nonassertive.
After Lucy completed the four group therapy sessions, the couple
was seen again and a modified sensate focus program over 3 weeks
was outlined. Lucy was encouraged to continue the mindfulness prac-
tice; the similarities between the two therapies were obvious.

Outcome
When Tom and Lucy were seen 3 months later, each described more
rewarding sexual encounters. Lucy was still hesitant about initiat-
ing sex with Tom. Their sexual frequency had increased somewhat.
Though she was far less distressed about her situation, Lucy still
144   TREATING SEXUAL DESIRE DISORDERS

mourned her absent libido. Again the idea of brief psychotherapy to

address her anger was raised, and this time Lucy accepted.
Seen again 2 months later, Lucy spoke of the relief of finally los-
ing “her burden.” She felt free to be herself and was no longer check-
ing or censoring herself. She had decided to risk initiating sex and
allow her feelings to be apparent should Tom decline. So far Tom had
shown no intention of refusing her invitations!

The Role of Declining

Androgen Production

For men, if serum testosterone levels drop sufficiently low, desire

decreases, sexual fantasies cease, and self-stimulation becomes infre-
quent or stops altogether. As serum testosterone levels reduce and the
man attempts sexual activity, there is delay in ejaculation, minimal
ejaculate, and non-intense orgasm. Nocturnal erections stop as well.
Sexually stimulated erections may still occur if there are adequate
visual stimuli.
For women, there is no correlation sexual testosterone levels,
however measured, and sexual function. Two major confounds have
hampered conclusions regarding women’s sexual function and the role
of androgens. First, until recently, serum assays have been extremely
unreliable and insensitive because of the low level of testosterone
found in women. Now, at least in research settings, mass spectrom-
etry is available and accurate. Perhaps most important, the percent-
age of testosterone produced but never entering the circulation to be
measured is high in women although very low in men. At least 50%
of younger women’s testosterone is derived from precursor hormones,
namely, dehydroepiandrosterone (DHEA), DHEA sulfate, andros-
tenedione from the adrenal glands, and DHEA and androstenedione
from the ovaries. Androgen metabolites—most notably androsterone
glucuronide (ADTG)—reflect the total androgen production (Labrie
et al., 2006). Our clinic is collaborating with Professor Fernand Lab-
rie in Quebec, who has developed the assays for the metabolite mea-
surement: we have not identified any correlation between androgen
metabolites and women’s sexual function (Basson et al., in press).
Although surgical menopause has been cited as an example of
androgen deficiency, the prevalence of subsequent loss of sexual
desire and arousal is unknown. Cross-sectional studies of women
with surgical menopause report more distress over low desire and
 How Assessment Guides Interventions   145

low satisfaction than do naturally postmenopausal women. How-

ever, prospective studies of sexual outcome after elective bilateral
oophorectomy along with required simple hysterectomy fail to show
subsequent sexual dysfunction (Aziz, Brannstrom, Bergquist, & Sil-
fverstolper, 2005; Farquar, Harvey, Yu, Sadler, & Stewart, 2006; Tep-
lin et al., 2007). Aside from any loss of ovarian production of testos-
terone or its precursor hormones, adrenal production of precursors
is thought to decrease by some 70% between the mid-30s and the
late 60s. However the amount of variation among individual women
is unknown; decreased production in some women may still be suf-
ficient if the necessary enzymes in the cells that convert the precursors
to testosterone and estrogen remain sufficiently active. Measurement
of androgen metabolites reflects not only the level of substrate, that
is, the precursor hormones, but the ability of the enzymes to convert
them. However, there is still a large caveat to this: this measure of
androgen metabolites will still not account for any variation in sen-
sitivity of the androgen receptor and the availability of co-factors.
Moreover there may be an even more important confound, namely
the fact that the brain can synthesize sex hormones from the basic
building block of cholesterol (King, 2008). Additionally, there is some
evidence that after menopause this intracerebral production of neuro-
steroids increases (Ishunina & Swaab, 2007).
Despite these difficulties in correlating women’s sexual function
with androgen activity, in some countries outside North America
transdermal testosterone has been approved for women with a DMS-
IV diagnosis of HSDD subsequent to surgical menopause. There is
major concern about the lack of long-term safety studies. Somewhat
ironically, women are often denied estrogen therapy postmenopause
on the basis of the Women’s Health Initiative study, which showed
increased harm when estrogen is begun 10 or so years after meno-
pause. This decision to avoid estrogen therapy continues despite the
fact that the younger women closer to menopause showed benefit
rather than harm (Hodis & Mack, 2008). Women and their clinicians
are understandably very confused that with very limited data systemic
testosterone has been approved elsewhere and is given off label in
North America, while simultaneously estrogen is denied to women
whose histories suggest that they are in the subgroup of women who
would benefit. The transdermal testosterone approval has been for
estrogenized women only. A recent study showed benefit to estrogen-
deficient women with HSDD who are naturally menopausal; those
who were surgically menopausal did not benefit. Another recent study
146   TREATING SEXUAL DESIRE DISORDERS

showed minimal benefit from transdermal testosterone when given to

premenopausal women with HSDD.
Of major importance is the omission from all of these trials
of women with sexual interest/desire disorder (Basson, 2008). All
recruited women were reporting two to three satisfying sexual engage-
ments per month at baseline. Women with sexual interest/desire dis-
order report no satisfying events, as desire and arousal cannot be trig-
gered during the experience.

Case Example, Continued:

Lucy’s Androgen Metabolites

As part of our ongoing study of androgen metabolites and women’s

sexual function, Lucy agreed to complete questionnaires on her own
sexual function and have a blood sample taken for androgen metabo-
lites. The results showed values at the high end of the normal range
for the women of her age.

Commentary

Lucy and Tom’s story reflects some of the common themes present
when one or both partners complain of low desire. First, sexual func-
tion and dysfunction are inherently relational. Tom’s relative sexual
passivity enabled Lucy’s misgivings about sex to continue. Lucy never
felt that Tom was passionate about her. His affair further undermined
her low sexual self-image. Lucy’s preference for sex in the dark at
bedtime enabled Tom’s style of “sex alone” to continue. Without see-
ing his partner, Tom resorted to his own sexual fantasies but then felt
he was again being unfaithful. Thus, he avoided sex with Lucy even
more.
This case also illustrates the common finding that women’s feel-
ings for the partner generally and at the time of sexual engagement
correlate highly with their desire. For Lucy her feelings for Tom were
still marred by the nonresolution of her feelings surrounding his
affair.
When we consider which women complain about their low
desire, we are reminded that even when a diagnosis of clinical depres-
sion is excluded, women who report low desire have been shown
to have more anxious and depressed thoughts, more mood lability,
 How Assessment Guides Interventions   147

and lower self-esteem than control women (Hartmann, Philippsohn,

Heiser, & Ruffer-Hesse, 2004). Lucy’s self-image improved somewhat
from the CBT approach in the group therapy but more so from the
brief psychotherapy where she allowed herself to feel and express her
anger about Tom’s affair and receive support for having those feelings
rather than continuing with her self-condemnation.
The major helpful intervention in this case was explaining the
logic of the woman’s situation to Lucy and Tom (Basson, 2008).
Learning that they were reacting “normally” given their childhood
experiences, their past sexual history, and the current context rather
than being “broken” sexually was immensely therapeutic. Women,
especially, feel more competent sexually once they are reassured
that they are not sexually deficient. The CBT aspect of the group
session helped Lucy to identify negative and catastrophic thoughts
and to change them. Finally, the introduction of mindfulness practice
allowed Lucy to realize that the times she was not aroused were times
when she was not mentally present. Only with continued mindfulness
practice will distractions be less damaging, but the recognition that
the constant chatter in her mind precluded arousal and pleasure was
comforting. This case also illustrates the power of unresolved anger
and the need to address it.

References

Aziz, A., Brannstrom, M., Bergquist, C., & Silfverstolper, G. (2005). Peri-
menopausal androgen decline after oophorectomy does not influence
sexuality or psychological well-being. Fertility and Sterility, 83, 1021–
1028.
Bancroft, J., & Janssen, E. (2000). The dual control model of male sexual
response: A theoretical approach to centrally mediated erectile dysfunc-
tion. Neuroscience and Biobehavioral Reviews, 24, 571–579.
Basson, R. (2001). Female sexual response: The role of drugs in the manage-
ment of sexual dysfunction. Obstetrics and Gynecology, 98(2), 350–
352.
Basson, R. (2008). Women’s sexual desire and arousal disorders. Primary
Psychiatry, 15, 72–81.
Basson, R., Brotto, L. A., Petkau, J., Labrie, F. (in press). Role of androgens
in women’s sexual dysfunction. Menopause.
Basson, R., Leiblum, S., Brotto, L., Derogatis, L., Fourcroy, J., & Fugl-Meyer,
K. (2004). Revised definitions of women’s sexual dysfunction. Journal
of Sexual Medicine, 1, 40–48.
Brotto, L. A., Basson, R., & Luria, M. (2008). A mindfulness-based group
148   TREATING SEXUAL DESIRE DISORDERS

psychoeducational intervention targeting sexual arousal disorder in

women. Journal of Sexual Medicine, 1, 40–48.
Brotto, L. A., Bitzer, J., Laan, E., Leiblum, S., Luria, M. (in press). Women’s
sexual desire and arousal disorders. Journal of Sexual Medicine.
Farquhar, C. M., Harvey, S. A., Yu, Y., Sadler, L., & Stewart, A. W. (2006).
A prospective study of 3 years of outcomes after hysterectomy with and
without oophorectomy. American Journal of Obstetrics and Gynecol-
ogy, 194, 711–717.
Graham, C. A., Sanders, S. A., Milhausen, R. R., & McBride, K. R. (2004).
Turning on and turning off: A focus group study of the factors that affect
women’s sexual arousal. Archives of Sexual Behavior, 33, 527–538.
Hartmann, U., Philippsohn, S., Heiser, K., & Ruffer-Hesse, C. (2004). Low
sexual desire in midlife and older women: Personality factors, psychoso-
cial development, present sexuality. Menopause, 11, 726–740.
Hodis, H. N., & Mack, W. J. (2008). Postmenopausal hormone therapy and
cardiovascular disease in perspective. Clinical Obstetrics and Gynecol-
ogy, 51, 564–580.
Ishunina, T. A., & Swaab, D. F. (2007). Alterations in the human brain in
menopause. Maturitas, 57, 20–22.
Janssen, E., McBride, K. R., Yarber, W., Hill, B. J., & Butler, S. M. (2008).
Factors that influence sexual arousal in men: A focus group study.
Archives of Sexual Behavior, 37, 252–265.
King, S. R. (2008). Emerging roles for neurosteroids in sexual behavior and
function. Journal of Andrology, 29, 524–533.
Labrie, F., Belanger, A., Belanger, P., Berube, R., Martel, C., & Cusan, L.
(2006). Androgen glucuronides, instead of testosterone, as the new
markers of androgenic activity in women. Journal of Steroid Biochemis-
try and Molecular Biology, 99, 182–188.
Meston, C. M., & Buss, D. M. (2007). Why humans have sex. Archives of
Sexual Behavior, 36, 477–507.
Teplin, V., Vittinghoff, E., Lin, F., Learman, L. A., Richter, H. E., & Kupper-
mann, M. (2007). Oophorectomy in premenopausal women: Health-
related quality of life and sexual functioning. Obstetrics and Gynecol-
ogy, 109, 347–354.
 Chapter 9

Cognitive-Behavioral and
Mindfulness-Based Therapy
for Low Sexual Desire
Lori A. Brotto
Jane S. T. Woo

In this chapter, Lori A. Brotto and Jane S. T. Woo illustrate the additional
benefits of adding a mindfulness component to more traditional cognitive-
behavioral treatment of low desire. The authors suggest that mindfulness is
particularly helpful for those women and men who are given to distraction
and/or distressing negative automatic thoughts during sexual activity. By
learning to be aware of their thoughts in a nonjudgmental way, such patients
can not only learn to be fully present and alert to their sexual arousal, but
also to understand that thoughts are just thoughts and are not necessarily
accurate representations of reality.
In the case presented, treatment interventions are focused on the
“identified” patient, the woman who feels guilty and deficient about her lack
of desire and who tends to be self-critical and easily distracted from her
own sensual experience. The additional component of a four-session short-
term small-group intervention along with mindfulness training appears to be
quite helpful in reinforcing the learning that occurs during therapy.
Lori A. Brotto, PhD, is Assistant Professor in the Department of
Obstetrics and Gynaecology at the University of British Columbia. Her
research focuses largely on testing psychoeducational interventions for
women with various forms of sexual dysfunction (e.g., low desire, arousal,

149
150   TREATING SEXUAL DESIRE DISORDERS

vestibulodynia). Dr. Brotto is on the Sexual Dysfunctions subworkgroup for

DSM-V.
Jane S. T. Woo, MA, is a doctoral candidate in Clinical Psychology
at the University of British Columbia. Her research is focused on Asian
women’s sexuality and barriers to reproductive health testing.

Problems in sexual desire are the most frequent complaint in

every population-based and clinical study conducted on women.
The prevalence of low desire with distress ranges anywhere from
8 to 26%, depending on the study, the country, and the methodol-
ogy. In the clinical practice setting in which we work—a tertiary care
hospital-based sexual medicine clinic—low sexual desire in women
is the most frequent presenting complaint. The challenge in treating
desire cases—whether the identified patient is male or female—is the
comorbidity of low desire with other issues such as mood disorders,
anxiety, fatigue, acute and/or chronic health problems, medications,
inadequate nutrition, demands of parenting, work-associated stress,
financial issues, poor body image, insufficient or inaccurate knowl-
edge about genital anatomy and physiology, and poor dyadic com-
munication. Other challenges include the level of insight and motiva-
tion of the woman and her partner. It is not uncommon for patients
to present with the expectation that problems can be identified and
resolved in a few short sessions. Misconceptions about treatment are
common, and patients may be disappointed to learn that there will be
no “quick fix” for restoring their sexual motivation.
The challenge of untangling the many issues associated with
desire cases is further complicated when problems have been present
for many years, with the resulting layers of resentment, guilt, frustra-
tion, and anxiety. In our clinic, women often describe their loss of or
absent desire in any number of ways including: “I don’t care about
sex,” “I only have sex to please my partner,” “I’d rather do laundry
then have sex,” and so on.

How To Define Desire

There are varying definitions of sexual desire disorder in the clinical

research literature. In the current edition of the Diagnostic and Statis-
tical Manual of Mental Disorders (DSM-IV-TR), hypoactive sexual
desire disorder (HSDD) is defined as “persistently or recurrently defi-
cient (or absent) sexual fantasies and desire for sexual activity.” It is
 Cognitive-Behavioral and Mindfulness-Based Therapy   151

interesting to note that women rarely (if ever) present with the com-
plaint of lack of sexual fantasies. In the definition proposed by an inter-
national consensus committee in 2003, women’s sexual desire /interest
disorder is defined as “absent or diminished feelings of sexual interest
or desire, absent sexual thoughts or fantasies and a lack of respon-
sive desire.” This definition suggests that it is the lack of “responsive
desire,” or desire to continue the sexual encounter once some excite-
ment is reached, that is a better indicator of a desire problem.
Validated questionnaires also define sexual desire in slightly dif-
ferent ways. For example, in the Sexual Interest and Desire Inventory,
sexual desire is captured by a number of different items, including
receptivity to and initiation of sexual activity, wanting sexual activity,
thinking about sex, and responsive sexual desire. In the Sexual Desire
Inventory, sexual desire is conceptualized with a focus on the cogni-
tive domain and is defined as “interest in sexual activity. It [desire]
is primarily a cognitive variable, which can be measured through
the amount and strength of thought directed toward approaching or
being responsive to sexual stimuli.”
It is evident from these examples that sexual desire may be con-
ceptualized and operationalized quite differently. When women them-
selves are asked how they define desire, their definitions are even more
varied, with some expressing confusion about what desire is or con-
flation between the terms desire and arousal. Desire may be viewed
as a cognitive experience (e.g., thoughts or fantasies; motivations),
an emotional entity (e.g., feelings of sexual interest, wanting sexual
activity), or a behavioral event (e.g., receptivity to or initiation of sex-
ual activity), with the different questionnaires and definitions empha-
sizing the cognitive, emotional, and behavioral elements to varying
degrees. To illustrate how these three dimensions may manifest them-
selves, consider the example of a woman who reports avoiding going
to bed at the same time as her partner (i.e., behavior) given her belief
that he will request sexual activity (i.e., cognition) resulting in her
feeling frustrated that she is “not in the mood” and resentful that he
has the energy to devote to sex whereas she feels utterly exhausted
(i.e., emotions). (See Figure 9.1.) Thus, this conceptualization lends
itself well to cognitive-behavioral treatment interventions.

What Is Cognitive-Behavioral Therapy?

Cognitive-behavioral therapy (CBT) is a form of psychotherapy that
emphasizes the interconnections among cognitions, emotions, and
152   TREATING SEXUAL DESIRE DISORDERS

behaviors. The CBT model suggests that changing any one of these
three components leads to changes in the others. Treatment for emo-
tional difficulties targets cognitions and behaviors as a pathway to
moderate emotions. CBT emerged from the synthesis of the radical
behaviorism of the 1950s with cognitive therapy and was heavily
influenced by the work of Beck (1993) and Ellis (1962), who regarded
irrational thoughts and faulty cognitive processing as the source of
emotional distress.
CBT has been applied to the treatment of numerous mental dis-
orders including mood disorders, anxiety disorders, schizophrenia,
eating disorders, and personality disorders, and has received consis-
tent empirical support for its efficacy. In the domain of female sexual
disorders, CBT has been shown to be efficacious for orgasmic disor-
der, vaginismus, and some types of dyspareunia.
To date, only two studies have explored the efficacy of CBT in
the treatment of low sexual desire. In an uncontrolled study, McCabe
(2001) examined the utility of CBT in treating men and women with
various sexual dysfunctions. The 10-session treatment program con-
sisted of exercises designed to improve communication between part-
ners, enhance sexual skills, decrease sexual and performance anxiety,
and alter cognitions and behaviors that interfered with these domains.
Of the 43 women who complained of lack of sexual interest and who
completed the treatment program, 33% reported that treatment was
helpful. Trudel and colleagues (2001) randomly assigned 74 couples
in which the female partner had low sexual desire to either a CBT
treatment group or a 3-month waitlist group. Following treatment
(12 weekly group couple therapy sessions plus homework), CBT was
helpful for 74% of women, and 64% of the women maintained their
gains after 1 year.
What follows is a case example illustrating the use of CBT with
a middle-aged couple.

Case Example: Mona and Harry

Presenting Complaint
Mona, 49, and Harry, 56, who have been married for 20 years, pre-
sented for treatment with the primary complaint of infrequent sexual
intercourse. Mona is a premenopausal woman who owns her own
fashion design company and Harry is a manager of a busy factory.
They have one 10-year old son. They described once-monthly sexual
 Cognitive-Behavioral and Mindfulness-Based Therapy   153

activity, occurring late at night. Typically, Harry would ask Mona if

they could have sex and she would reluctantly agree. They described
minimal to no foreplay, consisting of a few minutes of kissing fol-
lowed immediately by sexual intercourse.
During sexual activity, Mona said that her mind was focused
on wondering when sex would be over. She reported thinking about
work or the many items on her to-do list. She described herself as a
multitasker in the rest of her life as well, during which she found it
difficult to stay focused on one task at a time. She also feared their
son would hear her and as a result requested that Harry keep his
sounds of pleasure to a minimum. She reported having desire “out of
the blue” approximately once a month during ovulation, but she did
not seek out Harry during these times nor did she ever masturbate.
Mona reported only a minimal genital arousal response during sex,
and denied ever having an orgasm in her life. However, intercourse
was not painful. She indicated that she has never really craved sexual
activity, but that her current absence of any desire has been especially
pronounced for at least 10 years, since the birth of their son and the
death of her father at about the same time.
Prior to seeking treatment, Mona and Harry had tried a few dif-
ferent sexual positions (at Harry’s suggestion) in hopes of creating
more pleasure. They had also tried a course of AndroGel (50 mg),
which she applied to her abdomen four hours before sexual activ-
ity, prescribed by Mona’s family physician. Neither of these interven-
tions was helpful. Their current request for treatment was prompted
by Harry’s increasing frustration at their infrequent sexual activity,
which was creating tension in their relationship. Whereas their com-
munication, in general, was very good, the topic of sexuality made
Mona anxious and she retreated to her office when Harry wanted to
discuss sex.

Assessment
During her individual interview, Mona described a dislike of sexual
activity and embarrassment about sexual topics. She avoided clitoral
touch and did not allow Harry to touch her genitals. Mona had had
a few boyfriends prior to Harry, but he was her first sexual partner.
Within 6 months of meeting they began to have sexual intercourse.
For Mona this was accompanied by significant guilt—she believed that
she should remain a virgin until marriage. To this day, she reported
still carrying guilt whenever she was sexual. Religious reasons also
154   TREATING SEXUAL DESIRE DISORDERS

prevented her from ever trying to masturbate, stemming from her

belief that masturbation is a sin. Mona did have nocturnal orgasms
though she kept this information private.
In terms of psychiatric status, Mona had experienced one major
depressive episode following the death of her father 10 years ago. It
coincided with a bout of postpartum depressive symptoms. Presently,
her mood was good though she was prone to anxiety and occasional
panic attacks. She described having a hard time relaxing, which was
difficult for Harry, who enjoys spending time away from work watch-
ing movies or taking naps. She denied any history of childhood or
adult sexual abuse.
During his individual interview, Harry stated that he feared
his sexual desire was abnormally high as he desired sex every day.
Prior to meeting Mona, he had had 15 different sexual partners.
He desperately wanted to please Mona but she was highly resistant
to his efforts. Harry reported being firmly committed to Mona and
although he was tempted to have an extramarital affair, he would
not. He thought that Mona’s low desire was attributable to her strong
Christian faith, which precluded premarital intercourse. He also wor-
ried about Mona’s distractibility—he could sense that her mind was
elsewhere when they made love. He described this experience as feel-
ing like he was having sex with a robot.
Mona’s health was excellent. She exercised regularly and did
not smoke or consume alcohol. She was not using any medications,
although she did suffer from migraine headaches (once a month) for
which she used Tylenol 3 with adequate effectiveness. She had no his-
tory of endocrine problems and her surgical history included appen-
dectomy and tonsillectomy at the ages of 17 and 19, respectively.
Following their conjoint and then individual interviews, Mona
took part in an investigational hormone assessment as part of a larger
research trial. This involved assaying a small sample of her serum for
testosterone metabolites and precursors (e.g., dehydroepiandroster-
one and dihydrotestosterone), as well as mass spectrometry analy-
ses of free testosterone and estradiol. The results of her androgen
metabolites and precursors, estradiol, and testosterone were all in the
normal range for women in their 40s and 50s.

Formulation
Mona did not have sexual thoughts, fantasies, or desire for sexual
activity. She did not want sexual stimulation to continue when actively
 Cognitive-Behavioral and Mindfulness-Based Therapy   155

engaging in sex even when her body started to show signs of physi-
cal arousal. Thus, she met criteria for both the DSM-IV definition of
HSDD and for sexual desire/interest disorder, as defined by the Inter-
national Consensus Committee, focusing on lack of responsive desire.
On the basis of her medical history, her premenopausal status, and
the results from her androgen metabolites, it is unlikely that there was
a significant medical and/or hormonal component to Mona’s reduced
sexual desire.
Mona had several problematic automatic thoughts. Among them
was the belief that her son might hear them having sex, masturbation
was wrong, and it was inappropriate for Harry to touch her geni-
tals. Mona had sex solely out of a sense of obligation, she resented
being asked for sex by Harry, and she experienced guilt for not mak-
ing it enjoyable for Harry. Her behaviors included avoidance of talk-
ing about her low desire, deliberately going to bed after Harry, and
thinking about other obligations on her to-do list during sex. Each of
these cognitions, emotions, and behaviors led to a cascade of other
thoughts, feelings, and behaviors; thus, a tightly woven vicious circle
was spun around Mona’s sexual activity and low desire.
A CBT approach seemed indicated for Mona in light of her core
beliefs, which resulted in her emotional and behavioral difficulties.
Such a treatment would focus on identifying, challenging, and replac-
ing her automatic thoughts related to sex. It was helpful for Mona
to complete a thought–feeling–behavior form (Figure 9.1) to see the
range of her automatic thoughts and how they gave rise to a host of
negative emotions and problematic behaviors. She was given instruc-
tion to use a blank CBT diagram and to fill in her thoughts, feelings,
and behaviors during a recent negative sexual interaction with her
partner. However, given Mona’s significant distractibility, multitask-
ing, and anxiety proneness, a mindfulness-based cognitive-behavioral
intervention seemed important to add.

What Is Mindfulness?

Mindfulness is the practice of intentionally being fully aware of one’s

thoughts, emotions, and physical sensations in a nonjudgmental way.
Although mindfulness is rooted in Eastern spiritual practices, it is
rapidly being embraced in Western approaches to both physical and
mental health care. Mindfulness-based treatments have been found
to have therapeutic benefits in disorders ranging from pain to depres-
156   TREATING SEXUAL DESIRE DISORDERS

Thought
“If I don’t feel desire, I must have a sexual problem.”
“My body is broken sexually.”
“Why does he keep asking me for sex if I don’t want it?”
“He must not be listening.”
“He must not love me.”
“I’ve tried everything and nothing works.”
“Everyone else seems to have great sex but me.”
“I should be working, not having sex.”

Situation triggered by her

partner asking for sex

Feeling Behavior
Sad Avoid going to bed at the same time
Frustrated Pull away when he touches/kisses me
Anxious Fight
Angry Grind my teeth
Disappointed Distracted
Depressed
Resentful
Furious
Fearful

FIGURE 9.1. Thought–feeling–behavior form.

sion, anxiety disorders, eating disorders, substance abuse, and bor-

derline personality disorder.
Mindfulness has been referred to as the third wave in the evo-
lution of behavior-based therapies, with the first phase (behavior
therapy) characterized by an exclusive focus on correcting prob-
lematic behaviors and the second (CBT) defined by the inclusion
of irrational thoughts and faulty cognitive processing as additional
treatment targets. Mindfulness complements CBT by providing
additional tools with which to understand the phenomenological
experience of their thoughts and feelings. By teaching patients to
be aware of their thoughts in a nonjudgmental way, for instance,
the experience of mindfulness leads patients to understand that
thoughts are just thoughts and are not necessarily accurate repre-
sentations of reality.
 Cognitive-Behavioral and Mindfulness-Based Therapy   157

Mindfulness-Based Treatments and Sexuality

The literature testing mindfulness for sexual problems is limited to

two studies from our group as well as one qualitative study in nondis-
tressed couples. Among the latter, a mindfulness-based intervention
significantly enhanced relationship satisfaction and reduced distress
(Carson, Carson, Gil, & Baucom, 2004). In a study of women who
were treated for cervical or endometrial cancer, a brief individual
psychoeducational intervention (PED) with mindfulness as one of its
core components led to significantly improved sexual desire, arousal,
orgasm, and satisfaction (Brotto et al., 2008). Importantly, sexuality-
related distress and depressive symptoms also decreased. Qualitative
analyses of women’s experience during the PED revealed that the
mindfulness component was seen as most helpful because it helped
women become aware of residual genital arousal that they believed
had been lost by virtue of their prior surgery. Attending to these sen-
sations further enhanced their subjective excitement.
Following the positive findings of the PED group in the first study,
we studied a population of women with sexual arousal and desire
complaints unrelated to cancer. The general interventions remained
the same, although the PED was administered in a group format.
The results revealed an increase in self-reported sexual desire and a
decrease in sexuality-related distress. In particular, those women with
a history of sexual assault and who were therefore prone to distrac-
tion during sexual activity responded especially positively (Brotto,
Basson, & Luria, 2008).

