Female sexual problems:
loss of desire
Josie Butcher, University of Central Lancashire and Withington Hospital, Manchester, UK
Loss of desire for sexual activity is the arousal mechanism through neurological after chemotherapy for cancer, when treat-
female sexual dysfunction most common- pathways. The thought could be anticipa- ment with testosterone can improve loss of
ly presented. It is also often the hardest to tion of the evening ahead or a memory of desire. Conditions and drugs that cause
treat. Much literature is available on female a previous sexual encounter. Women who hyperprolactinemia have a direct effect on
loss of desire. The American Psychiatric do not desire sexual activity can operate reducing sexual drive (see box).
Association’s Diagnostic and Statistical quite well sexually once engaged in the sex- The effect of changing hormone pat-
Manual of Mental Disorders (DSM-IV), ual encounter. Touch around the clitoris and terns at different life stages is poorly under-
which gives our working classification of genital area facilitates neurological path- stood, but it is well known that loss of desire
psychosexual dysfunction, would classify it ways, producing good arousal and good is more common with premenstrual ten-
as hypoactive sexual desire disorder and sex- lubrication, moving on to orgasm. sion, in the postnatal period, and around
ual aversion disorder. It has long been menopause. Many drugs can also cause loss
debated whether such a loss of sexual desire Illnesses that may result in a loss of of desire. Loss of desire can also be sec-
should be seen as abnormal or simply as a sexual desire ondary to poor sexual arousal and lack of
variation of normal. • Gynecological disorders causing pain on orgasm (see box).
Masters and Johnson’s original “human sexual intercourse Any health problem that might affect
sexual response curve” helps us understand • Obstetric disorders causing pain on sexual sexual anatomy, the vascular system, the
loss of desire in the context of the normal intercourse neurological system, and the endocrine sys-
sexual response. This diagrammatic repre- • Urological disorders causing pain on sexual tem must be considered. Indirect causes are
sentation describes increasing sexual plea- intercourse conditions that can cause dyspareunia; con-
sure against time—desire for sexual activity • Alcohol and substance misuse ditions that cause chronic pain, fatigue, and
followed by arousal, orgasm, and ﬁnally res- malaise; and conditions that interfere with
• Stress and chronic anxiety
olution. It is important to remember, how- the vascular and neurological pathways.
• Endocrine disorders
ever, that the physiologies of desire, arousal,
and orgasm are separate entities and there- • Neurological disorders Psychological causes
fore not dependent on each other. Women • Psychiatric disorders It is often difficult to disentangle organic
with a loss of desire (hypoactive sexual • Depression possibilities from the psychogenic variables
desire disorder) can have good sexual func- • Fatigue in women at different life stages that affect
tioning. In essence, they will not initiate
Is desire a thought or a feeling? The CAUSES OF LOSS OF DESIRE Drugs that can affect women’s sexual function
answer is not clear. Certainly, early in lov- Much research into sexual desire is now • Anti-androgens
ing relationships, physical arousal closely underway, but the subject is still poorly Cyproterone
follows any sexual thought. We have a sex- understood. We know that certain medical
Gonadotropin-releasing hormone analogs
ual thought, which then facilitates the conditions affect sexual desire. Depressive
• Anti-estrogens and other hormones
illness, for example, often dramatically
reduces it, as do stress and fatigue. Tamoxifen
Possible causes of hyperprolactinemia
• Pituitary tumors
Organic causes • Cytotoxic drugs
Testosterone has a part to play in women’s • Psychoactive drugs
sexual desire, although much smaller • Sedatives
• Stress amounts are required than in men. In • Narcotics
• Hypothalamic disease women, testosterone production is split
• Hepatic disease evenly between the ovaries and the adrenal
• Breast surgery gland. Androgen deficiency syndrome
should be considered after hysterectomy • Stimulants
• Drug treatments
and bilateral salpingo-oophorectomy and
Volume 171 July 1999 w m 41
(with parents and relations), social time, was probably high, with the times when sex-
personal time, and relationship time (time ual desire was low. This study shows how
spent together alone, as a couple). This last priorities change and how these changes can
category is, of course, the time when sexual inﬂuence the desire for sexual activity.
activity is most likely to be realized Looking at what happens in a sexual sit-
successfully. uation often gives much information about
A timetable almost always shows that the the defenses erected when a patient engages
elements missing are relationship time and in sexual activity. We can look at what turns
personal time. Roles are, of course, not only a patient on and off, how absorbed she
about the practicalities of who does what becomes in the sexual experience, whether
but also about how a woman feels about her loss of desire occurs on every occasion, or
responsibility for the roles she takes on. whether it is situational. Discussing other
topics, such as sexual fantasy, masturbation,
It is useful to ask a woman about her expe-
riences of learning about sexuality and their
influence in the development of her sexu-
ality. Sexual learning and role prioritization
Tony Stone Images.
are often intertwined. An example of this
is the woman who found that she had lost
sexual desire after the birth of her ﬁrst child.