Case Example, Continued

Treatment
Following the initial two assessment sessions, Mona took part in four
90-minute group sessions, which combined elements of education,
cognitive and behavioral skills, and mindfulness practice. Education
focused on a discussion of the definition of sexual desire and arousal,
provided her with available epidemiological data on the prevalence
of sexual difficulties, and discussed aspects of female genital anatomy
and physiology. The latter was particularly helpful for Mona, who
had never “explored” her own genitals and was unaware of the rich
vasculature of the clitoris and vestibular bulbs.
The CBT elements of treatment involved a detailed discussion
158   TREATING SEXUAL DESIRE DISORDERS

and illustration of the cognitive-behavioral model, using an exam-

ple from Mona’s own experience to illustrate the vicious cycle of
thoughts, feelings, and behaviors (see Figure 9.1). Mona took home
and completed thought records to track the frequency and inten-
sity of her irrational beliefs and to form new balanced thoughts to
replace them (see Figures 9.2 and 9.3). She benefitted from hearing
other women normalize aspects of their own sexual experience, and
after four sessions, Mona was able to allow Harry to touch her
without the previous experience of anxiety and belief that this was
wrong. She also began to identify and challenge her own avoidance
behavior as she now realized the role of avoidance in perpetuating
her anxiety and low desire.
The mindfulness exercises were varied and extensive and
involved in-session practice as well as daily practice between ses-

A thought record can be an effective way of identifying negative thoughts, under-

standing their link with particularly strong emotions, and challenging and replacing
them with more balanced (or rational) thoughts. When you have a strong emotion
(e.g., anger, sadness, resentment, guilt, frustration), this can be a clue that there are
automatic (and negative) thoughts present. For this exercise, we would like you to
practice tracking your automatic thoughts for 1 week. When you have a strong emo-
tion, document the emotion and how intense it is on a scale of 0–10 in column 1. Note
the day and time and the situation that triggered it in column 2. Then, try to identify in
column 3 what are the automatic thoughts underlying or associated with that emotion.
In column 4 write how strongly (from 1 to 10) you believed that thought. Columns 5
and 6 are where you collect the evidence for and against the particular thoughts listed
in column 3.
Some questions to ask yourself to help find evidence against your automatic
thought are:
• “Have I had any experiences that would suggest this thought is not true all the
time?”
• “If my best friend or someone I loved had this thought, what would I tell them?”
• “When I am not feeling this way, would I think about this type of situation differ-
ently?”
• “When I have felt this way in the past, what did I do or think about to make myself
feel better?”
• “Are there any small things that contradict my thoughts that I might be discounting
as not important?”
• “Am I jumping to conclusions with my automatic thoughts?”
• “Am I blaming myself for something over which I do not have complete control?”
If your exercise in collecting the evidence does not support your automatic thought,
then in column 7 write an alternative or balanced view of the situation that is consistent
with the evidence. Then, in column 8, rate your belief in the balanced thought, any
change in your mood, and the outcome.

FIGURE 9.2. Thought record instructions.

 Emotion Situation Automatic Strength Evidence Evidence not Alternative Outcome
How did you Who? What? thought(s) of thought supporting supporting the or balanced How much do you
feel? (0–10) Where? When? What exactly How strongly the automatic automatic thought thoughts believe the balanced
were your do you thought thoughts (0–10)?
thoughts? believe this How do you now feel
thought (0–10)? What can
(0–10)? you do?
Angry (3) Husband came up “He must not (9) He touched Touching my back Touching my back Balanced thought: 10
Anxious (7) behind me while I love me if he my back—an is not the same as is a sign of Old thought: 2
Resentful (5) was on the keeps asking intimate part. asking for sex. affection, not
computer and for sex.” He shows me he necessarily a
placed his hand loves me. request for sex.
on my back. He tells me he loves My husband does
me. love me.
I’ve never told him
not to touch my back.
I’m tired and thinking
emotionally.

FIGURE 9.3. A thought record in response to one specific negative thought evoked when anticipating sexual activity.

159
160   TREATING SEXUAL DESIRE DISORDERS

sions. Mona first took part in a nonsexual exercise in session that

involved exploring, sensing, and tasting a raisin in great detail. She
was given the instruction to “take in” this raisin—to drink it with
her eyes and to bring her mind back to the present should she be
distracted, and to resist judging herself should her mind wander. In
doing this nonsexual exercise, Mona realized just how distractible
she was. However, she also learned that she could guide her atten-
tion into the present moment if she chose to do so. This was very
rewarding for Mona to realize given her prior belief that her brain
was “wired” only to multitask. She then practiced a 30-minute body
scan four times per week, which involved mindfully noticing the dif-
ferent parts of her body and breathing diaphragmatically into those
parts. With practice she became more aware of what triggers led to
distraction.
Mona next began to practice mindfulness exercises involving
her own body. She was asked to take a bath or shower and mind-
fully be aware of her skin as she dried—not spending time on the
negative judgments that would inevitably come up. Mona learned
to remain focused in the present and to squelch such judgments.
She practiced a mindfulness exercise while visually exploring her
own genitals with the aid of a diagram and handheld mirror, and
secondly with the use of her own fingers. She found these exercises
difficult as she strongly associated genital touch with guilt. How-
ever, she was able to redirect her mind into the present and enjoyed
learning about her genitals, which ultimately resulted in reduced
anxiety with genital touch.
We then practiced a mindfulness exercise in which she first
attempted to adopt a positive sexual self-schema (e.g., she read a
paragraph indicating to her that she enjoyed her own sexuality, and
she was feminine and sensual). With this cognitive schema in mind,
Mona practiced the body scan exercise. Although she did not believe
the schema stating that she enjoyed her sexuality, she could adopt
it temporarily during these practice sessions. Another component of
the mindfulness exercises involved encouraging Mona to utilize fan-
tasy, erotica, and/or vibrators as a means of boosting sexual arousal.
This was a challenging exercise for Mona given her resistance to these
tools and view of them as being inappropriate. However, we concep-
tualized them as sexual aids to be used in a very specific way. After
experiencing some arousal after a few minutes of either imagining a
fantasy about herself and Harry, watching some “female-friendly”
erotica, or using a personal massager on her genitals, Mona was to
 Cognitive-Behavioral and Mindfulness-Based Therapy   161

then discontinue this and immediately do a body scan for 15 min-

utes. The rationale was given that by first exciting her mind (through
fantasy) or body (through erotica or vibrator), this would increase
the chances that her mind and body could remain in sync through
mindfulness.

Therapy Outcome
The combination of mindfulness and CBT was ideally suited for
Mona. CBT allowed her to identify, challenge, and replace many
of the automatic (and irrational) thoughts she had about sexu-
ality. It also allowed her to understand the role that avoidance
behavior played in maintaining her resentment of Harry and in
perpetuating her low desire. The detailed thought records com-
pleted by Mona (Figure 9.3) allowed her to see the delicate inter-
actions between her thoughts, feelings, and behaviors so that
she could predict ahead of time how having a particular thought
might lead her to feel bad or avoid interactions with Harry. They
also encouraged her to adopt new, balanced thoughts to replace
irrational beliefs.
Mindfulness directly targeted her distractibility and judgmental
tendencies. Mona believed at the outset that her mind was naturally
wired to be in many different places at one time. She never chal-
lenged this during any activity, for she perceived it as beneficial to
“accomplish” many things at the same time. However, this meant
that during sexual activity she was focused on other, nonsexual
events that were more pressing. Mona accepted the rationale of
mindfulness in session. The fact that mindfulness has been found to
result in structural and functional changes in the brain provided for
Mona the necessary evidence to immerse herself completely in the
exercises. By beginning our practice in nonsexual situations, Mona
was able to hone her practice and start to enjoy the experience
of being in the moment throughout various activities in her day.
Mona found that practicing mindful exercises with her own body
was more challenging (as most women do), given that an array of
body-specific negative judgments were triggered. She realized that
she was a highly judgmental person—of herself and of Harry—and
began to wonder how much her judgmental style led her to be natu-
rally resentful of Harry. When the mindfulness exercises were even-
tually paired with some sexually arousing activities (e.g., fantasy,
erotica, vibrator use), she learned that her body was indeed capable
162   TREATING SEXUAL DESIRE DISORDERS

of becoming aroused. The rationale presented to Mona was based

on the finding that women’s subjective and genital arousal are often
desynchronous. By first exciting the mind sexually through fantasy,
she could be more likely to tune in to potential signs of arousal in
her body during her mindfulness practice. By first exciting her body
(with erotica or a vibrator), and then practicing mindfulness imme-
diately afterward, she was able to notice her body’s arousal and
focus on it. This ultimately enhanced her subjective excitement, for
she experienced firsthand that her body was not “broken,” and, in
fact, was quite responsive. Education about the nature of fantasy
emphasized the range of sexual fantasies and challenged Mona’s
preconception that fantasizing would be synonomous with being
unfaithful. She could evoke a sexual fantasy in her mind, and then
deliberately focus her attention onto her body, thus enhancing the
connection between her mind’s and her body’s excitement. She
struggled coming up with her own fantasy; therefore, she enjoyed
reading some of the fantasies provided in books by Nancy Friday
(My Secret Garden, Forbidden Flowers).
The ultimate result was that Mona had a significant improve-
ment in sexual desire as measured by validated questionnaires and
by her own self-report. She began to initiate sexual activity and was
more responsive to Harry’s advances. By planning sexual activity, she
could anticipate sex positively, which improved her sense of self and
further enhanced her connection with Harry.
How is mindfulness different from sensate focus? Sensate focus is
designed to teach one to increase concentration on the sensual aspects
of touching while experiencing relaxation. At this level, mindfulness
and sensate focus bear a striking resemblance and one can see aspects
of mindfulness (as well as desensitization) in the practice of sensate
focus. However, unlike sensate focus, mindfulness is a state of being
that can apply to all situations—not only sexual ones. Mindfulness
also does not require the presence of a partner, and in fact, in our
practice we encourage women to practice mindfulness alone and in
nonsexual situations for several weeks before attempting to integrate
it into their sexual experiences.

Commentary
After her group sessions Mona became better able to remain focused
and present oriented during sexual activity and, in fact, during many
nonsexual situations. Changes in her sex life included an increased
 Cognitive-Behavioral and Mindfulness-Based Therapy   163

willingness to accept Harry’s invitations to sex, increased arousal

during sex, increased ability to tune in to the experienced arousal
and thus an increase in sexual desire, reduced distractibility during
sex, and reduced frequency of irrational beliefs about sex. Because
her tendency to multitask and become distracted was so automatic,
the gains she achieved were conditional upon continued mindfulness
practice. Clinically we use the analogy that the mind is like a puppy,
continually wanting to run this way and that in search of excitement.
However, if one wants the mind to stay focused, one needs to guide
it back, as if gently tugging on the leash of that puppy. With practice
and over time, Mona may become more adept at remaining in the
present. However, she will need continued practice in order to realize
the full benefits of mindfulness.

Conclusion

Overall, we feel the addition of mindfulness to CBT for women

with low desire is very helpful. Individual and/or couple sex ther-
apy may then be more targeted to specific needs of the woman and
her partner. As East meets West in many other domains of Western
medicine, we may increasingly see mindfulness (and other Eastern
approaches) being incorporated into the treatment of sexual dys-
function, as well as an increase in empirical efforts to establish its
efficacy.

References

Beck, A. T. (1993). Cognitive therapy of depression: A personal reflection.

Aberdeen, Scotland: Scottish Cultural Press.
Brotto, L. A., Basson, R., & Luria, M. (2008). A mindfulness-based group
psychoeducational intervention targeting sexual arousal disorder in
women. Journal of Sexual Medicine, 5, 1646–1659.
Brotto, L. A., Heiman, J. R., Goff, B., Greer, B., Lentz, G. M., Swisher, E.,
et al. (2008). A psychoeducational intervention for sexual dysfunction
in women with gynecologic cancer. Archives of Sexual Behavior, 37,
317–329.
Carson, J. W., Carson, K. M., Gil, K. M., & Baucom, D. M. (2004). Mindful-
ness-based relationship enhancement. Behavior Therapy, 35, 471–494.
Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stu-
art.
164   TREATING SEXUAL DESIRE DISORDERS

McCabe, M. P. (2001). Evaluation of a cognitive behavior therapy program

for people with sexual dysfunction. Journal of Sex and Marital Therapy,
27, 259–271.
Trudel, G., Marchand, A., Ravart, M., Aubin, S., Turgeon, L., & Fortier, P.
(2001). The effect of a cognitive-behavioral group treatment program
on hypoactive sexual desire in women. Sexual and Relationship Ther-
apy, 16, 145–164.
 Chapter 10

Dancing to Their Own Music

David C. Treadway

In this beautifully written and illuminating chapter, David C. Treadway shows

how he helps couples dance to their own music and orchestrate a mutu-
ally acceptable and satisfying sexual life. Rather than being prescriptive in
his therapy, Treadway offers couples a range of possibilities for working on
their sexual complaints. From the outset, couples learn to communicate
effectively and sensitively. Along the way, he offers a variety of exercises
to move the treatment forward, such as nurturing exercises in which each
partner explicitly asks the other for a “unilateral gift” or communication exer-
cises in which partners are encouraged to hear the other without rebuttal
or defense.
In his work with Kit and Jack, Treadway’s warmth and clinical skills
become apparent. By providing the actual dialogue exchanged over the
course of several therapy sessions, Treadway offers the reader a unique
window into the treatment process. As with any case, there is initial opti-
mism and progress, followed by hurt and recrimination when unexpected
material emerges. In this case, it is Kit’s discovery of Jack’s exploration of
female domination pornography on the Internet. It is instructive to see how
Treadway provides support and reassurance to both Kit and Jack when this
uncomfortable discovery surfaces.
While recognizing that a host of factors contribute to desire complaints,
Treadway focuses on the essential therapeutic ingredients that move treat-
ment forward: building a safe and nurturing environment, normalizing dif-
ferences in sexual appetite, providing a variety of therapeutic interventions,
and acknowledging the difficulty in sustaining a sexual life in the face of

165
166   TREATING SEXUAL DESIRE DISORDERS

real-life demands, unrealistic expectations, and individual differences. The

critical therapeutic ingredients Treadway advocates are acknowledging and
accepting differences and sharing feelings and yearnings with compas-
sion.
David C. Treadway, PhD, is a marriage and family therapist who has
been practicing therapy and giving workshops for the past 30 years. He is
the author of four books, most recently, Home before Dark: A Family Portrait
of Cancer and Healing, which he wrote with his wife, Kate, and his sons,
Michael and Sam.

Session Eight

“Why do you look at stuff on your computer when I’m right here?
What’s so bad about me?” Kit asked in a small voice, with tears in
her eyes. She was perched on the edge of my blue sofa. Her knees
were pressed tightly together, calves splayed out and her toes pointed
toward each other. Her hands were folded in her lap, twisting a
Kleenex. Despite being a successful lawyer with two teenagers of her
own, she looked like a schoolgirl, embarrassed and shy.
Kit’s husband, Jack, was sitting as far away on the sofa as he
could, his arms folded across his chest and his legs crossed. He seemed
completely knotted up. In his late 40s, he was a physician and teacher
at the medical school. He was lean and muscular, with a full head of
hair flecked with gray. He was staring at the floor glumly.
I leaned forward in my chair and waited.
“Listen,” Jack started haltingly. “It’s not about the computer
stuff. It’s just the way we are. We’re never in the ‘mood’ at the same
time. And the kids are almost always there. And you’re always telling
me how unsexy you feel because you’ve put on a few pounds. And
besides, you never approach me. You complain, but you don’t do
anything. You make it all my problem.”
Kit began to cry hard.
I looked at them, a good man and a good woman, working hard
at raising their kids, pursuing their careers, kind and loving toward
each other most of the time. And yet they felt lonely, unloved, and
undesired. From time to time, they managed to have sex in order to
reassure themselves that they were normal, but it had become another
“to-do,” like the food shopping and the laundry. It usually left them
even more separate and isolated. They felt like failures, and wondered
 Dancing to Their Own Music   167

if the “spark” was simply gone. Secretly they worried that when the
kids were grown, one of them might leave or have an affair. They
didn’t just miss sex. They missed being “in love.” The intoxicating
romance. Seeing the glow in each other’s eyes. Even the simple com-
fort of touching and being touched.
My heart ached for them, but I was also hopeful. They’d already
made progress in our therapy. We had met eight times and they were
fighting less and working together better. They were doing their ther-
apy homework. We knew from the start that they both felt badly
about their sexuality and wanted to change. I believed that they could
find a way to reach each other’s hearts and find renewed pleasure,
even joy, in each other’s bodies.

**   **   **

What Kit and Jack didn’t fully appreciate was how normal their
painful difficulties in sustaining an active and intimate sexual life
were. Despite our living in a sexually saturated and permissive cul-
ture, where virtually every movie theater, magazine, and TV show
celebrates copulation, many couples are experiencing a dramatic less-
ening of sexual libido and activity. In the privacy of their own homes,
couples are headed for bed to sleep, not for sex, and often feel either
profound shame or blame that ripples through the rest of their rela-
tionship. This diminution of desire is true for men and women alike,
gay and straight, old and young.
There are many proffered explanations for the large decrease in
sexual desire and sexual behavior in long-term couple relationships.
One important contribution to low sexual desire for many couples is
the complexity and challenge of contemporary life.
In the last 40 years, the majority of couples have become dual-
career families, with both working hard outside the home as well as
sharing the responsibilities for raising the children and maintaining
the home. Couple relationships are no longer as defined by gender
roles as they used to be, and the net result is that most couples are
trying to negotiate virtually every aspect of their relationship. They
are working out how to be wage earners, co-parents, housekeepers,
best friends, and lovers. Nonstop negotiations about who will drive
Johnny to soccer and who is doing the income tax and whose turn it is
to do the food shopping are rarely erotic. Couples are often so inter-
twined with each other around the business of life that they evolve
168   TREATING SEXUAL DESIRE DISORDERS

into a kind of sibling relationship, which may be highly functional

but makes sexuality seem almost incestuous. As Esther Perel (2006)
emphasizes in her book, Mating in Captivity, distance and differentia-
tion are key elements in sustaining erotic energy and mystery.
Another variable is that couples’ sexuality is no longer orga-
nized by the old, repressive contract that men were entitled to sex
in exchange for providing for and protecting women. Today, both
men and women want and expect greater intimacy, mutuality, and
reciprocity than perhaps ever before in human history. This puts a tre-
mendous pressure on couples to not just “do it” but be “into” doing
it. Unfortunately, regardless of gender or sexual orientation, usually
one member of the couple wants to be close and intimate before being
sexual and one thinks being sexual is a good way of connecting and
feeling closer. As with Kit and Jack, the pressure on both members of
the couple to feel “in the mood” at the same time and place can be
daunting.
Finally, as couples make the transition from being in love to being
in life, they have to handle the shift from the intensity of romance to
the routines of attachment. Couples often wound each other in the
process because they lack the skill to negotiate a mutual understand-
ing about how to fit sexuality and romance into the necessities of
life.
I remember treating a couple in their mid-60s and when we were
discussing their early marriage the wife burst into tears and told about
how she grew up with a lot of sexual energy but, having been given a
strict religious upbringing, she had dutifully saved herself for her mar-
riage. Apparently the first few months of the marriage were a sexual
Cirque du Soleil for her, but one day she decided to be really bold and
surprise her husband when he got home from work. She had put on a
slinky black negligee and greeted him at the door with a chilled bottle
of champagne and a fluted glass. He opened the door and was star-
tled (and probably anxious, as many men are when confronted with
sexually assertive women). He tried to cover his nervousness with a
little joke. “What have you’ve been doing all day, lying around in bed
drinking?” he said. The young bride walked out of the room, threw
out the champagne and the negligee, and in the ensuing 43 years of
marriage never initiated another sexual encounter.
Most couples feel a profound, almost spiritual yearning to be
fully known and loved for who they are. However, in the complex
business of being a couple, they inevitably bring their flawed and
 Dancing to Their Own Music   169

limited humanity. They disappoint each other and cannot meet all
of each other’s needs. They inadvertently hurt each other, but don’t
know how to talk that through to resolution. They learn to soldier
on, either deflecting conflict or avoiding it, feeling some mix of accep-
tance and resignation. Rarely can they share their natural sense of
disappointment and loss with each other. This separates them. For
many, it’s like their own experience of being expelled from the Garden
of Eden.

Session One

Kit and Jack didn’t come to therapy to work on their sexuality. Most
couples come to me for a variety of presenting problems, from affairs,
power struggles and conflict, lack of communication, parenting, and
money to in-law problems. Many come with one or both members of
the couple considering divorce.
I begin all of my couple interviews by focusing on their strengths,
what first attracted them to each other, what they like each about
other, and what they do best. Most couples soften a little with this
emphasis on the positive before we get into their presenting problem.
Then, after interviewing them about their difficulties, I ask couples
how their issues impact their intimate sexual life. I frequently get a
response like Jack’s: “What sexual life?” To which Kit responded with
an eye roll and a nervous laugh.
I explained:

“Many couples’ struggles have a direct and unfortunately negative

impact on their intimate lives. Most couples choose to work on
the frustrations and tensions that brought them here first. Every-
one tends to assume that if they can be better friends, fight less,
and work together better, their sexual intimacy will reignite on
its own. Frequently this isn’t true. The progress couples make in
their relationship often doesn’t translate into a better sexual rela-
tionship. Issues around sexuality can be difficult to change even
when you’re feeling closer together. If that happens to you guys,
don’t panic. I work with a lot of couples around rejuvenating
their sex life. Some couples even decide to start there. One couple
said that if they could have a good intimate life, their other con-
flicts and struggles would melt away.”
170   TREATING SEXUAL DESIRE DISORDERS

“Well, Dr. Treadway, I think we would have to be feeling a lot

closer before dealing with those issues,” piped up Kit quickly.
“No problem, Kit. Most couples, particularly most women, want
an improvement in the closeness, intimacy, and trust in their relation-
ship before focusing on sex. Sometimes I tease men and say, ‘Don’t
worry, just consider the talking part, foreplay. We’ll get there.’ ”
I was pleased to see that they both smiled, albeit a little shyly. I
introduced the issue of sexual intimacy and the notion that it might be
necessary to work on it explicitly early in the therapy, but not before
they were ready. I usually start by presenting three options for struc-
turing the therapeutic work.
I described the alternatives to Kit and Jack:

“The first option is putting aside your past hurts, resentments,

and blame and focusing on the here and now. The emphasis is
on developing new relational skills and ways of communicating,
decision making, and nurturing each other.
“The second option, which is especially valuable for couples
who have accumulated significant hurt, anger, and mistrust from
many painful moments in their relationship, is to put your pres-
ent relationship on hold, establish a truce, and have zero expecta-
tions for improvement. Rather, we would focus on acknowledg-
ing your painful history in a safe, compassionate way. You each
would have a session or two with your partner and me where
both of us would just listen with tenderness and compassion to
your accumulated hurts and disappointments. I would help the
listening partner put aside defensiveness and self-justification and
simply hear and make amends for the harm they’ve done along
the way. Most couples can’t talk about their hurts without mak-
ing it worse. We would work on your being able to open your
hearts, apologize, and begin to forgive each other. We would
really be working on bringing closure to the marriage you have
had, before beginning to work on the relationship you might
have.
“The third option is that we would begin with the story
of your childhoods and the families you grew up in. For many
people, their childhood experiences of love and loss, attachment
and isolation, competency and insecurity shape who they grow
up to be, what they seek in their intimate relationships, and why
their present behavior doesn’t work for them. So, we might start
 Dancing to Their Own Music   171

with several sessions exploring those themes before we even get

to your wedding day. And, in the meantime, you would go on
in your regular way together, even if it’s sometimes difficult. For
some couples, it helps to have a deeper understanding of their
relationship before even beginning to try and change it.”

Kit looked overwhelmed. “This is a lot. I have no idea where we

should start.” Jack nodded.

“Not to worry. There’s no right or wrong answer. Couples rarely

have the time and the safety to decide together how to work on
improving their relationship, how to collaborate on creating a
more intimate and satisfying marriage. Let’s just pause here.”

I gave them each a handout describing the choices. “Take a look at

this and let’s talk about it.”
When they were done reading the choices, I encouraged them
to turn toward each other and discuss the possibilities. They didn’t
know what to say. They had no set speeches of shame or blame, no
clarity about right/wrong, good/bad. They were working together on
something brand new and potentially exciting for them. They were
creating their own therapy model.
Kit was intrigued by the family-of-origin work, because she
thought Jack’s family had been traumatizing for him. And, in a gen-
der-typical way, Jack wanted to focus on skills going forward, not
on rehashing the past. I helped them negotiate, not interrupting each
other, showing respect for their different ideas, listening carefully.
They were taking ownership of their treatment and learning to work
together. They understood that all three elements of their relation-
ship—their past, present, and future—were key to changing their
relationship, and that they could not work on everything at once.
They would have to learn how to tolerate their unresolved issues,
while taking only one step at a time. Therapy had begun.

Session Six

At first they did well. After more discussion, they decided to work
on learning new relationship skills. I gave them a talk/listen exercise.
They each spend 15 minutes listening carefully and reflecting back,
172   TREATING SEXUAL DESIRE DISORDERS

but an important element is that the partners’ turns as the talker are
separated by at least 24 hours so that the exercise doesn’t dissolve
into a debate. The emphasis is on each person having a safe place to
talk about his or her feelings without rebuttal. I also taught them a
nurturing exercise, in which each of them gives the other an explicitly
requested, unilateral gift. Enhancing a couple’s communication/nego-
tiation skills and capacity for giving and receiving nurture are key to
future work on intimacy and sexuality.
Both Jack and Kit had difficulty coming up with gifts they would
like to receive from one another. “Listen, you’re not alone,” I reas-
sured them. “Many couples have difficulty specifying one particular
thing. Think in terms of an action, like breakfast in bed or bringing
home flowers. Don’t ask each other to be kinder or in a better mood.
It’s got to be something the other can do.”
They sat quietly for a while and then Kit said, “Well, I would
really like it if one night a week we could go to bed a half hour earlier
and I could curl up next to Jack and put my head on his chest, and
he would read out loud to me from my favorite childhood book, The
Secret Garden.”
Jack smiled tenderly, and said he would be happy to do that.
Then, after much hesitation, Jack asked if Kit could draw him a bub-
ble bath and then wash his hair. She reached for his hand and said,
“Sure thing, sweetie.”
This is going great, I thought to myself.

Session Eight Revisited

They continued to make progress, doing better as a parenting team

with their kids, not fighting, and doing the talk/listen and “gifting”
exercises. But two sessions later, the bottom fell out. Kit arrived in
tears and Jack was withdrawn and defensive. The night before, Kit
had inadvertently discovered that Jack had been logging on to female-
domination pornography sites on their computer. She was devas-
tated.
“I thought things were so much better,” she said.
I look at them with compassion and tenderness. I’d hoped they
would want to work on their sexuality issues as a result of the positive
steps they were making in their relationship. But frequently, couples
stumble into their sexual dilemmas like Alice falling down the rabbit
hole.
 Dancing to Their Own Music   173

Here they were, hurt, angry, and humiliated. Their lack of fre-
quent sexual engagement didn’t mean they had no sexual desires or
needs. There’s a reason why pornography is the biggest business on
the Internet and why women buy vibrators and read romance novels.
Jack and Kit had lost the ability to turn toward each other for intimate
sexual connection. Instead they had either turned off or turned away.
First, I needed to help Jack move out of shame and defensiveness
and help Kit feel less rejected and blamed. I leaned toward her and
said gently, “I know it must be horrifying to see some of these aggres-
sive images and to think of Jack being responsive to them.”
She nodded, choking back sobs.
I turned toward Jack. “And it’s got be incredibly embarrassing
for you to have Kit come across this stuff. I mean, there’s everything
you can imagine on the Internet and a lot of guys—but not just guys—
find it easier to get their sexual relief with a click of the mouse than
to deal with all the stuff around having a sexual encounter with their
partner.”
He looked at the floor.
I returned to Kit. “But it’s got to be hard for you, when he is
kind of making it sound like it’s all your fault. I think he’s so ashamed
that he’s lashing out a little. I think he knows perfectly well that the
dilemma around maintaining sexual intimacy is a challenge for both
of you.
“And you share equal responsibility, Jack. Do you agree?” I was
giving him a gentle nudge.
“Yes.” He turned to Kit. “And I am really sorry.” He started to
tear up. “I am so sorry.”
She reached out and took his hand. After a long silence, she asked,
“Does that stuff I saw mean that’s what you want me to do to you?”
“God, no!” he said quickly. “I mean, that’s just fantasy, you
know. I’ve never even thought about you and me and—”
Kit started to pull back. We were getting ahead of ourselves.
“Listen, you two, there’s a lot to talk about here. Almost every-
body has powerful erotic fantasies, and many couples never share
them with each other. Just because something’s a turn-on in some-
one’s mind doesn’t mean that they want to act it out. Kit, what could
Jack do that would help repair things?”
“Well, Dr. Treadway, I . . . ”
“Speak to him.”
“I’d like it if you didn’t go on those Internet sites anymore
secretly.”
174   TREATING SEXUAL DESIRE DISORDERS

“I can do that,” Jack replied.

“Good. That’s a start. You have been going great in our work
together. Maybe it’s time to open up the conversation about your
intimate life and explore how to rejuvenate your sexual inti-
macy. Would you be willing to do a simple exercise to kind of get
started?”
“Depends on what it is,” Jack said, warily.
“We’ll try it and if it’s too uncomfortable for either of you, we’ll
stop, okay?”
They both nodded.
“Kit, turn on the sofa so your back is to Jack, and Jack, you slide
toward her so that you can comfortably massage her shoulders. Is
that okay with you, Kit?
“I guess.”
“So we’ll give it a try, and in a few moments we’ll change posi-
tions and you’ll give him a massage. Could you both close your eyes?
And while this gentle massage is happening, I want each of you to just
feel whatever feelings you have.”
Jack began to massage Kit’s shoulders while I talked to them.
“Each of you may be experiencing a whole host of emotions, starting
with how contrived and silly this exercise feels . . . ”
Jack chuckled.
“But also, Kit, you may be feeling wary and distrustful, ambiv-
alent about whether you even want Jack to be touching you right
now. Or you may feel self-conscious with me being here and even
frustrated that it’s hard to relax and enjoy yourself. While Jack, you
might feel on the spot and not sure how to give a comforting massage
or whether Kit’s just going through the motions to be a good sport in
therapy. You may be worried about what Kit’s feeling. I’d like both
of you to experience this touch while feeling whatever emotions are
going on and try not to worry about what you think you should be
feeling.
“Now let’s pause before we switch and hear some of your feel-
ings.”
“That felt pretty gimmicky and I was pretty confident she was
tense about it.”
“That’s fine, Jack. And how about for you, Kit?”
“It made me sad. We don’t ever touch each other that way any-
more. To be honest, I’d prefer for us to be able to do this at home and
not have to be in your office. But actually, it felt kind of good,” she
said, softly.
 Dancing to Their Own Music   175

“Well, the whole idea behind this exercise is that all couples develop
a mixed up mess of feelings toward each other as they make their
way through life. In one way or another, you’ve hurt each other
a lot through the years, and this episode with the Internet porn is
only one of many things that have been difficult.
“For couples to be truly intimate in the bedroom, you have
to be comfortable with your own sad/mad/bad feelings that
have accumulated. It is truly liberating when you can bring all
of yourselves, including your bad feelings, to each other in the
bedroom without shame, blame, and fear. And still make love.
You can discover that you have these hurt, resistant, even angry
emotions and let it all be part of your intimate touch. Instead of
what most couples do, which is try to sweep it under the rug in
order to be sexual, an approach that makes for lumpy rugs and
lousy sex.”

The session was very painful but very intimate, and it ended with
their feeling closer. The core reason why couples withdraw from sexu-
ality is that true intimacy is very hard. The touching exercise intro-
duced the idea that Kit and Jack could have gentle touch while still
acknowledging difficult feelings. Most people think intimacy is sup-
posed to be a feel-good experience, a Hallmark card event. Often, it
hurts. Being able to share the hurts allows couples to be fully present
to each other and to learn how to make love with each other’s whole
selves.

Session Ten

“We’re ready for the experiments, Dr. Treadway,” says Kit with a
giggle and a shy smile at Jack.
They’re sitting on the sofa, holding hands. Last session, we
reviewed their sexual history and considered whether there were
any medical, psychopharmacological, or trauma-based reasons for
their pattern of sexual avoidance. They had had garden-variety
difficulties: too little time, too high expectations, kids underfoot,
too much fighting, and so on. We agreed that instead of dealing
with their past and their history of hurts and disappointments
about their sexual life, they would try different approaches. They
were ready to risk a few trial-and-error experiments, but I cau-
tioned them first.
176   TREATING SEXUAL DESIRE DISORDERS

“Just as in the beginning, when you two negotiated and designed

your own therapeutic approach, it will be very important for you to
explore together what might be the best way to start working on your
sexual intimacy. The main thing you have to accept, though, is that
whatever we choose it will involve work, scheduling, organizing. And
learning to be comfortable with ambivalent, resistant, anxious, dis-
couraged, and even angry feelings. Most people yearn for easy spon-
taneity and mutual desire and responsiveness. They just want to flow
together the way Fred Astaire and Ginger Rogers danced. They want
sex to be relaxed, romantic, even playful. So it’s hard to accept how
hard you actually have to work at it.
“Let me give you a menu of possibilities for getting started.
Would that be okay?”
They nod, with slightly anxious smiles.

“Here are four choices and either of you may have your own pro-
posals as to how to begin. The first is simply talking and each of
you sharing your own unfolding story as a young child, sharing
your private experiences about sexuality and gender as you devel-
oped. You might talk about your first awareness of being a boy
or a girl, how affection and sexuality were expressed between
your parents, your earliest sexual feelings, imagery, touch, expe-
rience of puberty, first crush, first kiss, and so forth. Exploring all
the tender, shy vulnerability that is still deep within each of you.
I have a questionnaire that you can use at home or we could even
do it here, if you prefer.”

I could tell that Kit liked this idea but I kept going.

“Second, since you did so well with the giving and receiving
exercise, you could set aside a time each week when one of you
would give and receive sexual pleasuring; or, if you’re not ready
for receiving that, simply giving and receiving sensual massage. It
will help you guide each other. Ironically, both men and women
often have difficulty receiving pleasure without reciprocity, so it’s
a huge step forward as part of your sexual repertoires to simply
learn to take turns.
“Third, very few couples are comfortable really being seduc-
tive with each other, nor do they know how to turn their partner
down lovingly and affirmingly when they aren’t feeling respon-
sive. Some of the couples in my practice learn to lighten up by
 Dancing to Their Own Music   177

role playing. One night one member of the couple has the chal-
lenge of being seductive, while knowing that their partner has
the challenge of declining the seduction in a loving, appreciative
way.
“Finally, some couples benefit from deciding that intercourse
and orgasm are off limits. They just practice the adolescent joys
of making out with clothes on, but not in the bedroom. Experi-
menting with being sexual in a different place—the kitchen, the
car, or even between floors in an elevator. This allows for playful
flirtation without performance pressure. Actually, my wife and I
tried this out in the high school parking lot once after going to a
movie. Believe it or not, we got busted! A cop banged on the car
window and flashed his flashlight on us. He was young enough
to be our son. There we were, me with my bald pate and my wife
with her silver hair. He turned red.”

Kit and Jack chuckled. I often throw something in the mix

about the vagaries and comedy of my own sexual history as a
way of defusing the tension and creating a little humor around
the issue.
“So that’s a lot to start with and you may have entirely different
ways to engage each other. What do you think?”
Naturally, Kit and Jack chose differently. She liked the idea
of talking about their childhood experiences and he was respon-
sive to taking turns giving pleasure. It didn’t matter that they dis-
agreed. They could negotiate and experiment. They could even
flip a coin.
My job was to create a safe, nurturing environment when they
could open to each other. Now it was their time to write their own
love song, dance to their own music.

Conclusion

Over the ensuing five sessions, Kit and Jack tried a variety of experi-
ments and exercises with some pleasant surprises and some duds.
We had a very sweet session about their childhood sexuality, and
the power of Jack’s responsiveness to female domination seemed
directly linked to his highly critical and dominating mother, who he
both rebelled against and desperately wanted to please. Jack was very
open and vulnerable and Kit was able to be empathic and compas-
178   TREATING SEXUAL DESIRE DISORDERS

sionate about how these painful issues could be expressed through

sexual desires, but she still didn’t want him to turn away from her
and toward the Internet. Jack readily agreed to this but I worried
aloud whether he would be able to stick to it or just go underground
again. The taking turns strategy actually increased their frequency of
sexual engagement, which did help Jack feel less bad about his sexual
drive and Kit feel less pressure to “be in the mood” every time. They
also tried the seduction/rejection game and found it too silly and con-
trived. But mostly what happened was that they learned to talk with
each other, nurture each other, and accept the inevitable compromises
in their sexual relationship with grace and tenderness. Jack and Kit
found their own rhythm as they rediscovered each other, the man and
woman they had become, and learned to truly make love with each
other.

Commentary

In telling their story, I’ve tried to show the core of what I do to help
couples work with their struggles around sexual incompatibility, lack
of desire, and intimacy. Of course, not all stories work out so well.
Each couple has to find their own gentle balance between resignation
and acceptance, daring to try changing, yet embracing each other as
they are.
Clearly therapists, myself included, have to consider many ele-
ments in working with couples who have low sexual desire. Age, bio-
logical and medical factors, gender differences, relationship issues,
and trauma history may all be significant variables.
There were several key ingredients in my work with Kit and Jack;
most of these are obvious and much practiced by many of my col-
leagues who work with these difficult issues.

1. Building a safe and nurturing therapeutic environment.

2. Helping the couple design their own therapeutic protocol of
either going forward or dealing with past, even the family of
origin, while tolerating the limitations of unresolved and dif-
ficult issues that are deferred by their choice.
3. Normalizing their difficulties and helping them feel less bad
about themselves as a couple.
4. Helping them learn how to communicate difficult feelings to
each other and how to give and receive nurturance well.
 Dancing to Their Own Music   179

5. Helping them accept the necessity of prioritizing and schedul-

ing to make time for each other.
6. Teaching them how to be emotionally open with each other,
including discussing their hurt/anger/mistrust, while also
enjoying relaxed sensuality and touch.
7. Helping them reduce their performance anxiety and expecta-
tions. I encourage couples to accept a modicum of mediocre,
ho-hum sexuality instead of always expecting fireworks. This
increases the chance that the “magic” will happen some of the
time.
8. Encouraging them to choose their own therapeutic homework
and creative experiments.

The heart of the work with all couples lies in helping them
become more comfortable with their discomforts and differences and
able to share their feelings without shame or shoulds, and hear each
other’s feelings without taking them too personally. Both members
of every couple need to learn how to be carefully true to themselves
while in the presence of the other, to apologize and forgive, and to
accept the flaws of each other’s shared humanity—and, finally, to
adopt the Serenity Prayer (accepting the things they cannot change
and having the courage to change the things they can) as a way of
life.
Then they can learn a new dance.

Bibliography

Bischoff, R. J., McKeel, A. J., Moon, S. M., & Sprenkle, D. H. (1996). Ther-
apist-conducted consultation: Using clients as consultants to their own
therapy. Journal of Marital and Family Therapy, 22(3), 359–379
Gottman, J. M. (1999). The marriage clinic: A scientifically-based marital
therapy. New York: Norton.
Gurman, A. S., & Jacobson, N. S. (2002). Clinical handbook of couples
therapy (3rd ed.). New York: Guilford Press.
Leiblum, S. R., & Rosen, R. C. (Eds.). (2000). Principles and practice of sex
therapy. New York: Guilford Press.
McCarthy, B. (2004). Rekindling desire: A step-by-step program to help low-
sex and no-sex marriages. New York: Brunner-Routledge.
Mellody, P., & Freundlich, L. S. (2003). The intimacy factor: The ground
rules for overcoming the obstacles to truth, respect, and lasting love, San
Francisco: HarperCollins.
180   TREATING SEXUAL DESIRE DISORDERS

Perel, E. (2006). Mating in captivity: Unblocking erotic intelligence. New

York: HarperCollins.
Schnarch, D. (1997). Passionate marriage: Sex, love and intimacy in emo-
tionally committed relationships. New York: Norton.
Stuart, R. B. (2003). Helping couples change: A social learning approach to
marital therapy. New York: Guilford Press.
Treadway, D. (1994, March/April). In a world of their own. Family Therapy
Networker, 32–39.
 Chapter 11

Treatment of Low Sexual

Desire in the Context of
Comorbid Individual and
Relationship Dysfunction
Douglas K. Snyder

In this chapter, Douglas K. Snyder highlights the relationship dynamics

that so critically contribute to, and often exacerbate, sexual desire com-
plaints. While acknowledging the value of psychological exploration of each
partner’s psychodynamic and developmental issues that may be thwarting
sexual desire, Snyder suggests a more flexible approach—one in which a
collaborative alliance between the partners is first achieved and the major
couple conflicts are addressed before dealing with the sexual difficulties.
He recommends a “pluralistic affective reconstructive approach”, wherein
each partner becomes more aware of, and empathic to the other’s emotional
needs and struggles, so that better communication and greater receptivity—
both emotional and sexual—can be achieved.
Through the use of sample dialogue, Snyder illustrates how gently
challenging and encouraging couples to reconsider how they speak to,
and think about, each other paves the way for more effective communica-
tion and empathic responding. While an improvement in marital harmony
and appreciation is achieved, the change in sexual desire is less dramatic.
And, in truth, this is usually the outcome in most cases involving a sexual
desire discrepancy—actual increases in sexual frequency are often modest
despite greatly enhanced couple satisfaction.

181
182   TREATING SEXUAL DESIRE DISORDERS

Douglas K. Snyder, PhD, is Professor and Director of Clinical Training

in the Department of Psychology at Texas A&M University in College Sta-
tion, Texas. In addition to being a preeminent couple therapist, he (along
with his two colleagues, Donald Baucom and Kristina Gordon) is the author
of a popular book on dealing with the aftermath of an affair entitled Getting
Past the Affair: A Program to Help You Cope, Heal, and Move On—Together
or Apart.

Both clinical case illustrations and empirical literature document

the multifaceted structure of low sexual desire, both in terms of sub-
jective phenomenology and underlying etiologies. From a phenom-
enological perspective—in addition to prevalent or generalized lack
of subjective feelings of desire—individuals may report low levels of
sexual responsiveness in the presence of appropriate stimulation or
approaches by an intimate partner, limited mental imagery related to
sexual interactions, infrequent or negative sexual thoughts, or absence
of sexual drive or energy not consistent with vigor in other individual
or interpersonal domains. Etiologically, the literature cites similarly
diverse and sometimes interacting causes potentially contributing to
low sexual desire—including biological, psychological, interpersonal,
and broader systemic factors.
This chapter describes a framework for conceptualizing low
sexual desire and organizing therapeutic interventions from diverse
theoretical perspectives with couples distinguished by comorbid
individual and relationship dysfunction. In this context, “individual
dysfunction” refers to significant emotional or behavioral disorders
extending beyond low sexual desire to include substantial affective
or cognitive dysfunction and/or personality disturbance as defined
by diagnostic criteria enumerated in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR; American Psychiatric
Association, 2000). Similarly, “relationship dysfunction” refers to
relational difficulties extending beyond partners’ discrepant levels of
sexual desire to include high levels of conflict, low levels of emotional
or physical intimacy outside the sexual domain, inadequate commu-
nication skills involving either decision making or emotional expres-
siveness, or notable deficits in other domains related to developing
and maintaining interpersonal closeness. Adopting this emphasis does
not presume that cases of low sexual desire necessarily or even pre-
dominantly include significant individual or relationship dysfunction.
Rather, this chapter’s focus evolves from the author’s specialty clini-
 Low Sexual Desire and Comorbid Dysfunction   183

cal practice emphasizing almost exclusively couple-based interven-

tions with complex cases in which typically one or both partners have
already been diagnosed with individual psychopathology comorbid
with presenting problems of significant couple distress.

Empirical and Theoretical Rationale

Findings Regarding Comorbidity
The conceptual framework advocated here derives in part from the
broader empirical literature documenting that relationship difficulties
often co-occur with significant emotional, behavioral, and physical
health problems in one or both partners (see Snyder & Whisman,
2003, for detailed descriptions of couple-based interventions for cases
of coexisting mental and relationship disorders). For example, in com-
parison to nondistressed individuals, maritally distressed individuals
are three times more likely to have a mood disorder, 2.5 times more
likely to have an anxiety disorder, and two times more likely to have
a substance use disorder (Whisman, 2006). Moreover, findings indi-
cate that the presence of mental health problems is associated with
greater marital distress, above and beyond general distress in other
close relationships. Evidence also indicates that both physical health
and adjustment to physical health problems are positively associated
with relationship quality. For example, in a study on psychological
adjustment of adults with cancer, Rodrigue and Park (1996) found
that people with high relationship distress reported more depression
and anxiety, a less positive health care orientation, and more illness-
induced family difficulties. The preponderance of empirical evidence
indicates that relationship functioning, particularly negative com-
munication, has direct effects on cardiovascular, endocrine, immune,
neurosensory, and other physiological systems that, in turn, affect
health (Kiecolt-Glaser & Newton, 2001). Hence, to the extent that
sexual desire is susceptible to adverse influences of mood disorders,
substance use, and general health, one could anticipate sexual dif-
ficulties generally, and low sexual desire specifically, to be linked to
generalized relationship distress.
Indeed, more than 30 years of research has demonstrated dispro-
portionately higher incidence of difficulties in couples’ sexual relation-
ships in the presence of more generalized couple distress. For example,
in a mixed group of 2,140 individuals from combined representative
community and clinical samples, Snyder and Whisman (2004) deter-
184   TREATING SEXUAL DESIRE DISORDERS

mined that individuals reporting moderate or high global relationship

distress on a multidimensional measure of relationship functioning
(the Marital Satisfaction Inventory—Revised (MSI-R; Snyder, 1997)
were 6.2 times more likely to report moderate or extensive dissatis-
faction with their sexual relationship than individuals reporting only
low levels of general couple distress. On the basis of findings from
this same measure, Berg and Snyder (1981) outlined two situations
in which the clinician would be prudent to defer brief directive sex
therapy in favor of more extensive marital therapy: (1) when levels of
global couple distress exceed moderate proportions, or (2) when one
or both partners report primary distress around nonsexual aspects of
their relationship such as communication or emotional intimacy.

An Informed Pluralistic Approach to Couple Therapy

Couple therapists confront a tremendous diversity of presenting
issues, marital and family structures, individual dynamics and psy-
chopathology, and psychosocial stressors characterizing couples in
distress. Because the functional sources of couples’ distress vary so
dramatically, the critical mediators or mechanisms of change should
also be expected to vary—as should the therapeutic strategies intended
to facilitate positive change. Couples with comorbid individual and
relationship dysfunctions will benefit most from a treatment strategy
drawing from both conceptual and technical innovations from diverse
theoretical models relevant to different components of a couple’s
struggles. Snyder (1999) advocated a pluralistic approach to couple
therapy conceptualizing therapeutic tasks as progressing sequentially
along a hierarchy comprising six levels of intervention, from the most
fundamental interventions promoting a collaborative alliance to more
challenging interventions addressing developmental sources of rela-
tionship distress. Because couple therapy often proceeds in nonlin-
ear fashion, the model depicts flexibility in returning to earlier thera-
peutic tasks as dictated by individual or relationship difficulties (see
Figure 11.1). Pluralism recognizes the validity of multiple systems of
epistemology, theory, and practice and draws on these as intact units
in an integrative manner by adhering to an explicit and orderly model
of treatment selection.
As depicted in Figure 11.1, the most fundamental step in couple
therapy involves developing a collaborative alliance between partners
and between each partner and the therapist by establishing an atmo-
sphere of therapist competence as well as therapeutic safety around
 Low Sexual Desire and Comorbid Dysfunction   185

FIGURE 11.1. A sequential, pluralistic approach to couple therapy. The model

depicts progression from (1) lower-order interventions aimed at establishing a
collaborative alliance and crisis containment, through (2) positive-exchange and
skills-building techniques, to (3) higher-order interventions targeting cognitive
and developmental sources of relationship distress. Couple therapy may include
recycling through earlier stages as required by emergent crises or erosion of indi-
vidual or relationship skills.

issues of confidentiality and verbal or physical aggression. Subsequent

interventions may need to target disabling relationship crises such as
substance use, psychopathology, illness or death of a family member,
infidelity, or similar concerns that—until resolved—preclude devel-
opment of new relationship skills and progress toward emotional
intimacy. Because some couples initially present with overwhelm-
ing negativity, the therapist may need to instigate behavior change
directly before assisting the couple to develop behavior-exchange and
communication skills of their own. Along with promoting general
relationship skills, the couple therapist may need to assist partners in
acquiring a prerequisite knowledge base and competence in specific
domains such as parenting, finances, or time management.
A common impediment to behavior change involves misconcep-
tions and other interpretive errors that individuals may have regarding
186   TREATING SEXUAL DESIRE DISORDERS

both their own and their partner’s behavior; such cognitive influences
are particularly relevant to persons’ views of their own and their part-
ner’s sexuality. Interventions targeting partners’ relationship beliefs,
expectancies, and attributions aim to eliminate or restructure cogni-
tive processes interfering with behavior change efforts. However, not
all psychological processes relevant to couples’ interactions—sexual
or otherwise—lend themselves to traditional cognitive interventions.
Of particular importance are partners’ developmental relationship
experiences resulting in enduring interpersonal vulnerabilities and
related defensive strategies interfering with emotional or sexual inti-
macy, many of which operate beyond partners’ conscious awareness.
Hence, when couple distress persists despite system-restructuring,
skills-building, and cognitive interventions, then interpretation of
maladaptive relationship patterns evolving from developmental pro-
cesses comprises an essential treatment component (Snyder & Mitch-
ell, 2008).
With respect to the treatment of low sexual desire, this pluralistic
approach presumes that couples will vary in the extent to which they
require interventions at any level of the treatment hierarchy but also
presumes that higher-order interventions (e.g., cognitive or insight-
oriented techniques targeting intrapersonal processes) would ordinar-
ily not be implemented unless lower-order interventions (e.g., crisis
intervention, relationship strengthening, or skills-building techniques
targeting interpersonal processes) had already proven insufficient.
The following case illustrates implementation of this pluralistic
approach in treating low sexual desire in a woman with comorbid
dysthymia and a prior history of vaginismus, compounded by signifi-
cant marital difficulties and enduring emotional issues in both part-
ners rooted in early developmental experiences.

Case Example: Don and Carol

Presenting Problems
Don and Carol were referred for couple therapy by Carol’s primary
physician. The couple presented with extensive difficulties in their
sexual relationship stemming primarily from Carol’s lack of inter-
est in sexual relations. Don preferred intercourse at least once or
twice weekly, whereas Carol was content with sexual relations once
a month or less. With the exception of their sexual relationship, both
partners described their marriage as “a good friendship,” although
 Low Sexual Desire and Comorbid Dysfunction   187

Carol was somewhat more willing than Don to acknowledge perva-

sive difficulties in their communication patterns. Among other con-
cerns, she referred to Don’s emotional aloofness—a trait that at times
also characterized his approach to lovemaking.
The couple had been married 3.5 years and had not been sexu-
ally intimate prior to marriage. Carol stated that during latter stages
of their courtship, they had become more physically intimate but
stopped short of intercourse. Don had viewed these exchanges posi-
tively, but Carol disclosed that she had felt emotionally distressed
and guilty at the same time she had felt physically aroused. Their
first attempt at intercourse after marriage had been painful, which
Carol attributed to their both having been sexually inexperienced.
Sexual relations continued to be difficult and painful for Carol for
months after their marriage. Carol was diagnosed with vaginismus
and had been given a set of dilators to use, but stated that she had
little motivation to use these, as reflected in her consistent “forget-
ting” to proceed through the dilation exercises. Only when the urge
to have children impelled her to address this problem directly did
Carol initiate and maintain vaginal dilation exercises and eventually
overcome this difficulty.
Following the birth of their daughter 2 years into their marriage,
Carol developed significant and enduring clinical depression. Her dys-
thymia was initially attributed to postpartum depression and treated
with sertraline hydrochloride; although Carol’s low sexual desire pre-
dated her dysthymia and initial antidepressant medications, pharma-
cotherapy was altered to bupropion to minimize adverse libidinal side
effects. Although Carol’s depression lifted somewhat, her low sexual
desire persisted. Her physician suggested to Carol that she and Don
would likely benefit from couple therapy targeting significant marital
difficulties that Carol had disclosed. Don acknowledged ambivalence
about this assessment, and suggested that Carol’s sexual difficulties
may relate more directly to her upbringing, which included strong
negative attitudes toward sexuality.

Diagnostic Assessment
The clinical interview revealed that both partners had been reared
in highly conservative religious environments that espoused a hier-
archical structure for spousal roles and restrictive if not negative
views of sexuality. Carol was the oldest of eight children, had exten-
sive responsibilities in caring for her younger siblings as a teenager,
188   TREATING SEXUAL DESIRE DISORDERS

and had vowed not to replicate her mother’s role of submission to an

autocratic husband. Indeed, in Don she had chosen someone who was
gentle mannered but also somewhat passive and emotionally aloof.
Don was the second of six children and had an older sister who had
died in adolescence. He had learned to escape his mother’s depression
and his father’s frequent criticisms by retreating to his bedroom for
extended periods throughout his adolescence—a pattern of avoidance
he replicated in his marriage. Both partners had been in individual
therapy as undergraduates—Carol to address conflicts with her father,
in a process she found only modestly helpful, and Don for assistance
with his own depression.
Both Don and Carol were graduate teaching assistants in differ-
ent programs at a local university. Each felt overwhelmed by their
respective responsibilities, with Carol reporting inadequate time for
her studies because of child-care responsibilities at home, and Don
alluding to academic requirements that at times seemed beyond his
ability. They each cited little leisure time together at home as a con-
cern. Don attributed this to Carol’s lack of enthusiasm for computer
games he enjoyed, whereas Carol ascribed their lack of interaction to
Don’s persistent retreat into solitary pursuits.
Both partners completed the MSI-R (Snyder, 1997), a multidi-
mensional measure of relationship functioning composed of 150
true–false items, with strong psychometric underpinnings and empir-
ical relation to treatment outcome (Snyder et al., 2004). The MSI-R
includes two validity scales, a measure of global relationship dis-
tress, and 10 additional scales assessing satisfaction with the couple’s
sexual relationship, affective and problem-solving communication,
aggression, leisure time together, finances, and interactions regarding
children—in addition to measures of role attitudes and family-of-
origin distress. Sample items assessing global distress include “Our
relationship has been disappointing in several ways” and “At times I
have very much wanted to leave my partner.” Sample items assessing
satisfaction with the sexual relationship include “My partner some-
times shows too little enthusiasm for sex” and “My partner has too
little regard sometimes for my sexual satisfaction.” Partners’ raw
scores on each scale, reflecting the number of items answered in the
scored (distressed) direction, are converted to normalized T-scores
with a mean of 50 and standard deviation of 10. In most domains
(including Global Distress and Sexual Dissatisfaction), scores of
50–60T suggest moderate levels of distress, whereas scores ≥ 61T
reflect more extensive distress in that domain.
 Low Sexual Desire and Comorbid Dysfunction   189

In many respects Carol and Don described their marriage in

similar terms on the MSI-R, citing extensive difficulties in their sex-
ual relationship as their primary concern, but also citing moderate
concerns with shared leisure time together and overall relationship
distress (see Figure 11.2). In comparison to Don, Carol reported
more deficits in their communication—particularly involving emo-
tional expressiveness and understanding—as well as more extensive
conflicts regarding her family of origin. Interpretive feedback to the
couple regarding their MSI-R profiles affirmed their primary con-
cerns about their sexual relationship but also afforded the therapist
opportunity to cite communication difficulties and deficits in both
emotional and behavioral intimacy as potential contributing causes
to Carol’s low sexual desire—feedback aimed at encouraging Don
to reframe Carol’s sexual responsiveness within a broader systemic
perspective.

FIGURE 11.2. MSI-R profiles for Don and Carol at initial assessment.
190   TREATING SEXUAL DESIRE DISORDERS

Treatment Course
Treatment of Carol and Don progressed through six levels of interven-
tion, consistent with the hierarchical pluralistic approach described
earlier. Exemplars of interventions at each level are provided in Table
11.1, and they are described in greater detail below.

Initial Interventions
After offering a clinical formulation to the couple emphasizing likely
contributions to Carol’s low sexual desire from multiple sources
including biological, psychological, relational, and broader sys-

TABLE 11.1. Interventions with Don and Carol Using a Hierarchical

Pluralistic Approach
Level 6—Examine developmental sources of relationship distress.
• Explore and resolve Don’s enduring fears of inadequacy contributing to avoid-
ance behaviors.
• Explore and resolve Carol’s enduring conflicts around femininity (extending
beyond sexuality) contributing to ineffective patterns of engaging and respond-
ing to Don.

Level 5—Challenge cognitive components of relationship distress.

• Challenge Don’s cognitive distortions and overgeneralization of Carol’s com-
plaints.
• Challenge Carol’s negative views of sexuality and promote expanded acceptance
and expression of sexual feelings.

Level 4—Promote relevant relationship skills.

• Challenge couple’s demand → withdraw pattern and promote improved
decision-making skills.
• Promote Don’s emotional expressiveness skills.

Level 3—Strengthen the couple dyad.

• Modify couple’s interactions around sexual requests contributing to verbal
aggression.
• Challenge Don’s avoidance patterns and promote more active role as a husband
and father.

Level 2—Contain disabling crises.

• Address individual and relationship factors contributing to Carol’s depression.

Level 1—Establish a collaborative alliance.

• Frame couple’s complaint of low sexual desire from a systemic perspective with
multiple contributing factors.
• Conduct relevant clinical assessment and develop a shared formulation.
 Low Sexual Desire and Comorbid Dysfunction   191

temic considerations, initial interventions targeted those factors most

directly related to Carol’s overall levels of energy. While allowing that
Don was not responsible for Carol’s low sexual desire, he was encour-
aged to be responsive to her low desire by intervening where possible
in processes that might be contributing to her generalized fatigue.
Specifically, the therapist encouraged Don to consider a more egalitar-
ian approach to spousal roles and to assist with housework and par-
enting responsibilities he had previously ascribed primarily to Carol.
He was only modestly equipped for these, given the absence of such
male role models in his family of origin but was moderately recep-
tive toward specific directives offered by his male therapist, whom
he generally trusted as advocating a healthier sexual relationship. In
turn, Carol benefitted from explicit directives from the therapist to
relax the stringent criteria she held regarding housework and parent-
ing—not only on Don’s behalf, but on her own as well. With Don’s
support, she undertook modest self-care initiatives to attend more
faithfully to her need for sleep, exercise, and occasional interactions
with women friends.
The couple described a classic pattern of avoiding sexual
approaches or discussion of their sexual relationship. Don feared
Carol’s rejection of his sexual overtures and tended to brood privately
about their low rate of sexual exchanges. He stayed up late at night
after Carol had gone to bed to avoid the impulse to approach her
sexually, but then slept late during the morning, which in turn exacer-
bated Carol’s resentment about his lack of assistance with child care.
Their sexual repertoire was also highly constricted in terms of both
content and timing of sexual exchanges. With encouragement, Don
became more willing to approach Carol sexually and to tolerate occa-
sional rejection of his overtures. Carol learned to communicate more
clearly when she did not want sexual exchanges, without an aggres-
sive style she had previously used as a means to cover her feelings
of guilt or embarrassment. She also became receptive to suggesting
sexual relations at times during the day when she had higher energy,
and to tolerate doing so even when housework remained undone.
Don was receptive to information about gender differences in arousal
patterns and became somewhat more effective in promoting a sexu-
ally conducive atmosphere and stimulating Carol before attempting
intercourse. Concurrent with his progress in this regard, Carol found
it easier to become sexually aroused, although she remained resistant
to exploring different ways of satisfying Don sexually. However, over
several weeks, resentments about their discrepant desires for sexual
192   TREATING SEXUAL DESIRE DISORDERS

intercourse diminished, and their frequency of sexual exchanges

showed a modest increase.

Intermediate Interventions
Initial directives aimed specifically at altering structural elements of
the couple’s relationship to promote sharing of household responsi-
bilities, reduce Carol’s generalized fatigue, and increase the range of
potential sexual exchanges produced noticeable but limited improve-
ments in the couple’s sexual relationship. Constraining further gains
were more enduring relationship difficulties in promoting intimacy
and negotiating change around allocation of household tasks. Carol
and Don demonstrated a prototypical demand → withdraw pattern of
communication in which Don’s passive retreat and Carol’s entreaties
for assistance progressively escalated. Similar to Don’s style for deal-
ing with their sexual relationship, Carol brooded about Don’s passiv-
ity until her levels of frustration mounted and her requests assumed
an intense and frequently critical tone. Therapeutic interventions
emphasized her adopting an assertive but more regulated approach
to seeking Don’s engagement. Don benefitted from interventions that
helped him not to generalize Carol’s complaints as indictments of his
character or indications of his inadequacy—particularly once Carol
learned to link her requests for assistance to the subsequent potential
for more shared leisure time together, which sometimes culminated in
sexual intimacy. Don struggled with a limited view of emotional or
behavioral intimacy. He had difficulty labeling or describing his own
feelings and even greater limitations in recognizing or responding to
Carol’s. Retreat was his preferred response, and this behavioral ten-
dency needed to be addressed in therapy directly.

Therapist: So what’s it like when Carol lets you know she’s frustrated
with you?
Don: I don’t like it.
Therapist: And then what?
Don: I just tune her out.
Therapist: And how does that work?
Don: (after a pause) Not too well, I guess. I mean, I guess it helps me
not to think about what she’s saying. But she just gets madder
and madder with me—and soon we’re either yelling at each other
or I just leave.
 Low Sexual Desire and Comorbid Dysfunction   193

Therapist: Would you be willing to tolerate her being frustrated with

you?
Don: I don’t like it.
Therapist: No, but would you be willing to tolerate it? What do you
think would eventually happen?
Don: Well, I guess I could survive it, if that’s what you mean—but I
think I’d end up feeling worse about myself.
Therapist: Could you share that with Carol? Could you say some-
thing like, “Look—when you start telling me how I’m never help-
ful and not a responsible husband or father, I end up feeling even
worse and want to pull back even further”?
Don: How would that help?
Therapist: Well, then you could offer her an alternative—something
like “It would help if you could just let me know what you need
in this moment, and then maybe suggest a time window for get-
ting it done instead of my feeling like you’re ordering me about
like a little boy.”
Don: I don’t know how she’d like that.
Therapist: Try checking it out with Carol.
Don: Okay—so, Carol, how would you like that?
Carol: Well, if it were said respectfully, I could handle that. I don’t
mean to order you about, Don. I just get frustrated and feel aban-
doned by you—and then I take it out on you sometimes by the
things I say. I can try to do better at that if you’ll just talk with
me instead of going into your shell.

Final Interventions
Gradually the couple’s overall relationship improved, and their
frequency of sexual interactions increased. At the same time, the
partners’ levels of sexual desire remained discrepant and, compared
to modal couples in their age group and circumstances, their fre-
quency of sexual exchanges was relatively low. Once Carol experi-
enced Don’s willingness to examine his own contributions to their
marriage and she no longer anticipated that he held her singularly
responsible for the quality of their sexual relationship, she became
more willing to examine in therapy her enduring conflicts around her
own sexuality. Although Carol could have explored such conflicts in
individual therapy, there were distinct advantages to her doing so
194   TREATING SEXUAL DESIRE DISORDERS

within conjoint therapy involving Don’s participation. Specifically,

as participant-observers in their partner’s work on developmental
issues, individuals frequently come to understand their partner’s
behaviors in a more accepting or benign manner—attributing dam-
aging exchanges to the culmination of acquired interpersonal dispo-
sitions rather than to explicit motives to be hurtful. This new under-
standing often facilitates in-session exchanges challenging existing
relationship schemas, reducing defensive behaviors, and promoting
empathic and mutually supportive interactions (Snyder, 1999; Sny-
der & Mitchell, 2008).
In this case, Carol began to disclose deeply conflicted feelings
about her sexuality once Don stopped blaming her for all the dif-
ficulties in their sexual relationship. As she expressed these conflicts
in a more openly painful manner, he relinquished his own defensive-
ness and offered her considerable understanding. More important, his
empathic response to Carol’s conflicted sexuality extended outside of
the treatment sessions to include more supportive responses at home.
That is, Don became better able to temper his frustrations over their
low sexual activity with softened expressions of disappointment inte-
grated with statements of understanding. Over time this led to cycles
of sexual avoidance that were less frequent, shorter in duration, and
characterized by considerably less intense exchanges of negative feel-
ings. Therapeutic interventions characteristic of exploring develop-
mental components of low sexual desire are exemplified in the fol-
lowing exchange.

Carol: I recognized this past week that I was still pulling away from
Don when he approached me sexually, even when other parts of
our marriage had been going better.
Therapist: And what additional thoughts or feelings did you have
about that?
Carol: I don’t know—confusion, maybe. Sadness.
Therapist: Sadness?
Carol: Yeah, because that’s really not how I want it to be for us. I
mean, I think my parents’ marriage was pretty empty emotion-
ally, and I wanted more for Don and me.
Therapist: More emotional connection.
Carol: Yes.
Therapist: More passion?
 Low Sexual Desire and Comorbid Dysfunction   195

Carol: Well, yes—I guess. I mean, when I was growing up and read-
ing those cheap romance novels, I actually thought that would be
pretty neat.
Therapist: And now?
Carol: (smiling) I still think it would be neat.
Therapist: So what gets in the way?
Carol: (after a long pause) I don’t know. I mean, I wanted so much
not to be like my mother.
Therapist: In what ways?
Carol: You know—submissive, unemotional, inert.
Therapist: And in what ways do you think you may have wanted to
be like your mom?
Carol: What do you mean?
Therapist: Well, she wasn’t all bad, was she? What did you admire
about her? What pieces of her might you have wanted to take
inside of you for yourself?
Carol: (another pause) I admired her commitment—to her marriage,
and to the church. I didn’t always agree with the substance of
those commitments, but I admired that she followed through
with what she believed in.
Therapist: You admired her perseverance and also her fidelity.
Carol: Yes, I did.
Therapist: What about her spontaneity, or her emotional expressive-
ness?
Carol: Well, those didn’t exactly go with the other, right? I mean, to
be committed and spontaneous seems contradictory.
Therapist: I’m wondering if that belief leads to the contradiction you
feel internally.
Carol: What do you mean?
Therapist: Well, I’m struck by your admiration of your mom’s com-
mitment. But you clearly didn’t admire her submissiveness or the
emotional vacuum of your parents’ marriage. You’ve talked before
about your lingering resentments about your father’s bullying her
and later his domineering style with you. But it also seems that
his intensity, in his better moments, had an inner strength and a
kind of passion about life—even if that was expressed primarily
in his work and less about his family. Overtly, you identify more
196   TREATING SEXUAL DESIRE DISORDERS

closely with your mom mostly in terms of her values—but on

another level there are important parts of her you reject.
Carol: Yes . . .
Therapist: And overtly you reject identifying with your father, even
though in terms of your own emotional reactivity you’re prob-
ably not entirely unlike him.
Carol: And that bothers me.
Therapist: I’m wondering if you could find ways of taking the health-
ier parts of each of them and putting them together in ways that
work better for you.
Carol: How?
Therapist: Well, how do you think that might look in terms of your
sexual relationship?
Carol: I don’t know.
Therapist: (after waiting) Give it a shot.
Carol: (after a long pause) Well, I guess sometimes it would mean
responding to Don’s wishes to have sex without my viewing it as
my being submissive.
Therapist: Giving, rather than giving in . . .
Carol: Exactly . . . (another pause) . . . and I guess I could resist trig-
gering my automatic “off” switch whenever thinking about sex,
and leave it on.
Don: (interrupting) Or at least in “neutral” mode.
Therapist: (to Carol) That’s harder for you.
Carol: It is so hard for me. We were so ingrained to view sex as
wrong—especially before marriage—but it never became okay or
wonderful for me in its own right, even after marrying Don.
Therapist: Still linked to having babies . . .
Carol: Yep, and I had plenty of that caring for my younger sibs long
before I wanted to.
Therapist: Part of you struggles with those feelings. The rational
or conscious self doesn’t always go hand in hand with the old
thoughts or unconscious self.
Carol: No. It’s getting better. I can sometimes recognize the struggle
and talk myself through it. But not always.
Therapist: Are there ways you could help Don understand what you’re
experiencing in those moments?
 Low Sexual Desire and Comorbid Dysfunction   197

Don: Sometimes I can see it, Carol. I understand it better now, and
when I see you sometimes struggling when I approach you sexu-
ally, sometimes I can back off better without feeling hurt or get-
ting angry, and wait for you eventually to get to a better place.
But other times I just sense your irritation with me for wanting to
have sex with you and then I retreat or lash back.
Carol: What do you want from me, then?
Don: Well, it’s like we’ve talked about in here before. If you’re strug-
gling, try to let me know. Just say something like “It’s hard right
now,” rather than striking out or using your anger to push me
away. I think I could use that phrase as a cue or something—you
know—a signal that lets me ease up and give you some space
without lashing back.
Carol: I can try that. Sometimes I am irritated with you, Don, but
most of the time I’m not—certainly not as often as before—but I
can see I’ve been using the old ways of reacting to your overtures
even though our relationship has changed. I’ll try to recognize
what’s going on with me and do a better job of expressing that.

Outcome
The couple met with their therapist in conjoint sessions approximately
18 times over a 6-month period. Their levels of sexual desire never
converged at the same level, but the degree of discrepancy decreased
and the partners’ ability to manage it improved considerably. More-
over, improvements in the couple’s sexual relationship both con-
tributed to and were strengthened by gains in other areas of their
marriage—particularly in terms of communication and emotional
connectedness. Two years after their treatment, the therapist ran into
Don and Carol at the grocery store. By then they had a new baby in
tow as well as their young toddler. They disclosed that, following her
second pregnancy, Carol’s depression and disruption of sexual desire
had returned for several months. However, the couple had been able
to review steps they had taken previously to address challenges in
their marriage, and on their own had been able to restore the quality
of relationship they had enjoyed earlier.

Discussion
In many respects, the diverse contributing factors to Carol’s low
sexual desire reported at the outset of therapy are common among
198   TREATING SEXUAL DESIRE DISORDERS

couples presenting with this complaint. Similarly, the outcomes Don

and Carol achieved were somewhat typical. Differences in partners’
levels of sexual desire diminished but did not disappear. The couple
engaged in sexual relations about three to four times per month, and
both partners described the majority of these exchanges as satisfying.
Although Don still would have liked to have sex more often and Carol
would have been content to have it less frequently, each acknowledged
and made reasonable efforts to accommodate the other’s preferences.
The partners’ understanding of themselves and each other deepened,
although each at times reenacted old patterns of responding to inter-
nal conflicts and the other’s provocations. Communication patterns
and overall relationship quality improved, although the marriage
remained imperfect and the couple’s sexual relationship would always
require effort to maintain a steady flow of satisfactory exchanges. It
was important to normalize this pattern for the couple and to support
their efforts to find sustainable if nonpreferred compromises for the
sake of their marriage.
The most important aspect of this case involves the sequenc-
ing of therapeutic interactions. It was clear from the initial assess-
ment that Don’s propensity for feeling inadequate and his impulse to
retreat, and Carol’s deeply conflicted feelings around her sexuality,
were rooted in early developmental experiences that would eventually
require explication and at least partial resolution. However, adopting
a developmental approach using insight-oriented or interpretive tech-
niques before establishing prerequisite levels of individual and rela-
tionship strength is more likely to produce iatrogenic problems than
positive effects. Couples presenting with complaints of low sexual
desire remain inappropriate candidates for interpretive strategies so
long as they exhibit persistent hostility, mistrust, inflexibility, or resis-
tance to change. Until an atmosphere of safety can be established that
extends beyond therapy sessions to the couple’s interactions outside
of therapy, each individual may be reluctant to disclose the intimate
and emotionally difficult material from previous relationships essen-
tial to the process of affective reconstruction of relationship themes.
Both partners should exhibit some capacity for introspection, be open
to examining feelings, and be able to resurrect affective experiences
from previous relationships on a conscious level. Each needs to have
established a basic level of trust with the therapist, experiencing the
exploration of cyclical maladaptive patterns as promoting the indi-
vidual’s own relationship fulfillment. Moreover, both individuals need
to exhibit levels of personal maturity and relationship commitment
 Low Sexual Desire and Comorbid Dysfunction   199

that enable them to respond to their partner’s intimate disclosures

with empathy and support.

Commentary

For many couples, low sexual desire exists within a broader context
of significant individual dysfunction in one or both partners and rela-
tionship dysfunction extending well beyond the sexual relationship.
The diverse structures characterizing both the phenomenology of
low sexual desire and contributing etiologies require the therapist to
be theoretically and technically competent across an equally diverse
range of therapeutic modalities. Effective treatment requires tailoring
the selection and sequencing of interventions to the unique strengths
and challenges of the individual partners, their relationship, and the
broader socioecological system in which their sexual relationship is
embedded. The pluralistic approach proposed here advocates exam-
ining developmental origins of partners’ respective contributions to
relationship struggles only after stabilizing initial individual or rela-
tional crises, directing healthier patterns of individual and couple
behaviors, and promoting relationship skills involving both com-
munication and support behaviors, which provide a foundation for
more interpretive techniques. Implementing an affective reconstruc-
tive approach within the context of conjoint therapy enables partners
to become more aware of and empathically responsive to each other’s
emotional sensitivities and struggles—including those underlying dis-
crepant levels of sexual desire.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual

of mental disorders (4th ed., text rev.). Washington, DC: Author.
Berg, P., & Snyder, D. K. (1981). Differential diagnosis of marital and sex-
ual distress: A multidimensional approach. Journal of Sex and Marital
Therapy, 7, 290–295.
Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and
hers. Psychological Bulletin, 127, 472–503.
Rodrigue, J. R., & Park, T. L. (1996). General and illness-specific adjustment
to cancer: Relationship to marital status and marital quality. Journal of
Psychosomatic Research, 40, 29–36.
Snyder, D. K. (1997). Marital Satisfaction Inventory—Revised (MSI-R). Los
Angeles: Western Psychological Services.
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Snyder, D. K. (1999). Affective reconstruction in the context of a pluralistic

approach to couple therapy. Clinical Psychology: Science and Practice,
6, 348–365.
Snyder, D. K., Cepeda-Benito, A., Abbott, B. V., Gleaves, D. H., Negy, C.,
Hahlweg, K., et al. (2004). Cross-cultural applications of the Marital
Satisfaction Inventory—Revised (MSI-R). In M. E. Maruish (Ed.), Use
of psychological testing for treatment planning and outcomes assess-
ment (3rd ed., pp. 603–623). Mahwah, NJ: Erlbaum.
Snyder, D. K., & Mitchell, A. E. (2008). Affective–reconstructive couple
therapy: A pluralistic, developmental approach. In A. S. Gurman (Ed.),
Clinical handbook of couple therapy (4th ed., pp. 353–382). New York:
Guilford Press.
Snyder, D. K., & Whisman, M. A. (2003). Treating difficult couples: Helping
clients with coexisting mental and relationship disorders. New York:
Guilford Press.
Snyder, D. K., & Whisman, M. A. (2004, November). Comorbid relationship
and individual distress: Challenges for intervention and research. In E.
Lawrence (Chair), Adapting the theme of comorbidity to the study of
intimate relationships. Symposium presented at the meeting of the Asso-
ciation for Behavioral and Cognitive Therapies, New Orleans, LA.
Whisman, M. A. (2006). Role of couples’ relationships in understanding and
treating mental disorders. In S. R. H. Beach, M. Z. Wamboldt, N. J.
Kaslow, R. E. Heyman, M. B. First, L. G. Underwood, et al. (Eds.),
Relational processes and DSM-V: Neuroscience, assessment, preven-
tion, and treatment (pp. 225–238). Washington, DC: American Psychi-
atric Association.
 Chapter 12

The Role of Androgens

in the Treatment of
Hypoactive Sexual
Desire Disorder in Women
Joanna B. Korda
Sue W. Goldstein
Irwin Goldstein

Most of the chapters in this book have focused on treating sexual desire
complaints in a psychological or relationship context. In this informative
chapter, Joann B. Korda, Sue W. Goldstein, and Irwin Goldstein describe
the role of androgens specifically testosterone, in the treatment of primary
hypoactive sexual desire disorder (HSDD) in a young woman about to be
married.
A thorough physical exam and vascular and hormonal evaluation of
the client reveals significant evidence of hormonal insufficiency, evidenced
by labial resorption and mild genital sensory neuropathy, as well as long-
standing sexual complaints. The authors speculate that the low androgen
levels have led to cerebral changes in the patient’s neurotransmitters,
resulting in diminished sexual desire as well as changes in the structure of
the genital organs—all of which have interfered with the ability to respond
physically to sexual stimulation.
The case described is a challenging one in that it involves the pri-
mary lack of sexual desire as well as concomitant difficulties with arousal,
orgasm, and sexual pain. The authors provide a persuasive discussion of

201
202   TREATING SEXUAL DESIRE DISORDERS

the importance of adequate hormonal function for sexual satisfaction and

function. With the use of systemic testosterone, local estradiol, and a sys-
temic dopamine agonist, as well as several sessions of more traditional sex
therapy, the client reported significant improvement in all areas of her sex-
ual life. While she remains anorgasmic at the conclusion of treatment, she
is pleased with the treatment outcome and expresses a desire to remain on
hormonal therapy.
This case illustrates the importance of undertaking a thorough medi-
cal and hormonal as well as psychological and interpersonal evaluation in
individuals experiencing lifelong as well as acquired sexual complaints.
Joanna B. Korda, MD, is a research scholar at San Diego State Uni-
versity and a clinical research fellow at San Diego Sexual Medicine.
Sue W. Goldstein, BA, is the program and clinical research coordina-
tor at San Diego Sexual Medicine.
Irwin Goldstein, MD, is the Director of Sexual Medicine at Alvarado
Hospital in San Diego. He is admired and respected for his tireless and
effective efforts to position sexual medicine as a major health discipline
as well as his success in launching and serving as editor-in-chief of The
Journal of Sexual Medicine.

The authors work in a multidisciplinary facility consisting of a

physician, a sex therapist, and support personnel. As a medical office,
we may have a patient population that differs from that of a psy-
chologist’s office. The most common complaint of women seeking
consultation at our clinic is secondary hypoactive sexual desire dis-
order (HSDD). Often, this is associated with the aftermath of child-
birth, menopause, and the use of oral contraceptives or antidepres-
sants. The preportion of men complaining of HSDD is significantly
lower, approximately 10%. Women often come to our clinic because
of their feelings of guilt about denying a partner sex or fears of losing
a partner because of the lack of sexual intimacy. They also present
because they are distressed over their inability to feel the desire they
once had.

What Is Sexual Desire?

Sexual desire, the mental state of fantasy about and interest in sexual
activity, is under the control of both the autonomic and somatic ner-
vous systems. Neurotransmitters such as dopamine, noradrenaline,
melanocortin, and oxytocin are important for sexual response and
 The Role of Androgens in Treatment   203

interest. They are excitatory and act on the limbic system and hypo-
thalamic regions. Sexual inhibition is mediated by other neurotrans-
mitters, namely, serotonin, cerebral opioids, and endocannabinoids
(Pfais. 2008; Giuliano, Rampin, & Allard, 2002; Clayton, 2007).
The sexual excitatory pathway is stimulated hormonally by steroid
hormones—estrogens, androgens, and progestins. Natural or medi-
cally or surgically induced hormone deficiency is often accompanied
by a loss of interest in sex and reduced responsiveness to sexual stim-
uli.
This chapter provides a brief overview of the biological basis of
HSDD secondary to androgen deficiency and illustrates how the addi-
tion of testosterone was helpful in the treatment of a young woman
presenting with both lack of desire and long-standing difficulties
experiencing subjective sexual arousal.

Case Example: Remi

Remi is a 25-year-old woman who was engaged to be married in 3

months. She complained of a lifelong history of absent sexual desire
and arousal. Her concerns about embarking on a marriage in this state
as well as the realization that she was not alone with this problem led
her to seek help. When first seen, she reported feeling sexually indif-
ferent, apathetic, pessimistic, and impatient with and disappointed in
her overall sexual life.

Past History
Remi grew up in a loving and caring atmosphere. Her parents, both
atheists, were teachers and provided a safe and loving family environ-
ment, as Remi stated when we first met her. Her earliest sexual mem-
ory was from the age of 13 when her first boyfriend, with whom she
thought she was in love, wanted to kiss her. She experienced sexual
thoughts and fantasies, but did not feel the desire or need to mastur-
bate, and therefore has never done so. At the age of 14 she began to
kiss boys and found she liked it, but she experienced little pleasure
from kissing. During the following years she engaged in sexual inti-
macy with boyfriends only because of “peer pressure.”
She had oral sex at age 16 and intercourse at age 17 with a
26-year-old married high school teacher. She said it was primarily a
sense of curiosity that drew her to have with sex with him, although it
204   TREATING SEXUAL DESIRE DISORDERS

was not totally consensual. She hoped to experience sexual excitement

and pleasure with a more sexually experienced partner, although this
did not happen for Remi. Over a period of 3 months, she had inter-
course several times before she ended the sexual relationship with
the teacher. The following two relationships prior to her engagement
failed because of her lack of sexual desire.
Remi has been with her current partner for 3 years and describes
him as loving, caring, and understanding. Her partner initiates sexual
activity about once a week. He is supportive and does not pressure
her. She wishes to feel sexual desire and also to feel more during sex-
ual activity. A brief course of sex therapy in the past failed to improve
her desire for sex. She does not report a history of depression, anxiety,
obsessive–compulsive disorder, or other mood disorders.

Medical History
Remi started menstruating at the age of 13. She used oral contracep-
tion for 4 years, followed by a contraceptive patch at the age of 18,
and noted decreasing lubrication during sexual activity with both.
Currently, she does not use hormonal contraception. Notable in her
history was the fact that Remi had fallen off horses several times in the
past, injuring her perineal area when she was kicked. She had sought
medical help in the past to overcome her sexual complaints. Previous
hormonal blood testing and an evaluation for pudendal nerve entrap-
ment showed no abnormal findings. She was seen by a sex therapist
to rule out any negative impact from her sexual relationship with
her high school teacher. She was made aware of the imbalance in
maturity and power in this relationship because of the age and status
differences between the two of them. After a few sessions with the sex
therapist, she did not experience any improvement in her sexual func-
tion, so she stopped going.
Remi’s diagnosis is primary female HSDD, primary orgasmic dis-
order, and secondary sexual pain disorder.

Diagnosis
To assess possible biological causes of sexual dysfunction, all female
patients in our sexual medicine facility undergo the same diagnostic
paradigm consisting of physical examination including vulvoscopy,
quantitative sensory testing using biothesiometry and hot and cold
temperature testing, duplex Doppler ultrasound, and blood tests.
 The Role of Androgens in Treatment   205

Physical Examination and Vulvoscopy

Vulvoscopy is a procedure for examining a woman’s vestibular region
under a microscope. Remi’s examination revealed pathology consis-
tent with bilateral labial resorption of her labia minora (they were
actually disappearing) with absence of the lower third of the labia
in the area of the posterior fourchette. Furthermore the bilateral
superior vestibular glands, which are located at the vaginal opening,
showed erythema, or redness and tenderness, and she experienced 3
out of 10 and 6 out of 10 pain with Q-Tip testing. These local, genital
physical findings are typically seen in women affected by a hormonal
deficiency. Local estrogen deficiency leads to resorption of the labia
minora (Leung, Robson, Kao, Liu, & Fong, 2005). Testosterone defi-
ciency is one of the major causes of pain and erythema of the ves-
tibular glands, as was evident with Remi (Bouchard, Brisson, Fortier,
Morin, & Blanchette, 2002).

Blood Tests
Hormone blood values are measured in every patient presenting to
our facility to rule out hormonal dysfunction known to be a common
cause of sexual health complaints. To assess the function of the pitu-
itary gland, we determine the levels of thyroid-stimulating hormone
(TSH), luteinizing (LH) and follicle-stimulating (FSH) hormones and
prolactin. To evaluate the function of the ovaries and adrenal glands,
we determine the levels of estradiol, progesterone, and two of the
major androgens, dihydrotestosterone (DHT) and total testosterone.
To complete our assessment of the important blood values we deter-
mine the level of sex-hormone-binding globulin (SHBG). To rule out
bias within the testosterone determination, we calculate the value
of the free, bioavailable, and therefore active testosterone ourselves,
using the free testosterone calculator (www.issam.ch/freetests.htm)
rather than relying on the blood test.
We encourage every professional interested in sexual health to
measure hormone blood levels. The results of these multiple tests need
to be examined very carefully. Usually a pattern will emerge that helps
in recommending a course of action. It is generally agreed that a hor-
mone blood level in the lowest fourth or quartile of the normal range
is considered suspicious. The rationale behind this principle is that
laboratories developed current values for the “normal range” by mea-
suring hormone blood values of healthy women without knowledge
of the women’s sexual function. Thus the so-called “normal range”
206   TREATING SEXUAL DESIRE DISORDERS

may not reflect sexual health and may include women who were not
sexually healthy. Women’s blood test values have now been examined
in several studies that excluded women with health concerns, includ-
ing sexual health concerns (Guay et al., 2004).
Remi’s blood test results revealed a low value of testosterone,
consistent with testosterone deficiency (see Table 12.1).

Neurological Testing
Biothesiometry, which measures vibration perception thresholds,
showed a vibration perception threshold of 3 volts in the pulp of
Remi’s right index finger (nongenital site used as baseline) and a mildly
increased vibration perception threshold of 6 volts in her clitoris, and
left and right labia minora. Temperature testing is another valuable
methodology to assess neurological function of the external genitalia.
Since heat and cold are felt by different receptors, both are measured.
Temperature testing showed an elevated heat perception threshold in
Remi’s genital area with 30°C in her index finger, 35°C in her clito-
ris, and 37°C in her right and left labia minora, and an elevated cold
perception threshold in her genital area with 20°C in her index finger,
18°C in her clitoris, and 12°C in her right and left labia minora. This
quantitative sensory testing, using biothesiometry and hot and cold
temperature testing, revealed a mild to moderate sensory neuropathy

TABLE 12.1. Remi´s Blood Test Results at Her First Visit, before Treatment
Reference RR follicular RR midcycle RR luteal
Value range (RR) phase phase phase
TSH 0.62 mIU/ml 0.47–4.68
LH 5.3 mIU/ml 1.9–12.5 8.7–76.3 0.5–16.9
FSH 4.2 mIU/ml 2.5–10.2 3.1–17.7 1.5–9.1
Prolactin 6.4 ng/ml 3–30
Estradiol (E2) 39 pg/ml 27–161 187–382 33–201
Progesterone 0.39 ng/ml 0.12–1.7
0.39–5.88 1.02–22.4
DHEA-S 42 mcg/dl 45–320
Total 21 ng/dl 20–76
testosterone
SHBG 69 nmol/l 6–112
Note. Reference range is that of healthy premenopausal women.
 The Role of Androgens in Treatment   207

of the vestibule consistent with the weakened genital sensations that

Remi had described previously.

Duplex Doppler Ultrasonography

The purpose of performing duplex Doppler ultrasonography is to
visualize vascular structures in a noninvasive manner to see whether
blood flow is normal or not. Remi had adequate increases in peak
systolic velocity of the right and left cavernosal arteries. There was
no evidence of clitoral fibrosis or inhomogeneity of the erectile tis-
sue, and her arousal response was adequate. We were therefore able
to rule out any pathological changes in the structure of her external
sexual organs or in the blood supply to her external genitals. There
was no sign of a vascular origin of her sexual complaints.

Summary of Physical Findings

In summary, Remi was diagnosed with HSDD, arousal and orgasmic
disorder, and dyspareunia. On physical examination there was mild
genital sensory neuropathy, bilateral labial resorption, and adenitis
of the anterior vestibular glands at 1 and 11 o’clock. These abnormal
physical findings are commonly associated with a hormonal insuf-
ficiency, in particular, decreased testosterone levels. This finding of
androgen deficiency was supported by her blood test results, which
revealed insufficient testosterone levels. Our patient Remi was found
to have biologically induced sexual dysfunction secondary to low tes-
tosterone. The low testosterone led to changes in the cerebral neu-
rotransmitters that decreased her sexual desire and to changes in the
morphology or structure of her genital organs, leading to a dysfunc-
tional physical response to sexual stimulation (Pfaus, 2008; Giuliano,
Rampin, & Allard, 2002; Clayton, 2007).

Androgens
Androgens are often considered the “hormones of desire.” They
consist of seven different sex steroids that are naturally synthesized
from cholesterol by the ovaries and the adrenal gland, and from
other androgens in peripheral organs such as skeletal muscle and
skin. While all seven androgens are important for tissue structure and
function, four of the seven are often clinically measured: dehydro-
epiandrosterone (DHEA), androstenedione, testosterone, and DHT.
208   TREATING SEXUAL DESIRE DISORDERS

DHEA, the first or precursor androgen, is converted by an enzyme

into androstenedione, which is then converted by a different enzyme
into testosterone, which in turn is converted by yet another enzyme
to DHT. Studies have shown that 90% of the DHEA is synthesized in
the adrenal gland, with the remaining 10% synthesized in the ovaries
(Labrie, Luu-The, Labrie, & Simard, 2001; Bachmann et al., 2002).
Androgens have an effect on many physiological functions in
women including (1) stimulation of sexual desire, interest, thoughts,
and fantasies; (2) regulation of genital (vaginal and clitoral) blood
flow, amount and quality of vaginal lubrication, and structural and
functional integrity of the clitoris, prepuce, vagina, and minor ves-
tibular glands; (3) stimulation of bone growth; (4) increase in muscle
mass; (5) maintenance of energy and well-being; (6) maintenance of
lean body composition; (7) control of oil gland activity in skin; and
(8) regulation of body hair growth (Traish, Kim, Min, Munarriz, &
Goldstein, 2002; Traish, Kim, Stankovic, Goldstein, & Kim, 2007).
The level of circulating androgens in women declines with age,
beginning at about age 30 and continuing with each passing decade.
For example, at age 40, a woman’s testosterone values are half what
they were at age 20, and at age 60, the testosterone values are one-
third of the values at age 20. In addition to aging, there are other con-
ditions or situations associated with lower testosterone blood levels.
The most common is an elevation in SHBG. The purpose of SHBG is
to bind the sex steroids (androgens, estrogens, and progestins) in the
circulation. With sex steroids in general and testosterone specifically,
it is the “free” form, not the “bound” form, that is physiologically
active. SHBG values are increased by use of any synthetic estrogen
(e.g., oral, patch, or ring contraceptives, or estrogens for treatment
of menopausal symptoms), by tamoxifen (for breast cancer), and by
pregnancy, liver diseases such as cirrhosis, and some antiseizure medi-
cations, all of which result in less “free” testosterone. SHBG is low-
ered by androgen administration, a bonus of testosterone use. Low
androgen levels are associated with any condition, treatment, or type
of birth control that affects the ovary, such as natural, surgical, or
premature menopause; injury to the ovary by chemotherapy or radia-
tion treatments for cancer; oral, patch, or ring contraceptives; infer-
tility, or hormone treatments for endometriosis, or uterine fibroids
(Panzer et al., 2006).
The following symptoms may indicate androgen deficiency: (1)
a diminished sense of well-being, (2) feeling helpless or unhappy, (3)
having persistent or unexplained fatigue, (4) experiencing sexual func-
 The Role of Androgens in Treatment   209

tion changes such as decreased sexual interest, receptivity, or pleasure,

and/or decreased lubrication, (5) bone loss, decreased muscle strength,
or changes of memory (Brown, 2008; Kingsberg, 2007; Morsink et
al., 2007; Schwenkhagen, 2007). Before considering a diagnosis such
as depression or another psychological condition, we strongly recom-
mend assessing for hormonal insufficiency or other biological causes
of sexual health complaints.

Therapy
Remi was advised to begin sex therapy to deal with her fear of losing
her partner due to her lack of sexual desire, and to initiate strategies
such as directed masturbation and vibrator therapy. Directed mas-
turbation is very helpful in showing a woman how to experience and
appreciate physical reactions to sexual stimulation outside the con-
text of sexual activity with another person. In women diagnosed with
sensory neuropathy, it is very valuable to encourage masturbation
with a vibrator that is strong enough to stimulate a sufficient genital
arousal response. That kind of therapy is not only educational but
can improve genital morphology secondary to the increase in blood
supply to the clitoris and vagina.
In addition to sex therapy Remi was advised to consider hormonal
treatment. This included (1) systemic testosterone, (2) local estradiol
to the labia minora and the vestibule, and (3) a systemic dopamine
agonist. Currently there are no hormone therapies approved by the
Food and Drug Administration (FDA) for women with sexual health
problems except for vaginal atrophy. This means that the safety and/
or efficacy of androgen use in women with sexual health problems has
not yet been satisfactorily established. This type of androgen use is
currently considered “off-label” treatment. It is important for health
care providers to inform their patients of this and provide them with
appropriate evidence-based information on the risks and benefits of
each proposed medication. Each patient should be able to make an
educated decision as to the potential use of each off-label medication.
Remi asked about the data relating to adverse effects of testosterone
therapy. For testosterone, recognized concerns involve (1) hirsutism,
acne, and virilization; (2) cardiovascular issues and abnormal effects
on lipids, erythrocytes, blood viscosity, and blood coagulation; (3)
breast cancer; (4) stimulation of the uterine lining; and (5) liver func-
tion changes, sleep apnea, and aggression (Boulour & Braunstein,
2005; Shufelt & Braunstein, 2009).
210   TREATING SEXUAL DESIRE DISORDERS

A total of 3–8% of women using testosterone for management of

sexual health problems noted side effects. They were usually mild and
dependent upon dose and duration of treatment. Virilization could
occur with the high testosterone doses required for management
of female-to-male transsexuals, but at the low doses used to treat
women with sexual dysfunction, it is exceedingly rare. Even at the
high doses used in the management of female-to-male transsexuals,
testosterone use has not been linked to an increase in vascular deaths
or deterioration in vascular health including heart attack, chest pain,
or increased blood pressure. Women who used testosterone showed
no difference from placebo in data regarding abnormal changes in
lipids, erythrocytes, blood viscosity, or blood coagulation (Shufelt &
Braunstein, 2009).
There are fears concerning breast cancer because androgen recep-
tors are present in the breast cells. Breast stromal (not ductal) tissue
has the ability to undergo aromatization of testosterone to estradiol,
and some studies suggest a relationship between high testosterone
and breast cancer, but the significance of the data is questioned. Of
note, however, there is no increased risk of breast cancer in women
who have elevated testosterone from polycystic ovary disease. In mul-
tiple studies, testosterone use shows no increase in breast cancer risk,
and in many studies, one can infer that testosterone may actually be
protective. Breast cancer potential was measured in monkeys using an
index of breast tissue proliferation (Shufelt & Braunstein, 2009; Bitzer,
Kenemans, Mueck, & FSD Education Group, 2008). In those treated
with estradiol alone, the breast tissue proliferation was four times
that in the control animals. In those animals co-treated with estradiol
and testosterone, the risk was one-half that group treated with the
estradiol alone (Dauvois, Geng, Lévesque, Mérand, & Labrie, 1991).
In a breast cancer comparison study, the cases of breast cancer per
100,000 women-years in women using estrogen and testosterone or
estrogen, progesterone, and testosterone were lower than in women
using estrogen and progesterone (Dimitrakakis, Jones, Liu, & Bondy,
2004). Of note, whereas many studies show no increase in breast can-
cer in women using bioidentical testosterone, a recent study of nurses
showed that those who used the nonbioidentical form of testosterone
called methyl testosterone in conjunction with a fixed dose of estra-
diol did indeed have a higher risk of breast cancer compared to those
who used the bioidentical form of testosterone (Tamimi, Hankinson,
Chen, Rosner, & Colditz, 2006).
We use bioidentical products that are FDA approved (for other
 The Role of Androgens in Treatment   211

indications) whenever possible. After we discussed the pros and cons

of each medication, Remi was prescribed testosterone, local estradiol,
and a dopamine agonist. The testosterone gel is FDA approved for
men. She was advised to apply it daily to her calves at one-tenth the
amount prescribed for a man. Individual doses of testosterone are
best established by repeated follow-up blood tests of total testoster-
one and SHBG, usually at 3-month intervals.
A wide selection of topical estradiol products is available. It is
very important to acknowledge the outstanding resorptive capacity of
the vaginal tissue, leading to an increase in systemic hormonal values
depending on the administered dose, which requires repeated follow-
up. Remi decided to use estradiol cream, which she was advised to
apply daily on her vestibule and labia minora, as well as her clitoral
region. In addition, Remi started taking bupropion, one of several
available dopamine agonists. She was placed on 75-mg bupropion
tablets daily, the most common choice in our clinic.

Outcome of Treatment
After 3 months of treatment including sex therapy, daily testosterone
gel, daily estrogen cream, and daily bupropion administration, Remi
noted a marked improvement in her sexual function. She reported
initiating sexual activity and feeling sexual desire, and lubrication and
genital engorgement occurred more rapidly. She also noted improved
genital sensation and reported regular involuntary muscle contrac-
tions during sexual activity. Unfortunately she remained unable to
experience orgasm during sexual stimulation, but she had only been
on treatment for 3 months. She did not experience any negative side
effects associated with the androgen treatment,
At 6-months follow-up Remi showed a significant improvement
on a validated questionnaire, the Female Sexual Function Inventory
(FSFI), from baseline at her first visit. Both her FSFI total score and
the individual domain scores improved with the exception of orgasm,
indicating that she had experienced a significant improvement of her
sexuality. The physical examination, including vulvoscopy and quan-
titative sensory testing, also revealed significant improvement. During
the vulvoscopic examination the labial resorption in the fourchette
area was remarkably reduced, and both labia minora showed less
resorption. The vestibular glands did not show any erythema or ten-
derness. Her vibration thresholds improved to 4 volts for index fin-
ger and clitoris and 5 volts for her labia minora. The heat and cold
212   TREATING SEXUAL DESIRE DISORDERS

perception threshold values also improved. This showed measurable

improvement in the sensory function of her nerve structures as well
as a change in the morphology of the labia minora and the vestibule.
In support of these physical findings, which indicate an increase in
systemic androgen and local estrogen levels, the calculated free tes-
tosterone was 0.84 ng/dl (reference range: 0.6–0.8). We are currently
exploring other avenues, including oral administration of oxytocin,
to improve her orgasmic function.

Commentary

While there are numerous psychological and biological pathophysi-

ologies for HSDD, in this chapter we have focused on HSDD second-
ary to androgen deficiency syndrome, as illustrated through Remi’s
case report.
The central and peripheral sexual function response, which
includes the mental state of sexual desire and arousal as well as the
physical response of the genitals, needs an intact hormonal system.
Steroid hormones are critical for (1) the priming of the brain to be
selectively responsive to sexual stimuli and (2) maintaining the health
and function of the genital tissue involved in the sexual response.
To prime the brain for selective responses to sexual stimulation,
excitatory neurotransmitters and their receptors are synthesized in
the central nervous system. The synthesis of excitatory neurotrans-
mitters (dopamine, noradrenaline, melanocortin, and oxytocin) is
mediated in part by steroid hormones. There are numerous examples
in the literature of the hormonal relationship to sexual desire (Chuda-
kov, Ben Zion, & Belmaker, 2007; Clayton, 2007; Giuliano, Rampin,
& Allard, 2002; Kingsberg, 2007; Pfaus, 2008). Androgen depriva-
tion states, as seen in women after ovariectomy and adrenalectomy,
are commonly accompanied by a loss of libido and decreased sexual
activity. There are a large number of double-blind, placebo-controlled
trials in postmenopausal women diagnosed with HSDD showing the
restoration of sexual function and desire after testosterone therapy
(Kingsberg, 2007).
Steroidogenic enzymes in the peripheral genital tissue synthesize
androgens and estrogens locally intracellular from the adrenal precur-
sors DHEA and androstenedione. Estrogens modulate peripheral gen-
ital hemodynamics and are critical for the structural and functional
integrity of the vaginal tissue (Giraldi et al., 2004). Estrogen depriva-
 The Role of Androgens in Treatment   213

tion results in atrophic changes in the vaginal mucosa, thinning of the

epithelium, loss of vaginal rugae, reduction of vaginal lubrication,
and fusion of the labia. The sensory function of the vulvar epithelium
is known to improve in response to hormone therapy. Local genital
androgen and estrogen deficiency does not just lead to a disruption
in vaginal epithelial morphology and function, but may secondarily
affect intraepithelial nerve fibers, resulting in a decrease of genital
sensory function (Alatas, Yagei, Oztekin, & Sabir, 2008; Traish, Kim,
Min, Munarriz, & Goldstein, 2002; Traish, Kim, Stankovic, Gold-
stein, & Kim, 2007).
There are several research studies reporting a positive correla-
tion between low libido and an insufficient genital response to sex-
ual stimulation (Basson, 2001; Basson, Brotto, Laan, Redmond, &
Utian, 2005; Carvalho & Nobre, 2010). Considering the testoster-
one dependency of genital tissue and regulation of genital smooth
muscle tone, we believe in a dual, interdependent mechanism of
action. Testosterone increases subjective (central) and peripheral
(genital) arousal. Physical pleasure facilitates sexual desire. A poor
genital response leads to frustration and disappointment and inhib-
its sexual desire.
Both animal and human studies have shown alterations in genital
hemodynamics after testosterone treatment. Tuiten et al. (2002) dem-
onstrated statistically significant enhancement of vaginal blood flow
response to visual erotic stimuli after sublingual testosterone admin-
istration in healthy women. The increase in vaginal blood flow was
accompanied by an increase in subjective genital arousal and sexual
lust (Tuiten, van Honk, Verbaten, Laan, Everaerd, & Stam, 2002).
The positive effect of testosterone therapy in premenopausal
women affected by HSDD has been shown in a number of studies.
These results are in accord with our experience with Remi as well as
our daily observations in our sexual medicine clinic concerning ben-
eficial therapeutic outcomes with testosterone treatment in pre- and
postmenopausal women diagnosed with HSDD with low androgen
levels.
The testosterone deficiency in our patient led to a decrease in
her desire for sexual activity in at least two ways. One part was the
change of cerebral mediators, in fact excitatory neurotransmitters,
which are important in priming the brain to develop sexual desire
and be open and responsive to sexual stimuli. The other important
part was the change in her genitals, leading to a dysfunction of the
genital tissue itself with changes of the labia minora and vestibule and
214   TREATING SEXUAL DESIRE DISORDERS

also of the sensory function of her genital area, so she was not able to
react in a healthy and pleasurable way to sexual stimulation. We also
believe that the weak physical reaction resulted in a negative change
in psychological status and reaction, comparable to a negative feed-
back mechanism from her body to the brain.
How did our patient, Remi, develop androgen insufficiency syn-
drome along with local genital estrogen insufficiency, leading to her
sexual complaints? We believe the key to this answer was her choice
of hormonal contraception versus mechanical contraception, since she
did not have a surgically or naturally induced hormonal dysfunction.
Ethinyl estradiol, a synthetic estrogen often combined with a syn-
thetic progesterone, is the common ingredient found in all hormonal
contraceptives. Ethinyl estradiol is 600 times more potent for the
estradiol receptor than the bioidentical 17 beta-estradiol. Use of ethi-
nyl estradiol leads to diminished FSH and LH, the pituitary hormones
that act on the ovaries, and reduced ovarian metabolic activity with
decreased circulating levels of androgens and estrogens and marked
increase in hepatic synthesis of SHBG, the major binding protein for
sex steroid hormones in the circulation. Oral contraceptive–induced
hormonal modifications result in alteration of androgen hormone lev-
els, particularly in low levels of free and bioavailable testosterone.
The most common reported side effects include diminished sexual
interest, decreased frequency of sexual intercourse, diminished vagi-
nal lubrication, decreased sexual arousal, and increased pain during
intercourse (Panzer et al., 2006; Warnock et al., 2006).
Use of synthetic estrogens for contraception results in two prob-
lems. First, the ovaries, the main producers of estrogens, progester-
one, and androgens in premenopausal women, shut down as a nega-
tive feedback mechanism. For Remi, the problem was that with her
oral contraception she had a supply of estrogen and progesterone but
not of androgen, since most oral contraceptives have very low or no
androgenic activity. Women using oral contraception provoke andro-
gen insufficiency by shutting down their own production of steroid
hormones in the ovaries. The second important contributor to low
androgen levels was the fact that the estrogen Remi was taking was
a synthetic estrogen (ethinyl estrogen). Her liver was trying to rid her
body of the foreign substance and therefore increased the synthesis of
SHBG, binding the remaining steroid hormones in her blood, which
resulted in another decrease of free, active androgens.
The androgen insufficiency led to a disruption in the functional
integrity of the vestibule, vagina, and clitoris, resulting in inflamma-
 The Role of Androgens in Treatment   215

tion of the vestibular glands and therefore pain during intercourse.

This was the third contributing factor to Remi’s HSDD and anorgas-
mia (Bouchard et al., 2002; Greenstein et al., 2007).
In summary, androgen deprivation may alter neurotransmitters
and their receptors as well as genital tissue integrity and function.
Taking into account that desire and arousal are dependent on the
balance and integration of multiple physiological systems controlled
by neurotransmitters, vasoactive agents, and endocrine factors and
require a functional and healthy tissue structure of the genital sexual
organs, it is easy to understand how the pathophysiology of androgen
deficiency can lead to HSDD in women and men.
Our patient, Remi, experienced improved sexual function while
on testosterone treatment and wishes to remain on the treatment.

Conclusion

What is the bottom line? DHEA and testosterone are critical sex
steroids for sexual function and structure in women and men. New
clinical studies of safety and efficacy data for the judicious use of
bioidentical testosterone continue to be gathered and are available
for all patients (and partners) and health care providers to analyze.
Each individual must weigh the risks and benefits of using these sex
steroids to treat androgen insufficiency. For those who decide the ben-
efits outweigh the risks, the most prudent plan is to use bioidentical
testosterone in doses that maintain hormone values in an appropri-
ate physiological range, undergo frequent and regular blood testing,
and undergo routine breast exams, mammograms, and gynecological
exams.
While our understanding of the biological mechanisms of sexual
desire, arousal, and orgasm is still unfolding, it is hoped that research-
ers and clinicians alike understand that sexual desire—both its stimu-
lation and inhibition—is indeed biologically “in the head.”

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218   TREATING SEXUAL DESIRE DISORDERS

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 Chapter 13

Sexual Psychopharmacology
and Treatment
of Desire Deregulation
Bonnie R. Saks

While there has always been a search for a “perfect” drug that might stimu-
late sexual desire or enhance sexual pleasure, the sad fact is that no such
pill exists. Nevertheless, the addition of well-chosen medications can play
an important role in the management of sexual problems. Certainly, many
men with erectile problems have benefited greatly from the availability of
the phosphodiesterase (PDE5) inhibitors, such as tadalafil, sildenafil, and
vardenafil (e.g., Cialis, Viagra, and Levitra). Often these are first-line inter-
ventions for men with organic erectile dysfunction. Unfortunately, these
medications do little to enhance sexual desire.
The majority of cases in this book deal with low or absent sexual inter-
est. However, often the problem is not with too little sexual interest, but
rather with too much. For such individuals, sexual psychopharmacology
can be an important adjunct to treatment.
In this chapter, Bonnie R. Saks describes a unique case in which both
wife and husband report sexual behaviors that detract from their marital
relationship and reflect a reliance on sex to distract from, or attempt to deal
with, unfinished issues stemming from childhood. Sally engages in multiple
affairs to seek affirmation of her desirability, and Richard uses pornography
and prostitutes to deal with underlying feelings of inadequacy and to cope
with periods of stress or anxiety. Both have “addictive personalities” and
a past history of substance abuse. Psychotherapy alone is ineffective in
reducing their sexual impulsivity, yet finding the right medication that con-
trols, but does not destroy, their sexual function is challenging.

219
220   TREATING SEXUAL DESIRE DISORDERS

Displaying an impressive knowledge of pharmacology and genuine

empathy in working with both Sally and Richard, Saks determines the most
efficacious medications with the fewest negative side effects. In this and
similar cases the thoughtful adjunctive use of medications can provide bio-
chemical support that facilitates a positive therapeutic outcome.
Bonnie R. Saks, MD, is a Clinical Professor of Psychiatry at the Uni-
versity of South Florida, Tampa, and Managing Partner of Bonnie R. Saks,
MD, and Associates, LLC, a multidisciplinary group of psychopharmacolo-
gists and therapists. She is the Immediate Past President (2007–2009) of
the Society for Sex Therapy and Research.

Development and Focus of Desire

Sexual desire is a complex phenomenon influenced by early devel-

opmental (usually parental) models and attachments, social, cul-
tural, and religious beliefs and taboos, comfort with and control of
one’s body, and relationships, past and present. Sexual urges are also
affected by physiological and biochemical factors, both internal and
externally introduced. Sexual desire is a normal and natural phenom-
enon, usually involving another adult person or persons. Sometimes
sexual desire deviates toward a paraphilic (e.g., fetishistic, non-adult,
or nonhuman) object or toward oneself (autogynophilic) or is dis-
placed or absent altogether (asexual).
For women seeking sexual consultation, the most common com-
plaint is low or lost sexual desire.
Perhaps they have picked a partner for qualities or comforts other
than physical or sexual attraction. The sexual attraction might be
to “bad boys” or toward someone “exciting and dangerous” (Perel,
2008) rather than their “best friend,” the father (or mother) or their
children. Perhaps they have been reminded of some earlier abuse or
have “serviced” their partner to the point of quashing their desire.
Perhaps they are distracted by a new job, a child, other family mat-
ters, or financial concerns. Menopause, illness, and medication can
also interfere with sexual interest.

Hypersexual Desire

While many patients complain of too little sexual interest, others

complain of excessive or compulsive sexual desire. Most of these con-
 Sexual Psychopharmacology and Desire Deregulation   221

cerns come from men (or from women about men), but women, too,
may have compulsive desire, usually manifesting in multiple affairs.
Compulsive activity for men includes affairs, excessive masturbation,
frequenting strip clubs or massage parlors, telephone sex, and, most
commonly, Internet pornography (Golden, 2009).
To date, there is no biological explanation for “sexual addiction,”
although it has many similarities to physiological cravings for drugs
or alcohol. Many “sex addicts” also have these other addictions.
Like other addicts, those who engage in excessive sexual activities
are often embarrassed and secretive about their compulsive activities
and usually disassociate them from the rest of their lives. They try to
compartmentalize, to separate their sexual preoccupations from their
relationships with those they love. They feel “invisible,” as if they are
“in another world.” They are not.
Through therapy they realize that time spent in impulsive sexual
activities is time stolen from family and relationships. It is not behav-
ior they wish to exemplify for their children. They do not want to
acknowledge that they may be violating a partner’s trust and sabotag-
ing relationships. At first, they cannot stop themselves.
Addictions have been most effectively treated through groups
such as Alcoholics Anonymous (AA) and Sex Addicts Anonymous
(SAA) and pharmaceutical aids. Psychodynamic/cognitive-behavioral
techniques in conjunction with serotonin medications have proven
effective in treating impulsive and compulsive disorders as well. In
my practice, I have facilitated an ongoing sexually compulsive men’s
group for over 20 years. It is fascinating watching these men find
relief in acceptance by and connection with others in the group, forgo
the idealized “high” of their compulsions and the facade of “invis-
ibility,” and substitute empathy for their partner for their narcissistic
needs. They learn to recognize their vulnerabilities and “triggers” and
what brought them to these sexual pseudo-solutions to developmen-
tal traumas and tribulations and twisted family messages. For them,
medication, too, offers hope, a beginning of mastery.

Depression, Antidepressants, and Desire

It will be helpful to review the biological underpinnings of sexual

desire. Desire is a bit more individualized and complex than libido,
a biological readiness for sex, so let’s focus on how antidepressants
may affect libido.
222   TREATING SEXUAL DESIRE DISORDERS

The most common biological interface affecting libido relates to

depression and antidepressant medication. Depression is always due
to low serotonin and/or norepinephrine. More than 40% of depressed
men and 50% of depressed women have low sexual desire (Ken-
nedy, Dickens, Eisfeld, & Bagby, 1999). All antidepressants increase
either norepinephrine, serotonin or both. Trauma and life events also
decrease serotonin and/or norepinephrine. Premenstrual syndrome
and menopause, particularly surgical removal of the ovaries, decreases
estrogen (and serotonin) levels and causes vasomotor dysregulation,
resulting in hot flashes. Pregnancy and postpartum hormonal changes
increase the risk of depression.
Illness, such as cancer (e.g., prostate and breast cancer) may also
lead to depression, along with feelings of loss of control, body image
insecurity, and lessened sexual desire.

Neurotransmitters

Two neurotransmitters are key in regulating libido: dopamine and

serotonin. Norepinephrine has not been shown to directly affect
libido. Increasing dopamine, which, in turn, lowers prolactin, can
increase libido. Levodopa (used for treating Parkinson’s disease) and
bupropion (Wellbutrin or Aplenzin), an antidepressant that increases
dopamine (and norepinephrine), have been associated with reports of
greater libido (Barbeau, 1969; Ashton & Rosen, 1998). Wellbutrin
has not been demonstrated to relieve anxiety, and since two-thirds of
depressed patients are also anxious, Wellbutrin is not often prescribed
as a first-line medication for the treatment of depression.
Increasing serotonin in the space between neurons, the “syn-
apse,” helps lessen anxiety and depression. However there are recep-
tors on the other side of this space that serotonin (5-HT) will bind
to. Antidepressants like Paxil (paroxetine) and Celexa (citalopram)
bind tightly to the 5-HT2 and 5-HT3 postsynaptic receptors. It is this
stimulation that decreases libido (Fredman & Rosenbaum, 2003;
Clayton, 2009). These same drugs lower dopamine and increase pro-
lactin (Stahl, 2008), which also depresses libido. Other antidepres-
sants like Lexapro (escitalopram), Pristiq (o-desmethylvenlafaxine),
and Cymbalta (duloxetine) do not bind to 5-HT2 or 5-HT3 so tightly
and consequently result in less inhibition of libido (Saks, 2002).
The antianxiety medication Buspar (buspirone) stimulates only
the 5-HT1a receptor; 5-HT1a mildly stimulates libido. Thus, Buspar
 Sexual Psychopharmacology and Desire Deregulation   223

may slightly increase libido. Serotonergic antidepressants like Serzone

(nefazodone) and Remeron (mirtazapine) block 5-HT2, so they do
not result in an inhibition of libido. Serzone had been associated with
liver failure and other side effects, while Remeron is associated with
weight gain and an increase in appetite. These negative side effects
often preclude the use of these medications (see Table 13.1).
The following case presentation illustrates how the use of both
psychotherapy—individual and conjoint—and psychotropic medica-
tions is effective in reducing compulsive sexual behavior and enhanc-
ing intimacy for couples. (This example is an amalgam of several cases
and does not represent particular individuals.)

Case Example: Sally and Richard

Presenting Problem and Background
Sally and Richard are an attractive, affluent couple in their mid-30s.
They have two sons, ages 10 and 8, and a 5-year-old daughter. Their
marriage was challenged by Sally’s recent affair with her young male
tennis instructor, as well as her diminished desire for Richard.
In our initial session, Sally and Richard said they were seek-
ing treatment in order to reignite sexual desire for each other—they
wanted to have a successful marriage and family. This initial session
was followed by individual sessions with each of them. During that
session, Sally confessed to a past history of multiple affairs. She was
now fighting her attraction to 26-year-old Dan, the tennis coach. She
felt drawn to Dan like a moth to a flame. Although she tried to resist
this attraction, she found excuses to drive by the tennis club, hop-
ing to see him. She was grateful to have wonderful children and a
supportive and understanding husband, and be better off materially
than she had ever imagined. She wanted to be a responsible wife and
mother and give back to the community. However, she could not fight
her self-destructive urges regarding this young man. She described the
relationship as superficial but incredibly exciting, a great escape, a
hot, thrilling, dangerous game that made her feel powerful.

Sally
Sally did not look like a powerful person. She was petite with a pixie-
like quality, self-effacing, wore minimal makeup, dressed smartly but
casually, and did not have a “femme fatale” presentation.
224   TREATING SEXUAL DESIRE DISORDERS

TABLE 13.1. Pro- and Anti-Sexual Medications

Pro-sexual (dose-related): Anti-sexual (dose-related):
Increases dopamine; blocks Stimulates 5-HT2 ;
5-HT2 stimulates 5-HT1a increases prolactin
SSRIs
Paxil +++
Celexa +++
Prozac ++
Zoloft ++
Luvox ++
Lexapro +
Serzone (nefazodone) Blocks 5-HT2
SNRIs + (dopamine at higher doses)
Effexor ++
Pristiq +
Cymbalta +
Wellbutrin (bupropion) ++
Aplenzin
Remeron (mirtazapine) (blocks 5-HT2)
BuSpar (buspirone) + (stimulates 5-HT1a)
+ = mild; ++ = moderate; +++ = strong

Medical History
Medically Sally had her vulnerabilities: gastroesophogeal reflux,
migraine headaches, and nonspecific body aches (which she attrib-
uted to depression or fibromyalgia). She took the antiseizure medi-
cation Topamax (topiramate) for migraine headaches and Nexium
(esomeprazole) for gastroesophageal reflux. Sally did not like taking
medication and was reluctant to ask for treatment.
It was emotionally difficult for her to come to the office. She had
been to psychiatrists before without much success, especially with
respect to medications, but she was intelligent and anxious to under-
stand herself and was motivated to make a better life for her husband
and children. She was also depressed and irritable.

Psychiatric History
At age 6, Sally was sexually abused by a babysitter, an older male
cousin, age 15, whom her mother would leave to watch Sally and her
older sister. At 12 she was assaulted by one of her mother’s boyfriends.
She became “a wild child,” using drugs and alcohol as a teen. She had
 Sexual Psychopharmacology and Desire Deregulation   225

been depressed and anxious but never suicidal or self-mutilating. She

had never been hospitalized. Various psychiatrists had given her anti-
depressants and psychotropics as a teen.
Paxil (paroxetine) and Celexa (citalopram) made her tired,
increased her appetite, and resulted in weight gain. They did, how-
ever, give her more control of her impulses. Unfortunately, they also
decreased her sexual desire toward her husband and interfered with
orgasm. Prozac (fluoxetine) was not as fatiguing but she experienced
loss of libido and delayed and inhibited orgasm. The same was true
of Lexapro (escitalopram) and Cymbalta (duloxetine). Cymbalta, a
more activating serotonin-norepinephrine reuptake inhibitor (SNRI),
made it difficult for her to sleep. Wellbutrin (bupropion) XL, more
activating still, did not inhibit sexual function, but the increase in
norepinephrine and dopamine made her jittery and more irritable.
Effexor (venlafaxine) XR helped her depression, anxiety, and sexual
compulsivity, but at 300 mg, inhibited libido and gave her a bloody
nose (all selective serotonin reuptake inhibitors [SSRIs] and SNRIs
can affect platelets). She had also been prescribed Depakote (a mood
stabilizer), which upset her stomach, and Risperdal 0.5 mg (a major
tranquilizer), which calmed her and decreased her sex drive (probably
due to increased prolactin) but “wiped her out,” a not uncommon
side effect with sedative major tranquilizers/antipsychotics like Clo-
zaril (closapine), Zyprexa (olanzapine), Seroquel (quetiapine), and
Risperdal (risperidone) as well as with less sedating ones like Abilify
(aripiprazole), Geodon (ziprasidone), and Invega (paliperidone).
In her 20s Sally became involved with AA and started attending
church more regularly. She stopped abusing drugs and alcohol and
met and married her husband. However, her feelings of depression
and anxiety continued, as did her uncontrollable sexual urges.

Family History
Sally’s family history was problematical. Her father, who was an alco-
holic, left when her older sister was 4 and she was 2. Her mother was
depressed and “desperately in need of a man to take care of her and her
girls,” but she chose rather abusive ones or alcoholics. Sally became
the confidante of her mother and sister as they repeated the drama of
taking in and being disappointed by countless men, yet continuing to
seek “the one.” Sally swore she would never be dependent on a man.
The dependency issues caused her conflict about her marriage and
226   TREATING SEXUAL DESIRE DISORDERS

difficulty with intimacy. She had realistic reasons for concern. She
had met Richard, her husband, in her AA group, and he shared some
compulsive tendencies with her. But they achieved a strong emotional
and verbal connection, which solidified their attachment. They were
first friends, then lovers, then married partners. They both struggled
to be good parents and faithful mates.
Sally was a caretaker. Her mother and sister were constantly ask-
ing for help and dragging her into their high-drama situations. She
felt fortunate to be blessed financially and found it difficult to set
limits with them. No matter how much time, money, and emotional
support she gave, though, it never satisfied them.

Mental Status Examination

Sally was depressed and experienced insomnia and anxious, restless
nights. She was active in her community and church-related activi-
ties and took good care of her children despite fatigue, occasional
migraines, reflux, body aches, and family pressures. She did not share
with friends, trying to be tight-lipped and stoic. She was always wor-
ried, but had no panic attacks or phobias. She had some compulsive
tendencies (checking, counting) and was attempting to cope with her
distracting sexual fixations. Sometimes she would get up at night and
clean the house. She would often snap irritably at her husband but
was more successful controlling herself with her children. She did not
overeat, binge or purge, or restrict her food intake, though she did
have some history of bulimia as a teen. She had no flagrant manic
episodes, no dissociation, delusions, or hallucinations. She had no
suicidal or homicidal ideation. She had not used alcohol or drugs
since prior to her first pregnancy, 11 years earlier.

Richard
Richard was a young man with neatly parted blond hair and the air of
a Ralph Lauren Polo model. While he came to therapy to support his
wife, he revealed a past history of compulsive tendencies as well.

Family and Psychiatric History

Richard was the oldest son of a prominent and well-connected family.
He had a younger brother and sister. For him (and his family) drink-
ing was a way to celebrate successes and drown sorrows.
 Sexual Psychopharmacology and Desire Deregulation   227

Richard’s parents were supportive financially but not emotion-

ally. Sex was never discussed. He had a strong religious background
in which sexual restraint was advocated. Richard was the model of a
successful son, a golden boy.
His strong adolescent urges were acted on secretly. On the sly, he
indulged in Internet pornography and later dangerous liaisons with
prostitutes, fueled more and more by alcohol. He was conflicted but
excited by the thrill of “dancing near the flame.” He was depressed
when he felt he was disappointing his parents. He began having
blackouts. Finally, two DUIs (driving under the influence) forced him
to deal with his alcoholism. He began attending AA meetings and
started outpatient psychotherapy. He was also taking 20 mg of Lex-
apro (escitalopram) daily to control his depression and sexual com-
pulsivity.
For 2 years he remained sober but continued to spend hours
looking at Internet pornography and was still occasionally visiting
prostitutes at the time he first met Sally. He was physically and emo-
tionally attracted to her and wanted to “rescue her.” She was wary.
They talked intimately for months before becoming sexually active.
He (temporarily) gave up his sexual predilections.

Formulation/Treatment/Intervention for Richard

The Lexapro 20 mg helped Richard control his compulsivity enough
to address his underlying feelings of inadequacy, entitlement, and emo-
tional reclusiveness. He continued using his medication and attending
outpatient therapy sessions, wanting to do better for himself, his mar-
riage, and his children. Nevertheless, stress of any kind, such as being
alone with unstructured time or meeting emotionally needy women,
could trigger his old compulsive rituals.
A small amount (2 mg) of Abilify (a nonaddictive major tran-
quilizer) usually helped him during these times. Alternatively, he
occasionally took 30 or 40 mg Lexapro to ameliorate stress and
compulsive urges. As he progressed in therapy, the extra Lexapro
and Abilify were needed less frequently. Extra exercise seemed to
help maintain serotonin levels and awareness of the consequences
helped him avoid falling into old compulsive patterns. He also
attended biweekly group therapy with other sexually compulsive
men, in a setting where he was accountable for his actions but did
not feel judged.
228   TREATING SEXUAL DESIRE DISORDERS

Formulation/Treatment/Intervention for Sally

Although she was intelligent and committed, Sally was working too
hard against impossible biochemical odds to succeed without phar-
maceutical intervention. Her depression was significant, as were her
anxiety and posttraumatic stress symptoms and compulsions. She
may also have had bipolar II disorder with periods of hyperfunction
and unwanted instability.
It was difficult to determine if the sedation from the Paxil and
Celexa early in her life or the agitation from the more activating Cym-
balta (SNRI) and Wellbutrin (norepinephrine–dopamine reuptake
inhibitor) were due to the medications themselves, an underlying mild
bipolar II disorder, or the combination of alcohol and drug use.
The irritability from Cymbalta 90 mg and Effexor XR 300 mg
could have been a norepinephrine effect or it could be that the antide-
pressants triggered some hypomania. The argument for bipolar II can
be made from the following factors: her grandmother may have been
bipolar and her mother may be bipolar II. Also, she did feel calmer on
Depakote and on Risperdal, as well as from her migraine medication,
Topamax 200 mg.
All of the serotonin-enhancing medications caused diminished
libido and inhibited orgasm. Paxil and Celexa resulted in the greatest
inhibition of sexual desire.
With Effexor XR 300, Sally had nosebleeds and loss of sexual
desire. The high doses of Effexor XR and Cymbalta also increased
sexual side effects (i.e., inhibited libido and orgasm). Therefore the
use of another medication was considered: Pristiq. Pristiq (o-desm-
ethyvenlafaxine, or ODV) is an active metabolite of Effexor XR. Both
Effexor XR and Cymbalta (as well as most SSRIs) are metabolized
through the 2D6 pathway of the liver’s cytochrome P450 system. We
know that 10% of people are slow 2D6 metabolizers. As an active
metabolite, Pristiq bypasses the liver, and levels are as high for slow
metabolizers as for active metabolizers (Preskorn et al., 2009). Per-
haps a lower dose of Pristiq would be as effective as the higher dose
of Effexor XR?
Cautiously, we agreed for Sally to start using Pristiq 50 mg daily.
Pristiq would not be as sedating as the previous SSRIs she had tried
and would not cause an increase in appetite. Yet, the serotonin would
help with her anxiety, compulsivity, and irritability (unless she was
bipolar II).
 Sexual Psychopharmacology and Desire Deregulation   229

After 4 weeks on Pristiq 50 mg, Sally felt less depressed but still
somewhat agitated. She did not have any sexual side effects. She
agreed to take Lamictal (lamotrigine), an antiseizure medicine that
is used as a mood stabilizer, in addition to Pristiq to help with her
irritability and anxiety. With therapy and with these two medications,
Pristiq 50 mg and Lamictal 200 mg, Sally felt capable of controlling
her unwanted sexual urges. However, she continued to feel uncom-
fortable with her body and could not yet connect sex with intimacy.
In order to increase self-acceptance, Sally was instructed to read
For Yourself (Barbach, 1975) and to focus on positive aspects of her
body. Over time, she was able to regard herself more favorably. Even
more slowly, she was able to see herself naked as a strong and sexual
person. She no longer needed sexual attention or validation from the
young, attractive stranger to feel good about herself, or to engage in
the empty pursuit of validation from other men. She became stabi-
lized on medication (without any sexual side effects), took owner-
ship and control of her body, and was ready to sexually connect with
Richard.

Sally and Richard

Ideally, Sally and Richard would have begun couple therapy with
a therapist who had not treated either of them individually so that
favoritism would be less of a factor in the transference or counter-
transference. Unfortunately, another qualified sex therapist was not
available. The patients were apprised of the therapeutic risks and
chose to continue with a 10-session behavioral course of sex ther-
apy. They were motivated to work together. They were encouraged
to adopt a more playful approach to sex and to focus more on their
own pleasure, first nongenitally, then during intercourse. With treat-
ment, their satisfaction and comfort have greatly improved, as well
as their sexual desire for each other. While they know they are both
capable of “slipping,” they do not police each other. They have both
decided to remain on their medications in order to maintain a stable
biochemical foundation.
They continue to make time and reserve energy for their private
time together, which often leads to greater desire. Richard is con-
sistently desirous and appreciative of Sally. Sally has much greater
appreciation of the strength and sexuality of her own body which she
is now more willing to share with Richard. She can also comfortably
230   TREATING SEXUAL DESIRE DISORDERS

protect herself and set limits when she is not ready for full engage-
ment. They are affectionate with each other and display greater sat-
isfaction with their sexual lives. They are cognizant that they need to
continue to be positive role models for their children.
They have been in therapy for 8 months but consider themselves
“always recovering,” aware of the possibilities of slipping under
stress. They work to maintain open and honest communication.

Commentary
The Role of Medications in the Assessment
and Management of Desire, Hyperactive Desire,
Sexual Addiction, or Sexual Compulsivity
Sexually compulsive (sometimes impulsive) people may be similar to
other patients with obsessive–compulsive disorders. We know that
patients with obsessive–compulsive disorder have low serotonin
levels. SSRIs and SNRIs are helpful in controlling “uncontrollable
urges.” However, when these medications inhibit orgasm, they are
not well tolerated by patients. Thus, the SSRIs like Paxil, which most
strongly stimulate the 5-HT2c receptor in the spinal cord, should not
be used in sexually impulsive compulsive individuals. Lexapro, Cym-
balta, and Pristiq (which increase serotonin but have fewer sexual
side effects) may be preferable.

Bipolar Disorder
Another consideration, especially in the patient with hypersexual
desire, is that hypomania may be present or an underlying bipolar I
manic episode or bipolar II hypomanic episode may have been trig-
gered by the antidepressant medication. A mood stabilizer, such as
Lamictal, which helps with depression, hypomania, and irritability,
might then be introduced. Lamictal is not known to have sexual side
effects. The greatest concern is the rare side effect of Steven–Johnson
syndrome, which begins with a skin rash. Older mood stabilizers,
such as Depakote (valproic acid), Lithium, and Tegretol (carbam-
azepine), may be helpful but have more sexual side effects as well
as other risks, particularly in women who might become pregnant.
Other mildly mood-stabilizing antiseizure medications (not indicated
for treating bipolar patients) are used sometimes for headache or pain
control. They do not appear to have sexual side effects. Topamax
 Sexual Psychopharmacology and Desire Deregulation   231

(topiramate, associated with decreased appetite), Gabitril (tiagabine),

Neurontin (gabapentin), and Lyrica (pregabalin) are in this category.
Minor tranquilizers such as Xanax (alprazolam), Ativan (loraze-
pam), and Klonopin (clonazepam) help with anxiety and mild hypo-
mania but may further inhibit desire for sex while increasing desire
for a nap. These medications can be addictive if used at a high dosage
and should be avoided in patients with chemical addiction histories.
The newer, atypical antipsychotic medications, also called “major
tranquilizers,” have been used for mood stabilization. The ones that
inhibit libido most are the stongest D2 receptor blockers. It is the D2
receptors in the pituitary that control (inhibit) prolactin production.
Thus the antipsychotic medications (e.g., Risperdal) that cause the
greatest increase in prolactin (sometimes to the point of lactation)
also cause the greatest decrease in libido. Abilify, Geodon, Saphris,
and Invega interfere less with libido.

Decreased Desire
Many patients have a low level of serotonin, particularly in times
of stress, when a greater reserve is needed. Studies are beginning to
show that staying on antidepressants can prevent recurrent episodes
of depression (Kocsis et al., 2007). Higher doses of antidepressants
may be necessary in stressful times, but increasing the dose could also
cause more inhibited libido or side effects.

Psychotropic Interventions for Low Libido in Patients

Taking Antidepressant Medications
When patients need to take antidepressant medications, there are
three interventions that may reduce or prevent a reduction or loss
of sexual desire: (1) switch to an antidepressant with less effect on
libido, (2) add a medication that enhances libido, or (3) add a medica-
tion that allows dose reduction of the one causing problems.

Switching Antidepressants
Avoid SSRIs with the strongest sexual side effects (e.g., Paxil and Cel-
exa). Lexapro, Pristiq, and Cymbalta are preferable. If the patient
among the 10% of the population with poor 2D6 liver metaboliza-
tion, Pristiq 50 mg (which does not need to pass through the liver)
will provide a good antidepressant effect without the side effects that
232   TREATING SEXUAL DESIRE DISORDERS

come with a higher antidepressant dose. Wellbutrin XL or Aplenzin

(bupropion) is preferable if serotonin is not needed for anxiety or
OCD control. Remeron is preferred if the patient needs sedation and
increased appetite is not a concern.

Adding Medication
Bupropion can be added to enhance libido. Viagra (sildenafil), Cialis
(tadalafil), or Levitra (vardenafil) have been added to enhance sexual
arousal in men and women (with the premise that the sex response
cycle may be circular, so enhanced arousal may lead to enhanced
desire) (Basson, 2007; Nurnberg 2008). If fatigue is an issue, for
instance, from sleep apnea or shift work, Provigil (modafinil) or
Nuvigil (armodafinil) may be helpful.

Ways to Reduce Doses of SSRIs or SNRIs

“Drug holidays” have been suggested to reduce sexual side effects,
but, of course, this runs the risk of the depression recurring. Adding
Wellbutrin or Remeron may provide enough antidepressant effect to
allow reduction of the SSRI or SNRI and thus alleviate the diminished
desire. A mood stabilizer, like Lamictal, may do the same. Buspar may
give enough anxiety relief to reduce the SSRI dose. In 10% of cases,
Pristiq may substitute for a higher dose of another antidepressant as
discussed.

Conclusion

Development of sexual desire is a fascinating process that encom-

passes predetermined genetic, intrinsic biochemical factors; develop-
mental influences; social, cultural, and religious influences and experi-
ences; body concept; relationship perceptions; and biological changes
that are iatrogenic or caused by pharmacological treatments. We are
better clinicians if we and our patients can master understanding of
all these threads. Medication must always provide more benefits than
risks, more control for the patient than concern.
We can certainly offer more help by knowing that psychophar-
macological interventions (among the others described in this book)
can be effectively utilized so that sexual desire neither comes to an
untimely demise nor spins hopelessly out of control.
 Sexual Psychopharmacology and Desire Deregulation   233

References

Ashton, A. K., & Rosen, R. C. (1998). Bupropion as an antidote for sero-

tonin reuptake inhibitor-induced sexual dysfunction. Journal of Clinical
Psychiatry, 59, 112–115.
Barbach L. (1975). For yourself: The fulfillment of female sexuality. New
York: Doubleday.
Barbeau A. (1969). L-dopa therapy in Parkinson’s disease. Canadian Medical
Association Journal, 101, 68–69.
Basson, R. (2007). Sexual arousal/desire disorders in women. In S. R. Leiblum
(Ed.), Principles and practice of sex therapy (4th ed., pp. 25–53). New
York: Guilford Press.
Clayton, A. L. H. (2002). Prevalence of sexual dysfunction among newer
antidepressants. Journal of Clinical Psychiatry, 63, 357–366.
Fredman, S. J., & Rosenbaum, J. F. (2003). Antidepressant-induced sexual
dysfunction and its management. American Journal of Psychiatry, 156.
Golden, G. H. (2009). In the grip of desire: A therapist at work with sexual
secrets. New York: Routledge.
Kennedy, S. H., Dickens, S. E., Eisfeld, B. S., & Bagby, R. M. (1999). Sexual
dysfunction before antidepressant therapy in major depression. Journal
of Affective Disorders, 56, 201–208.
Kocsis, J. H., Thase, M. E., Trivedi, M. H., Shelton, R. C., Kornstein, S.
G., Nemeroff, C. B., et al. (2007). Prevention of recurrent episodes of
depression with venlafaxine ER in a 1-year maintenance phase from the
PREVENT Study. Journal of Clinical Psychiatry, 68(7), 1014–1023.
Nurnberg, G. et al. (2008). Sildenafil treatment of women with antidepressant-
associated sexual dysfunction. JAMA 300, No. 4, 395–404.
Perel, E. (2006). Mating in captivity: Reconciling the erotic and domestic.
New York: HarperCollins.
Preskorn, S., Patroneva, A., Silman, H., Jiang, Q., Isler, J. A., Burczynski, M.
E., et al. (2009). Comparison of the pharmacokinetics of venlafaxine
extended release and desvenlafaxine in extensive and poor cytochrome
P450 2D6 metabolizers. Journal of Clinical Psychopharmacology, 29,
39–43.
Saks, B. R. (2002). Psychotropic medication and sexual function in women:
An update. Archives of Women’s Mental Health, 4, 139–144.
Stahl, S. M. (2008). Stahl’s essential psychopharmacology (3rd ed.). New
York: Cambridge University Press.
 Chapter 14

The Desire to Feel

Whole Again
The Quest for Sexual Desire
after Breast Cancer

Michael Krychman
Susan Kellogg Spadt

It is regrettable but true that a cancer diagnosis may become part of almost
everyone’s life. For women, breast cancer is especially common and is
greatly dreaded—not only because of survival concerns, but also because
of its impact on body image and concerns about sexual attractiveness. Loss
of, or diminished, sexual desire is not an infrequent aftermath of breast
surgery, chemotherapy, and radiation therapy.
In this chapter, Michael Krychman and Susan Kellogg Spadt describe
a multifaceted approach to treating the sexual problems of a 54-year-old
breast cancer survivor, a woman who was not only sexually enthusiastic,
but quite psychologically sophisticated prior to her diagnosis. However, fol-
lowing the successful medical treatment of her breast cancer, feelings of
loss of desirability and youthfulness, as well as the hesitation and discom-
fort experienced by her physician husband, contribute to significant depres-
sion and anxiety.
The importance of intervening on many fronts—pharmacologically,
medically, and psychologically—is evident in this patient’s treatment, which
eventually results in significant relationship and sexual improvement.
Behavioral as well as alternative treatment interventions are employed dur-
ing the course of treatment. The authors provide a variety of suggestions for

234
 Sexual Desire after Breast Cancer   235

empathically and effectively dealing with the sexual difficulties that accom-
pany and follow the diagnosis and treatment of breast cancer.
Michael Krychman, MD, is the Medical Director of Sexual Medicine at
Hoag Hospital in Newport Beach,California, and Executive Director of the
Southern California Center for Sexual Health and Survivorship Medicine.
Susan Kellogg Spadt, PhD, CRNP, is Director of Sexual Medicine at
the Pelvic and Sexual Health Institute in Philadelphia.
Both are practicing medical sexologists and AASECT-certified sexu-
ality counselors/educators who work in private, multidisciplinary sexual
health settings.

Sexual concerns are distressing complications for patients during

the diagnostic, treatment, and survivorship phases of breast cancer.
Several physiological and psychological factors are specific to oncol-
ogy patients. They include extensive surgical procedures, radiation,
chemically or surgically induced menopausal symptoms, preexisting
sexual dysfunction, and negative self-concept, all of which can neg-
atively impact sexual health and functioning. Body image concerns
may present a psychological barrier to intimacy. Partner conflicts
and relationship miscommunications may be severe, debilitating, and
painful.
Sexual problems may have an acute onset, appearing shortly after
treatment ends, or may develop more gradually over time. Studies
investigating the interaction between a woman’s sexual self-concept
and her sexual functioning show that women with a negative sexual
self-concept (sexual self-schema) are more likely to have greater sex-
ual morbidity. Many patients report that sadness and grief emerge
with the attempt to resume sexual activity, leaving them vulnerable to
sexual dysfunction and feelings of sexual inadequacy. For women with
partners, sexual dysfunction may threaten the integrity of their rela-
tionships, limiting this source of social support. Special populations
include single or lesbian women (single or coupled), who may also
experience problematical sexual lives following cancer. All patients
can benefit from comprehensive sexual and relationship assessment
and the development of individualized treatment plans.

Prevalence of Breast Cancer

It is estimated by the National Cancer Institute that over 2.5 mil-

lion women in the United States are breast cancer survivors, and
236   TREATING SEXUAL DESIRE DISORDERS

the 5-year survival rate for the disease is estimated at nearly 90%.
Approximately 50% of women who survive a breast or gynecologi-
cal malignancy report severe and long-lasting sexual problems. Other
reports estimate posttreatment sexual dysfunction incidences ranging
from 30–100%.
With regard to specific sexual dysfunction, Barni and Mondin
(1997) suggest that changes in desire or interest are estimated to occur
in 23–64% of breast cancer survivors; arousal/lubrication concerns
in 20–48%; orgasmic concerns in 16–36%; dypareunia concerns in
35–38%, and vaginismus in 18%.
The desire and sexual difficulties experienced by Dina, an attrac-
tive, outgoing 54-year-old family therapist, illustrate some of the
treatment challenges posed followed treatment for breast cancer.

Case Example: Dina

Dina requested help with her sexual life 9 months after a partial
lumpectomy for breast cancer. She came alone to the first visit and
was visibly upset. She reported receiving a “clean bill of health” from
her medical and surgical oncologists now that her postsurgical adju-
vant chemotherapy and radiation therapy has been completed. She
has been able to tolerate her aromatase inhibitor. “Everyone seems
to think I’m doing well . . . but I’m miserable. I feel like such an old
woman now. Overnight, I stopped menstruating, developed severe
hot flashes, and my vagina has basically dried up. I don’t feel like an
attractive, vital woman anymore.”
She reported that her husband, a handsome 47-year-old phy-
sician, barely looks at her while she is undressing anymore and
seems highly disinterested in sex. His efforts to avoid touching her
breast when they cuddle are obvious. They have not resumed inter-
course since her diagnosis. Her level of anxiety is compounded by
the fact that her own desire for sexual intimacy, once robust, seems
to be gone. “I finally stimulated myself the other day . . . at least
my orgasm is still there . . . but I’m not sure my sex life will ever
recover.”
Despite the fact that both Dina and her husband are medically
and psychologically sophisticated, she said that “trying to navigate
cancer and sex . . . we need all the help we can get.” She had not been
ready to address intimacy and communication issues until now that
her surgery was successful and radiation therapy completed.
 Sexual Desire after Breast Cancer   237

Sexual History Taking and Assessment

Surgical Considerations
Lumpectomy not only altered the structural anatomy of Dina’s breast
but may have also compromised its neurovascular integrity, which
could be critical to both her sexual responsiveness and feelings of
attractiveness. It was important to identify the role that breasts played
in Dina’s sexual script prior to breast cancer and to elucidate if she
currently views her breasts as a source of tenderness and pain, as neu-
tral and nonfeeling, or as a potential source of erotic pleasure. Dina
confirmed that she had no pain and experienced minimal feeling loss
in her affected breast. She was looking forward to having her breasts
touched during sexual play (as they had been prior to her surgery)
and was markedly distressed that her husband was avoiding them at
all costs.
After the surgical removal or alteration of a part of the body so
intrinsically linked with femininity, assessment of body image issues is
critical. In Dina’s case, it was important to address her feelings about
the cosmetic result of her surgery as it related to her feelings of attrac-
tiveness and desirability. Dina confirmed that she was “very pleased”
with the minimal scarring and “awesome cosmetic result” after her
lumpectomy. This further added to her confusion regarding her per-
ception that her husband was reticent to “even look at . . . much less
touch” her breasts since surgery.
Had Dina undergone a full mastectomy, a similar psychosexual
evaluation would have been imperative. Schover (1997) and Speer
and colleagues (2005) have examined the impact of breast surgery
on sexual functioning and conclude that conservative operative pro-
cedures and/or reconstruction play only minor roles in future sexual
functioning. Women who undergo immediate reconstruction after
mastectomy may be more likely to be satisfied with cosmetic/esthetic
results and less likely to feel loss with respect to sexual attractiveness.
However, at long-term follow-up, whether or not women have under-
gone breast reconstruction makes no difference with respect to coital
frequency, ease of orgasm, or overall sexual satisfaction.
Some women with breast cancer have a genetic predisposition
for the development of ovarian cancer (related to BRCA gene muta-
tions) and choose to undergo ovarian removal. Women who opt for
risk-reducing bilateral salpingo-oophorectomy may be negatively
impacted with respect to sexuality due to body image changes as well
as symptoms related to estrogen depletion, including vulvovaginal
238   TREATING SEXUAL DESIRE DISORDERS

dryness and painful intercourse. Dina tested negative for the BRCA
gene mutation and was advised not to undergo removal of her ova-
ries.

Radiation Therapy Considerations

Dina completed 8 weeks of adjuvant radiation therapy which she
described as “pure hell.” Radiation therapy can cause skin damage,
severe fatigue, alopecia, diarrhea, nausea, and vomiting. Many radia-
tion-induced symptoms contribute to general malaise and may impact
the sexual response cycle, most commonly sexual interest or libido.
Psychologically, some patients and/or their partners fear the myth of
being “radioactive.” Although this was not the case with Dina and
her partner, she noted that she “felt so tired and sick” during this time
that she could not even consider sex. She described how her partner
felt helpless. He was unaccustomed to seeing his vivacious, active wife
so overcome by malaise that she was “in bed before her 10-year-old
daughter . . . asleep by 9:00 P.M. each night.”

Chemotherapy Considerations
Like more than 40% of women receiving chemotherapy after the
age of 40, Dina was catapulted into menopause. She had been
actively menstruating at age 53 (at the time of her cancer diagnosis),
and although she knew that the initiation of menopause was likely
after chemotherapy, she did not welcome it. Menopausal symptoms
including hot flashes, night sweats, and vaginal dryness occurred
promptly. Dina’s hot flashes interrupted her sleep and led to irri-
tability and mood destabilization. Dina’s vulvar and vaginal tissue
became thin, with diminished elasticity, contributing to feelings of
bothersome introital irritation during the day, which were exacer-
bated when Dina attempted to self-pleasure with a vibrator. “It was
bad enough to get breast cancer, but now I’m a dried-up prune . . .
I was shocked and freaked out how much the vibrator hurt when I
put it inside.”
Dina was also troubled about the five pounds she had gained fol-
lowing chemotherapy. She had resumed an active workout program
with her personal trainer but had been unable to wear to her predi-
agnosis clothing. She noted that this contributed to feeling “not sexy
anymore.” Research by Goodwin and colleagues (1999) suggests a
mean overall weight gain of 1.6 kg, with an average gain of 2.5 kg, in
 Sexual Desire after Breast Cancer   239

newly diagnosed breast cancer patients receiving chemotherapy. The

exact mechanism for this common side effect is unclear.

Hormone Therapy Considerations

After chemotherapy and radiation therapy, Dina was started on an
aromatase inhibitor (AI) medication. This form of hormonal ther-
apy is rapidly becoming the mainstay of treatment for various stages
of breast cancer. AIs are given to halt the conversion of circulating
androgens to estrogen, thus diminishing exposure to estrogen in a
breast cancer survivor’s body. Many women on aromatase inhibition
complain of increased levels of vulvar and vaginal dryness, dypare-
unia, and loss of sexual desire (surpassing what they experienced as
a result of chemotherapy-induced menopause). Although there are
limited scientific data available that specifically address the impact
of aromatase inhibitors on female sexuality, many survivors, includ-
ing Dina, find the vulvovaginal side effects are most troublesome.
Dina noted that after chemo she needed only to use a lubricant at the
entrance of her vagina in order to comfortably insert a vibrator. Now
that she was on an aromatase inhibitor, her entire vaginal canal was
dry and raw and attempts with the vibrator had resulted in active
vaginal bleeding.

Sexuality and Relationship Considerations

Many women adapt well after they learn of their cancer diagnosis.
However, there is a subset of women who report continued anxiety,
depression, concerns regarding body image, fear of recurrence, post-
traumatic stress disorder, and sexual problems even after their cancer
treatment is completed. Women may link prior negative sexual expe-
riences, past sexual behavior (promiscuity, extramarital affairs, sexu-
ally transmitted diseases) to the cancer diagnosis.
Dina appeared to have made a good adjustment to the reality of
having a diagnosis of cancer. She did not ruminate over “why me”
and did not think that she was being punished for her past behavior.
What was most apparent was that she associated her diagnosis with
a loss of her youth and vitality. She had always looked and felt young
and “sexy.” People routinely took her for younger than her chrono-
logical age. She stated how important this was to her because her hus-
band was 7 years her junior and she wanted to make sure that her age
“never became an issue.” Dina’s cancer diagnosis and the side effects
240   TREATING SEXUAL DESIRE DISORDERS

of her treatment represented aging more than disease to her (and, she
feared, to her husband). She felt that her husband saw her as older
and less desirable. Her distress over this appeared to be significant,
affecting her desire, arousal, satisfaction, and sexual pain, as much or
more so than her lowered hormonal levels.

Other Psychological Considerations

Throughout Dina’s treatment course, she was able to continue work-
ing and managing her responsibilities to her 10-year-old daughter.
Other breast cancer survivors may feel a more acute impact on their
roles as caregivers and/or wage earners. This can directly affect family
or partner dynamics, and can create marital and financial tension as
well as worries about employment and insurance. Single women who
are breast cancer survivors may face these types of financial worries
as well as concerns about negotiating new relationship paradigms,
timing of diagnosis disclosure during dating, and sexual rejection hin-
dering intimate relationships.

Desire Issues
Assessment, diagnosis, and treatment of Dina’s sexual concerns
became the responsibility of several professionals, including her medi-
cal, surgical, oncological, psychobehavioral, and sexual medicine care
teams. Careful attention was directed to coordinate treatment and to
evaluate her social support network and her coping styles.
Sexually, the crucial first step was to identify Dina’s “baseline
or normal” pattern of initiation and receptivity to various forms of
sexual play. This included an assessment of her desire for self-stim-
ulation, incidence of erotic nighttime dreams, spontaneous sexual
thoughts during the day, and desire for sex with her partner. Dina
described her current pattern as vastly different from her “normal
self—a person who always thought about and was interested in sex.”
She stated that she forced herself to masturbate, because she knew it
“would be good for her tissues.” She felt that her partner’s response
to the cancer diagnosis and treatment was a definite contributing fac-
tor to her altered desire, as was the intense discomfort she experi-
enced when she self-pleasured. Despite the pain and her lack of desire,
Dina expressed a “need to be desired by her husband” and she was
interested in attempting intercourse, even though she knew it would
be uncomfortable.
 Sexual Desire after Breast Cancer   241

This clinical picture is consistent with current research suggest-

ing that low or absent sexual desire can be a pervasive problem, esti-
mated to affect up to 68% of breast cancer survivors. Despite this,
most women resume some form of sexual behavior after treatment,
even if it is uncomfortable or less arousing. This may be due to fear
of abandonment or it may serve as a means of maintaining emo-
tional support and connection through a difficult time. Regardless of
the motivation, women frequently look to their medical and mental
health care providers to assist them in the task of regaining desire and
sexual comfort.

Behavioral Treatment Approaches

Our first interventions with Dina consisted of bibliotherapy (regu-
lar erotic reading sessions performed in private, approximately 20
minutes three times a week with or without self-pleasuring), and the
strong recommendation that she begin individual cognitive-behavioral
therapy, followed by couple sex therapy. Initially, Dina was resistant
to these suggestions, stating, “Oh, I don’t need therapy. I know what
to do myself . . . it’s what I do for a living—remember?” It was only
after our repeated urging over several office visits that she agreed to
a short course of counseling with her husband. Her aim was to facili-
tate their communication about sexual expectations and needs and
physical comfort and to negotiate reinitiation of breast touch and
sexual intercourse.
Dina and her husband definitely benefited from third-party
involvement. Although Dina herself was a skilled therapist, she was
not able to discuss many sensitive issues surrounding sexuality with
her husband. Their communication issues were best managed by pro-
fessionals outside of the relationship (both the medical sexologist and
the couple’s therapist fulfilled these roles), and these interventions
were key for the return of her sexual wellness.
During their joint counseling sessions, Dina’s husband expressed
distress about being unable to help her during her cancer treatment.
He admitted to fear of hurting her with any type of breast caress or by
leaning on her in bed. He voiced his concern about the future, hoping
that she would be able to maintain her physically demanding career
and active lifestyle. In private sessions, he admitted that he did not
feel as though the cosmetic result after her lumpectomy was “great”
and that he felt it was “totally shallow and not politically correct” to
have or voice these feelings. He also told the therapist that their entire
242   TREATING SEXUAL DESIRE DISORDERS

relationship was “high energy,” characterized by lots of emotion and

lots of activity (regular gym workouts, skiing, and mountain biking).
He noted that he had never considered either one of them as acting or
feeling their ages . . . “until now.”
In couple therapy, Dina expressed the need for reassurance that
she was still physically and sexually attractive to her husband. She
wanted to be close and to make love again. She stated, “I have to see
if I can still have intercourse . . . I want to be treated like I was before
the cancer . . . young and sexy.” In private sessions, Dina admitted
feeling afraid that he would never again see her as the dynamic, sultry
woman that he fell in love with many years ago. She had no doubt
that she could keep up with the job and parenting demands as well as
their active lifestyle, but reiterated that she felt she had lost the mys-
tique of being the “sexy woman who could do it all.”
In therapy, both Dina and her husband were encouraged to talk
about their fears as well as their needs. They were encouraged to
dedicate time for caressing at night before sleep. Their focus was on
reestablishing intimacy and communication before attempting inter-
course.
In order to address her sexual pain, Dina started on a course of
creams, lubricants, moisturizers, and vaginal dilation exercises that
she performed in private. Simultaneously, the couple was given a plan
for a graduated sensate focus program that would ultimately culmi-
nate in intercourse when Dina was physically comfortable.
In working with other breast cancer survivors, we have also
incorporated functionalized acupuncture libido programs (with certi-
fied acupuncturists who practice eastern techniques to enhance sexual
libido) and mindfulness techniques, which have been shown benefi-
cial for desire enhancement by researchers at the University of British
Columbia.

Medical Treatment Approaches

Since breast cancer tumor cells possess estrogen and progester-
one receptors, treatment of menopausal symptoms with systemic
replacement hormones is almost always contraindicated. A modified
approach to addressing atrophic vulvovaginal changes and pain is
with the use of minimally absorbed local vaginal estrogen products
in concert with topical nonhormonal lubricants and vaginal moistur-
izers. Which product to use, as well as how much and how often to
use it, remains a unique decision based upon the woman’s surgical
 Sexual Desire after Breast Cancer   243

diagnosis, present physical and sexual needs, partner considerations,

and the advice of an oncological and sexual health care team. When
any form of estrogen intervention is initiated, it is generally done to
address severe vulvovaginal atrophy and sexual pain issues that are
not relieved with the use of over-the-counter products.
With Dina, we presented the option of limited use of a topi-
cal estrogen cream to help restore some vulvovaginal elasticity and
moisture. Although she was initially opposed to any form of topical
estrogen therapy (preferring to use only vitamin E oil on her genital
tissues), after worsening vaginal tearing and bleeding with vibrator
use, she consulted her oncologist for his permission.
Recent research suggests that women with a history of breast
cancer who are treated with aromatase inhibitors may experience
elevation of systemic estrogen levels after placing hormone cream
inside the vagina. Instead, the sexual medicine team, oncologist,
psychotherapist, and the patient agreed that a tempered approach
would be to have Dina apply estrogen cream topically to the vulva
at the introitus (rather than inserting it into the vagina) and only
two days per week and to use intravaginal nonhormonal moisturiz-
ers and lubricants on other days. In our experience, hypoallergenic,
nonhormonal water-based lubricants such as Astroglide, Silk, Slip-
pery Stuff, and Good Clean Love and intravaginal moisturizers such
as Replens, KY Liquibeads, and Me Again are best tolerated and
most effective.
Using the topical estrogen cream in this limited fashion, Dina
continued couple counseling, sensate focus exercises, regular erotic
reading, dilator placement, and self-stimulation. After 6 weeks, her
genital tissue no longer bled with dilator placement. When she was
ready to reintroduce sexual intercourse, she was educated about the
use of vaginal moisturizers before, during, and between coital epi-
sodes to insure comfort and maintain spontaneity. Dina’s desire for
sex with her partner increased as he demonstrated his desire to be
intimate with her and he began initiate intimate touch. She was able
to accommodate penile entry but experienced continued pain with
deep coital thrusting. Upon further assessment, it was evident that
Dina was experiencing guarding/spasms of the pelvic floor muscles
during intercourse (a common occurrence in cases of vulvovaginal
atrophy with a history of dyspareunia). She was prescribed muscle
relaxants and referred to a pelvic-floor-muscle physical therapist for
care. Her husband learned to do pelvic floor muscle-massage tech-
niques to facilitate comfortable coitus, which were incorporated into
244   TREATING SEXUAL DESIRE DISORDERS

their lovemaking. This activity helped him play an active role in their
sexual healing.

Other Medical Treatment Considerations

Many women with low desire ask for supplementation with testoster-
one creams or pills, believing that it will automatically restore their
sex drive. Although this was not the case with Dina, it is important to
note that the literature does not support the use of androgen therapy
for breast cancer patients with low libido. According to recent clinical
trials, treatment with testosterone has not proven to be more benefi-
cial than placebo for enhancing libido in breast cancer survivors. We
believe that although androgen therapy may confer benefit to some
women in isolated cases, it should not be considered a panacea. Long-
term safety data on the use of androgens with breast cancer survivors
are needed.
Our clinical practice and research suggest that equal or greater
libidinal enhancement can be achieved by combining behavior modi-
fication techniques with products containing the amino acid L-argi-
nine (e.g., Arginmax) or topical nutraceutical vasoactive compounds
(e.g., Zestra arousal oil) for women. We discussed the use of these
products with Dina, who stated that she “would consider using them
in the future.”
In our treatment, we often include suggestions for enhancing
arousal and orgasm in tandem with desire interventions. For example,
we have prescribed drugs such as sildenafil (Viagra) 25–50 mg 1 hour
before sexual play or bupropion (e.g., Wellbutrin) 75 mg 2 hours
before sexual play to augment arousal and/or reverse the orgasm-
inhibiting effect of selective serotonin reuptake inhibitors, commonly
used in the treatment of cancer-related depression.

Dina’s Outcome
After 12 weeks of combined topical estrogen therapy, dilator use, self-
stimulation, sensate focus, couple counseling and pelvic floor muscle
massage, Dina and her husband began to enjoy comfortable physical
intimacy, including intercourse. They were grateful for the guidance
given to them by the interdisciplinary health team. According to Dina,
their sexual life has changed for the positive and is more “communi-
cative and connecting” as opposed to “nonverbal, rushed, and used
for stress relief” as it had been in the past.
 Sexual Desire after Breast Cancer   245

Commentary

The diagnosis and treatment of breast cancer have a profound effect

on psychological, physical, and sexual well-being. Interventions to
improve sexual desire and overall sexual life include psychosexual
education and counseling as well as pharmaceutical and behavioral
strategies aimed at maximizing desire and comfort while minimizing
patient risk. These interventions can often result in better understand-
ing, negotiation of expectations, heightened desire, diminished pain,
and rekindling of the loving spark between a cancer survivor and her
partner.

References

Barni, S., & Mondin, R. (1997). Sexual dysfunction in treated breast cancer
patients. Annals of Oncology, 8, 149–153.
Goodwin, P. J., Ennis, M., Pritchard, K. I., McCready, D., Koo, J., Sidlofsky,
S., et al. (1999). Adjuvant treatment and onset of menopause predict
weight gain after breast cancer diagnosis. Journal of Clinical Oncology,
17, 120–129.
Schover, L. R. (1997). Sexuality and fertility after cancer. New York: Wiley.
Speer, J., Hillenberg, B., Sugru, D., Blacker, C., Kresge, C. L., Decker, V. B.,
et al. (2005). Study of sexual functioning determinants in breast cancer
survivors. Breast Journal, 11(6), 440–447.
 Index

Page numbers followed by an f or a t indicate figures or tables.

Adrenal glands, assessment of, 205 Antianxiety medications, libido and,

Age 222–223
androgen production and, 208 Antidepressants
sexual desire and, 11, 12–13 effects on libido, 187, 222, 231
American Foundation for Urologic prosexual, 15
Disease, Sexual Function Health Antipsychotic medications
Council of, 8 potential side effects of, 225
American Psychiatric Association, sexual side effects of, 231
diagnostic categories of; see Antiseizure medications, 230–231
Diagnostic and Statistical Manual Anxiety regulation, through
of Mental Disorders accommodation, 45
Amino acid L-arginine, for low desire Aromatase inhibitor medication, after
after breast cancer surgery, 244 breast cancer surgery, 239
Androgen deficiency Asexual Visibility and Education
case example of, 203–212 Network (AVEN), 4
neurotransmitter function and, Asexuality, characteristics of, 3–4
215 Autoeroticism, 4; see also
symptoms of, 208–209 Masturbation
Androgen production Automatic thoughts, 155, 161
aging and, 208
assessment of, 205 B
low sexual desire and, 144–146 Barthes, Roland, 30
Androgen therapy, 133, 201–218 Basson, Rosemary, 62, 74, 76,
contraindication for breast cancer 133–148
patients with low libido, 244 Behavioral treatments, after breast
off-label, 209 cancer surgery, 241–242
shortcomings of research on, 133 Bibliotherapy, 241
for triggering libido in men, 2–3 Biological factors
for triggering libido in women, 3 in HSDD, 202–218
Androgens, functions of, 207–209 in sexual desire, 221–222
Anger, sexual desire and, 140 in sexual disinterest, 13

247
248   Index

Bipolar disorders, hypersexuality and, Communication skills

228, 230–231 in comorbid individual and
Blood tests, for hormone values, relationship dysfunction, 190t,
205–206 191–193
Body image, breast cancer and, 235, developing, 178, 181
237 Comorbid individual and relationship
Body scan, in CBT with mindfulness dysfunction, 181–200
for HSDD, 160 assessment of, 187–189, 188f
Bowenian differentiation theory, 45, case example of, 186–199
58 in DSM-IV-TR, 182
Brain function, brightening and, 57 findings regarding, 183–184
Breast cancer pluralistic approach to, 184–186,
case example of, 236–244 185f
chemotherapy for, 238–239 sexual desire and, 183–184
hormonal therapy for, 210, 239 treatment course, 190–197, 190t
prevalence of, 235–236 Compulsive sexual desire/activity;
psychological considerations, 240 see also Hypersexuality; Sexual
radiation therapy for, 238 addiction
sexual desire after, 234–245, 240 with Internet fetish sites, 79, 82,
behavioral treatment approaches 84–85
to, 241–242 Contextual factors
medical treatment approaches in HSDD, 141
to, 242–244 improving, 178
sexual history taking and in sexual disinterest, 13
assessment in, 237–241 Control issues, 140
sexuality and relationship Couple therapy
considerations, 239–240 pluralistic approach to, 184–186,
Breetz, Alisa, 75–91 185f
Brief Index of Sexual Functioning for in treatment of hypersexuality,
Women, 16t 229–230
Brotto, Lori A., 133, 149–164 Crucible therapy, 44–60
brightening in, 57
C case example of, 49–57
Chemotherapy, for breast cancer, client-therapist co-creation in,
238–239 58–59
Chivers, Meredith, 11 critical mass in, 58
Cognitive-behavioral therapy, differentiation in, 45–48
149–164 heads on pillows exercise in, 56–
case example of, 152–155, 157–163 57
outcome of, 161–162 hugging till relaxed exercise in,
thought-feeling-behavior form in, 56–57
155, 156f intensives in, 52–53
in treatment of low sexual desire, paradigms of, 46
142 paradigms rejected by, 46
Cognitive-behavioral therapy with principles of, 46–48
mindfulness practices therapist role in, 55, 58
after breast cancer surgery, 241 and treatment of prior treatment
characteristics and applications of, failures, 51–55
151–152 two-choice dilemmas in, 53–54
 Index   249

Cultural factors reuptake inhibitors; Sexual

in sexual desire, 68–69, 116 psychopharmacology
sexual problems and, 118t, Duplex Doppler ultrasonography, 207
122–123, 125
sexual relationships and, 13, 36–37 E
Economic factors, sexual problems
D and, 118t
Decreased Sexual Desire Screener, 16t Ejaculatory inhibition, in male
Dehydroepiandrosterone (DHEA) hypoactive sexual desire disorder,
synthesis of, 208 77
in synthesis of androgens and Emotional gridlock, 45, 47, 48
estrogens, 212 Emotional suppression, sexual
Depression disinterest and, 139–140
biological factors in, 222 Erectile dysfunction
low serotonin/norepinephrine levels DSM versus New View approaches
in, 222 to, 128
low sexual desire and, 187 in male hypoactive sexual desire
Desire-arousal feedback loop, 62–63 disorder, 77
Developmental factors, in sexual treatment of, 15
desire, 13, 220 Erotic blueprints, 37, 41
Diagnostic and Statistical Manual of Erotic intimacy
Mental Disorders defined, 95–96
comorbid individual and optimizing (see Optimal erotic
relationship dysfunction in, 182 intimacy)
HSDD diagnosis of, versus New Erotic pleasure; see Pleasure
View approach, 122, 126 Eroticism
New View classification alternative nurturing, 28–30
to, 114–132 (see also New View versus sexual act, 29
approach) Estradiol products, 211
psychosexual disorders in, 7 for HSDD, 209
sexual desire disorder in, 150–151 Estrogens
Diamond, Lisa, 12 functions of, 212–213
Differentiation synthetic, problems caused by,
in crucible therapy, 45–48 214
versus pseudodifferentiation, 51 for treating sexual pain, 243
of therapist in crucible therapy, 58 Ethinyl estradiol, 214
Dihydrotestosterone (DHT), FSH and LH levels and, 214
assessment of, 205 Experiential Psychotherapy, 92–113
Domestic violence, sexual apathy and, and approach to sexual desire
61 problems, 93–97
Dopamine, libido and, 212, 222 goal of, 94
Dopamine agonists, for HSDD, 209, history taking in, 99–100
211 methods of, 94–95
Drive reduction model of sexual therapy process in, 100–109
desire, 2
flaws in, 3 F
Drugs; see Pharmaceuticals; Selective Fantasy
serotonin reuptake inhibitors; arousal and, 1, 4, 11
Serotonin-norepinephrine in sex therapy, 124–125
250   Index

Female Sexual Distress Scale, 16t for female hyposexuality, 209

Female Sexual Function Index, 16t giving and receiving massage,
Flibanserin, 15 174–175
Follicle-stimulating hormone mindfulness exercises, 158, 158f,
assessing levels of, 205 159f, 160–161
ethinyl estradiol and, 214 movie critique technique, 71
Free testosterone calculator, 205 in New View approach, 124–125
Freud, Sigmund, libido theory of, 2 psychosexual trust exercises, 82–84,
90
G for relapse prevention, 87–89,
Gender, desire differences and, 10–12 88t–89t
Gender roles for relationship skills, 171–172
changes in, 167–168 for sexual desire discrepancy,
low sexual desire and, 187–188 102–105, 108
in traditional sexual relationships, for stimulating desire, 33–34,
34–35, 97 38–40
Genital herpes, concerns about, 138, Hormonal contraception, androgen
140 insufficiency syndrome/estrogen
Genital sensory neuropathy, 207 insufficiency and, 214
Goldstein, Irwin, 201–218 Hormonal factors; see also Sexual
Goldstein, Sue W., 201–218 psychopharmacology; specific
Golombok-Rust Inventory of Sexual hormones
Satisfaction, 16t in sexual disinterest, 2–3, 13, 140
“Good-enough sex” model, 75–91 Hormonal insufficiency, in HSDD, 207
confronting variant arousal in, Hormonal testing, 205–206
84–85 Hormonal therapy
couple feedback session in, 81–84 after breast cancer surgery, 239
individualized relapse prevention for HSDD, 209–211
plan in, 87, 88t, 89 for low sexual desire, 64
past histories in, 80–81 Hormone blood levels, assessment of,
psychosexual trust exercises in, 205–206
82–83 Hormones; see also specific hormones
Group therapy, in treatment of low in sexual response, 203, 207–209,
sexual desire, 143, 157 212–215
HSDD Screener, 16t
H Hugging till relaxed exercise, 56–57
Hall, Kathryn, 61–74 Hypersexuality, 5; see also Sexual
Hall, Marny, 114–132 addiction
Heads on pillows exercise, 56–57 and bipolar disorders, 230–231
Heterosexual relationships, low sexual case example of, 223–230
desire in, 64–65 child sexual abuse and, 224–225
Homework assignments family history and, 225–227
attraction exercise, 83–84 obsessive-compulsive disorders and,
bibliotherapy, 241 230
client options for, 176–177 Hypoactive sexual desire disorder, 6;
comfort exercise, 83 see also Low sexual desire
for confronting variant arousal, assessment of
84–85 blood tests in, 205–206, 206t
in crucible therapy, 56–57 neurological, 206–207
 Index   251

physical examination and Lesbian relationships

vulvoscopy in, 205 low-sexual desire in, 65–74
ultrasonography in, 207 sexual problems in, 120–125
biological basis of, 202–218 Levodopa, libido and, 222
androgens in, 207–209 Libido; see also Sexual desire
case example, 203–215 antidepressants and, 187, 231
DSM definition of, 150–151 factors affecting, 2–3
gender and, 7 neurotransmitters in regulation of,
in men (see Male hypoactive sexual 222–223
desire disorder) Libido theory, 2
New View approach to, 122, 126 Lithium, potential side effects of, 230
therapy and, 209–211 Long-term relationships, reviving
therapy outcome and, 211–212 sexual desire in, 61–74
in women, 8 Love
androgen therapy for (see and absence of sexual activity,
Androgen therapy) 24–25
case example of, 139–140, and absence of sexual desire, 89
152–155, 157–163 Greek concepts of, 124
prevalence of, 202 as motive for sexual activity, 1
treatment of, 15 reconciling with desire, 23–43
Hypogonadism, treatment of, 2–3 relationship to desire, 23, 26–27
relationship to passion/idealism, 80
I Western attitudes toward, 62
Internet pornography, 165–166, “Love ethos,” women’s sexuality and, 5
172–174, 221, 227 Love relationships; see also
Interpersonal factors, in sexual Relationships
disinterest, 13 battles for selfhood in, 48
Intimacy; see also Sexual intimacy conflicts in, 58
female sexual desire and, 12 Low sexual desire, 7–9, 62; see also
other-validated, 45 Hypoactive sexual desire disorder
self-validated, 45 after breast cancer surgery,
sexual desire and, 1–2, 30 androgen therapy contraindicated
Intimacy exercises, 174–177 for, 244
androgen production and, 144–146
J case examples of, 30–43, 49–57,
Johnson, Virginia E., 45 78–90, 97–113, 120–130,
136–144, 152–155, 157–163,
K 186–199
Kaplan, Helen Singer, 45, 46 cognitive-behavioral therapy
Kleinplatz, Peggy J., 92–113 for, 152 (see also Cognitive-
Korda, Joanna B., 201–218 behavioral therapy with
Krychman, Michael, 234–245 mindfulness)
controversy over, 8–9
L conventional assumptions about, 97
Labial resorption, 205, 207 crucible therapy and, 47 (see also
Labrie, Fernand, 144 Crucible therapy)
Leiblum, Sandra R., 1–22 developmental histories in, 139
“Lesbian bed death,” 121– distress about, 12–13
122 factors in, 3
252   Index

Low sexual desire (continued) and sexual fetishes, 79–81

in heterosexual relationships, 64– sexual secrets and, 78
65 Marital Satisfaction Inventory-
hormonal treatment and, 64 Revised, in assessment of
Internet pornography and, 174–177 relationship functioning, 188–
(see also Internet pornography) 189, 189f
New View approach to, 127–130 Mastectomy, impact on sexual
polarized roles in, 104–105 functioning, 237–238
prevalence of, in women, 150 Masters, William, 45
as psychiatric disorder, 7–8 Masturbation
psychotropic medications and, cultural/religious attitudes toward,
231–232 137, 153–154
reframing, 70 excessive, 221
and relationship problems, 63–64, Internet fetish sites and, 79, 82,
69 84–85
in same-sex relationships, 64–65 as sex therapy, 128, 209
case example of, 65–74 Mating in Captivity (Perel), 168
sexual abuse and, 66, 68, 70 McCarthy, Barry, 75–91
testosterone levels and, 213 Meana, Marta, 12
therapeutic assessment of, 133–148 Media, sexual insecurity and, 116
case example of, 136–144 Medical factors, sexual problems and,
treatment of, 69–73 119t
in context of individual and Medications; see Pharmaceuticals;
relationship dysfunction (see Selective serotonin
Comorbid individual and reuptake inhibitors;
relationship dysfunction) Serotonin-norepinephrine
in women, 62–74 reuptake inhibitors; Sexual
Lumpectomy, sexual impacts of, psychopharmacology
236–237 Melanocortin, in sexual response,
Luteinizing hormone 212
assessing levels of, 205 Men; see also Male hypoactive sexual
ethinyl estradiol and, 214 desire disorder
“excessive” desire in, 7
M HSDD in, 78–90
Male hypoactive sexual desire hypogonadism in, 2–3
disorder, 75–91 as low-desire partner, 49
case example of, 78–90 sexual desire in, 10–12
conception and, 85–86 testosterone production in, 3
confronting variant arousal and, testosterone supplementation in, 3
84–85 Menopause
couple feedback session and, 81–84 after breast cancer surgery, 238
ejaculatory inhibition in, 77 surgical, low sexual desire and,
erectile dysfunction in, 77 144–145
individualized relapse prevention Mindfulness, versus sensate focus, 162
plan in, 87, 88t, 89 Mindfulness practice
past histories and, 80–81 with CBT (see Cognitive-behavioral
prevalence of, 202 therapy with mindfulness
primary, 78 practices)
secondary, 77 for HSDD, 158, 160–161
 Index   253

sources and characteristics of, 122–125, 129, 131 (see also New
155–156 View approach)
Mindfulness training, 133 power and, 130
Mindfulness-based treatments, skeptical view of, 114–132
sexuality and, 157; see also social nature of, 114–116
Cognitive-behavioral therapy Nutraceutical vasoactive compounds,
with mindfulness practices for low desire after breast cancer
Minuchin, Salvador, 42 surgery, 244
Mitchell, Steven A., 25
Motivation, sexual, expanded concept O
of, 134 Obsessive-compulsive disorders,
Moynihan, Ray, 8 hypersexuality and, 230
Multitasking, 153, 160, 161 Ogden, Gina, 39
Muscle relaxants, for treating sexual Oophorectomy, sexual desire and, 145
pain, 243 Optimal erotic intimacy, case example
of, 97–113
N past history in, 99–100
Neurological testing, 206–207 therapy outcome in, 109
Neuropathy, genital sensory, 207 therapy process in, 100–109
Neurotransmitters Orgasmic disorder, primary, 204
androgen deficiency and, 215 Ovarian cancer
in sexual response, 202–203, 212, breast cancer and, 237–238
222–223 genetic predisposition to, 237
New View approach Ovaries, assessment of, 205
absence of norms in, 117–118 Oxytocin, in sexual response, 212
case example 1, 120–125
case example 2, 126–127 P
case example 3, 127–130 PDE5 inhibitors, 15
classification scheme of, 117, Perel, Esther, 23–43, 168
118t–119t, 119–120 Pharmaceuticals; see also
versus DMS-IV-R diagnosis, Antidepressants; Antipsychotic
122–123 medications; Selective
to DSM-IV-R diagnosis of HSDD, serotonin reuptake inhibitors;
122, 126 Serotonin-norepinephrine
therapeutic advantages of, 117, 119 reuptake inhibitors; Sexual
and therapist role, 114 psychopharmacology
therapist’s role in, 123–124 alprazolam (Xanax), 231
Newsom, Gavin, 122 antiseizure medications, 230–231
Noradrenaline, in sexual response, aripiprazole (Abilify), 227
212 aromatase inhibitor medications,
Norepinephrine 239
antidepressants and, 222 bupropion (Wellbutrin/Aplenzin),
depression and, 222 15, 211, 222, 225, 232, 244
Norms buspirone (Buspar), 222–223
absence in New View approach, carbamazepine (Tegretol), 230
117–118 citalopram (Celexa), 222, 225
American Psychiatric Association clonazepam (Klonopin), 231
and, 115 o-desmethylvenlafaxine (Pristiq),
New View approach and, 117–120, 222, 228–299, 230, 231–232
254   Index

Pharmaceuticals (continued) Power

duloxetine (Cymbalta), 222, 225, sexual norms and, 130
228, 230 unequal, in relationships, 118t
escitalopram (Lexapro), 222, 225, Premarital sex, cultural/religious
227, 230 attitudes toward, 37
lamotrigine (Lamictal) 229, 230 Prolactin, assessing levels of, 205
lorazepam (Ativan), 231 Psychiatric disorders, diminished
mirtazapine (Remeron), 223 sexual desire as, 7–8
muscle relaxants, 243 Psychoeducation
nefazodone (Serzone), 223 with mindfulness, 157
paroxetine (Paxil), 222, 225, 230 in treatment of low sexual desire,
pro- and anti-sexual, 224t 142
pro-erection, 77 Psychological factors
risperdal, 225 in HSDD, 141
sildenafil (Viagra), 15, 232, 244 in sexual disinterest, 13
tadalafil (Cialis), 15, 232 sexual problems and, 118t–119t
valproic acid (Depakote), 225, Psychopharmacology; see
230 Pharmaceuticals; Sexual
vardenafil (Levitra), 15, 232 psychopharmacology; specific
venlafaxine (Effexor), 225, 228 drugs
Pharmacotherapy, 15; see also Psychosexual disorders, changing
Pharmaceuticals; Sexual DSM perspectives on, 7–8
psychopharmacology Psychosexual trust exercises, 82–84, 90
for HSDD in women, 15 Psychotropic medications, for
Phosphodiesterase inhibitors, 15 low libido in patients on
Physiological factors antidepressants, 231–232
in sexual desire, 202–203
sexual problems and, 119t, 187 R
Pituitary gland, assessment of, 205 Radiation therapy, for breast cancer,
Pleasure 238
after breast cancer surgery, 237– Relationship problems, 17
240 characteristics of, 182 (see also
arousal and, 134, 137 Comorbid individual and
asking for, 102–105, 108 relationship dysfunction)
cultural attitudes toward, 37–38 low sexual desire and, 69
eroticism as, 29–30 sexual problems and, 118t
inhibition of, in loving relationship, Relationship skills, 171–172
26 Relationships
learning to give and receive, familiarity and novelty in, 25
176–177 long-term, reviving sexual desire in,
listing sources of, 39 61–74
as motive for sexual activity, 5 modern pressures on, 167–
partner’s, focus on, 64, 66, 68–69 168
versus sexual frequency, 95, 111 same-sex, 64–65, 120–125
and use of vibrators, 238 Religious factors
Political factors, sexual problems and, hypersexuality and, 227
118t in low sexual desire, 153–154,
Pornography, Internet; see Internet 187–188
pornography sex and, 36–37
 Index   255

S motivations/incentives for, 5
Saks, Bonnie R., 219–233 norms for (see Norms)
Same-sex relationships, low sexual risky, 135
desire in, 64–65, 120–125 Sexual addiction, 5; see also
Schnarch, David, 14, 44–60 Hypersexuality
Selective serotonin reuptake inhibitors absence of biological factors in,
(SSRIs) 221
effects on platelets, 225 treatment options for, 221
in management of hypersexuality, Sexual and marital therapy
230 with individual versus couple, 70
therapist role in, 72–74
metabolism of, 228
Sexual apathy, sexual abuse and, 61
for obsessive-compulsive disorders,
Sexual desire; see also Libido
230
absence of, 4 (see also Hypoactive
sexual side effects of, 15, 224t
sexual desire disorder; Low
with strongest sexual side effects,
sexual desire)
231
in loving relationship, 89
ways to reduce doses of, 232
after breast cancer surgery, 240–241
Sensate focus, mindfulness versus, 162
biological factors in, 13, 221–222
Serotonin
categories of, 6
antidepressants and, 222 circumstances enhancing, 63 (see
depression and, 222 also Contextual factors)
libido and, 222 concepts of, 2–5
in sexual inhibition, 203 as culturally and socially
Serotonin-norepinephrine reuptake determined, 114
inhibitors (SNRIs) definitions of, 4–5
effects on platelets, 225 determinants of, in crucible therapy,
in management of hypersexuality, 46–47
230 early development and, 220
for obsessive-compulsive disorders, historical perspectives on, 1,
230 115–116
sexual effects of, 224t in long-term relationships, 61–74
ways to reduce doses of, 232 loss of (see Hypoactive sexual desire
Sex, obligatory, 61 disorder; Low sexual desire)
Sex Addicts Anonymous, 81, 221 normal variations in, 7
Sex-hormone-binding globulin norms for (see Norms)
(SHBG) numbing of, 25–28
aging and, 208 physiological factors in, 202–203
assessment of, 205 primary versus secondary versus
ethinyl estradiol and, 214 situational, 14
function of, 208 reconciling with love, 23–24
Sexual abuse, childhood reigniting, case example of, 30–43
hypersexuality and, 224–225 relationship to love, 23, 26–27
low sexual desire and, 61, 66, 68, versus sexual performance, 1–2
70 Western attitudes toward, 62
Sexual activity Sexual Desire Disorders (Leiblum and
absence of, in loving relationship, Rosen), 4
24–25 Sexual Desire Inventory, 16t
historical perspectives on, 115–116 sexual desire defined by, 151
256   Index

Sexual desire problems; see also Sexual motivation, expanded concept

Hypersexuality; Hypoactive of, 134
sexual desire disorder; Low Sexual pain disorder, 187, 205, 238
sexual desire after breast cancer surgery, 238–
assessment of, 9–10 240, 242
challenging assumptions about, 97 treatment of, 242–244
definitions of, 150–151 secondary, 204
as disorders versus opportunities for Sexual pleasure; see Pleasure
intimacy, 92–113 Sexual problems
etiology of, 13–14 after breast cancer, 234–245 (see
nonpathological approach to (see also Breast cancer)
New View approach) New View definition of, 117, 118t
normality of, 47–48 normalizing, 170, 178
overview of, 93–97 prevalence of, 167
pharmacotherapy for, 15 (see Sexual psychopharmacology; see also
also Pharmaceuticals; Sexual Hypersexuality; Sexual addiction
psychopharmacology) desire deregulation and, 219–233
prevalence of, 9–10, 48–49 role in management of
scales for assessing, 15, 16t hypersexuality/sexual addiction,
traditional approach to, 25–26 230
in women, 62–74 Sexual relationships
Sexual disinterest, attitudes toward, 2 breast cancer surgery and, 239–240
Sexual disorders, female, 8 and control by low-desire partner,
Sexual drive 47
androgens in familiarity versus novelty in, 35–36
in men, 2–3 in good relationships, 47
in women, 3 traditional gender roles in, 34–35
avoiding language of, 114, 134 Sexual response
traditional views of, 2 hormones in, 212–215
Sexual excitatory pathway, hormones traditional male expectations for, 77
in, 203 Sexual response cycle, 135f
Sexual fetishes Basson’s circular model of, 3, 62,
confronting, 84–85 76
as intimacy disorder, 85 in female HSDD, 141
male hypoactive sexual desire gender differences in, 135
disorder and, 79–83 vulnerability of, 134–135
Sexual Function Questionnaire, 16t Sexual secrets, 78; see also Internet
Sexual intercourse pornography; Masturbation
versus eroticism, 29 Sexual self-schema, transforming, in
frequency of, 6 CBT with mindfulness for HSDD,
painful (see Sexual pain disorder) 160
Sexual Interest and Desire Inventory, Sexuality
sexual desire defined by, 151 changing attitudes toward, 110,
Sexual intimacy 168
avoidance of, 44–45 (see also as expression of love, 73
Crucible therapy) mindfulness-based treatments and,
exercises for developing, 174– 157
177 optimal, 92
in men versus women, 64–65 research on, 96
 Index   257

search for guidelines for, 116 Testosterone deficiency

women’s versus men’s, 62–63 (see low sexual desire and, 213–214
also Men; Women) sexual pain disorder and, 205
Sexuality texts, science-focused, Testosterone supplements
115–116 after breast cancer surgery, 244
Sexual-marital therapy controversy over, 3
clients’ choices in, 170–171 Therapeutic assessment, guidance
Crucible, 44–60 (see also Crucible provided by, 133–148
therapy) case example, 136–144
with focus on strengths, 169 Thought records, in CBT for HSDD,
history of, 45 158, 158f, 159f
small-group format for, 136 Thought-feeling-behavior form, 155,
treating failures of, 51–55 156f
Shame/guilt Thoughts, automatic, 155
in low sexual desire, 153–154 Thyroid-stimulating hormone,
New View approach to, 124, assessing levels of, 205
129 Tiefer, Leonore, 114–132
SNRIs; see Serotonin-norepinephrine Tranquilizers
reuptake inhibitors (SNRIs) for bipolar disorders, 231
Snyder, Douglas K., 181–200 potential side effects of, 225
Social cues, 5 Transdermal testosterone, for HSDD
Sociocultural factors; see Cultural in women, 145–146
factors; Religious factors Treadway, David C., 165–180
Spadt, Susan Kellogg, 234– Two-choice dilemmas, in crucible
245 therapy, 53–54
Sprinkle, Annie, 124
SSRIs; see Selective serotonin reuptake V
inhibitors (SSRIs) Vaginismus, 187
Substance abuse, hypersexuality and, Vestibular glands, adenitis, 207
224 Vibrators, 238
Surgical menopause, low sexual desire Vulvoscopy, 205
and, 144–145
W
T Women
Technological options, 2 asexual/autoerotic, 4
Temperature testing, 206 “excessive” desire in, 7
Testosterone hypogonadism in, 3
bioidentical, 210, 215 low sexual desire in
for HSDD, potential side effects of, prevalence of, 150
209–210 testosterone and, 144–146
male libido and, 2 sexual desire in, 10–12
systemic, for HSDD, 209 sexual desire problems in, 62–74
transdermal, for HSDD in women, sexuality of, versus men’s, 62–63
145–146 testosterone and, 3
in women, 3, 144–146 testosterone supplementation in, 3
aging and, 208 Woo, Jane S. T., 149–164