Loss of desire is part of the normal female sexual response. Discussion showed that she had, not unnat-
urally, made the responsibility of being a
how they see sexuality ﬁtting into their lives. mother a high priority, but coupled with
It is important to consider these points and this was the clear message that she had
not to allow ourselves to be dragged into received when learning about her sexuality
the medical model. We should look at the that “mothers are not sexual beings.”
importance of the different roles that Many misunderstandings and myths can
women have in their lives and how they pri- be acquired during learning about sexuali-
Mother & Baby Picture Library.
oritize them. ty: for example, a man is always ready and
Many women have several roles—the able to have sex; sex is natural and sponta-
professional or worker, housewife, mother, neous; and sex equals intercourse. Sexual
daughter, friend, and lover. This last role myths are held by women as well as men
seems to fade away as the demands of the (see box).
others increase. When a woman meets her It is useful to repeat the “timetable” for
As a woman takes on the roles of mother and house-
ﬁrst serious partner, she has fewer of these different times in a woman’s life, compar- wife, the importance of her role as lover may diminish.
other roles. She may be only a worker and ing it during courtship, when sexual desire
a daughter. In later years, she will have more
roles to contend with. She may be a moth- Ten myths about sex
er and housewife as well. For many women
it seems that as the responsibilities of other • In general, a man should not express certain emotions
roles increase, the importance of the lover • In sex, as elsewhere, it is performance that counts
role diminishes. • An erection is essential for a satisfying sexual experience
Looking at these issues can be quite
• All physical contact must lead to sex
revealing. One way to give structure to this
• Sex equals intercourse
interpretation is to undertake a process
that we can call the “timetable of life.” Both • Good sex must follow a linear progression of increasing excitement and terminate in orgasm
partners in the relationship are asked to • Sex should be natural and spontaneous
fill in a timetable representing a typical • On the whole, the man must take charge of and orchestrate sex
week. They are then asked to look at the • A man wants and is always ready for sex
week in terms of time spent in different cat-
• We no longer believe the above myths
egories: family time (that is, with children
and partners), work time (both at work and Adapted from Zilbergeld B. Men and sex: a guide to sexual fulfilment. London: HarperCollins; 1995.
work in the house), extended family time
42 w m Volume 171 July 1999
genital functioning, and contraception can sarily discussing them. With counseling,
also give great insight. the aim is to encourage acceptance of dif-
ferences, a concept sometimes described as
TREATMENT OPTIONS “benign variation.”
An integrated approach to medical and psy-
chological treatments is optimal. Any med- Kaplan HS. The sexual desire disorders. New York:
ical elements of the problem, if present,
Callipygous Eve and Adoring Adam (1510) by Albrecht Dürer
Brunner Mazel; 1995.
must be treated to achieve a positive out- Hawton K. Sex therapy: a practical guide. Oxford:
Oxford University Press; 1985 (reprinted 1997).
come. In secondary loss of desire for sexual Heiman J, LoPiccolo L, LoPiccolo J. Becoming
activity, a psychogenic aspect often remains orgasmic: a sexual growth program for women.
New Jersey: Spectrum Books; 1976.
after the medical elements have been treat- Goodwin AJ, Agronin ME. A woman’s guide to
ed (see box). overcome sexual fear and pain. Oakland [CA]:
Most of the treatment will involve cogni- New Harbinger Publications; 1997.
Masters WH, Johnson VE. Human sexual inadequa-
tive behavioral approaches and psychody- cy. Boston: Little, Brown; 1970.
namic approaches, based on the discussions
previously described. One of the most difficult This paper was originally published in the BMJ
areas to approach and affect is loss of attrac-
Diagnostic checklist for women’s loss of We expect our partners to feel the same as we feel and
sexual desire to know when we feel sexual.
• Physical illness
tion for the partner, which can lead to serious “Frigidity” is not featured in this discussion
• Integrity of anatomy nor is it featured in any classification of
difficulties and have serious consequences.
• Integrity of vascular system female sexual dysfunction. The term is
Working with the couple when there is
• Integrity of neurological system loss of sexual desire allows both partners’ more a reflection of women’s feelings
• Integrity of endocrine system understanding of the problem to be exam- about themselves or of men’s feelings
ined by some of the techniques above. As about women. When a woman describes
• Drugs and treatments
partners begin to realize that they can no herself as frigid, she is really describing
• Psychological characteristics
longer assume that they know how their how she feels about herself as a sexual
• Relationship issues being and is often comparing her feelings
partner feels, or should feel, the differences
• Life changes and behavior with her own or others’
in sexuality and sexual needs can be
• Sexual history explored. We expect our partners to feel the expectations of how she should feel.
• Sexual knowledge same as we feel and to know when we feel Because frigidity is not a medical term, we
sexual. We expect them to be able to pro- should no longer use it.
• Attraction to partner
vide for our needs sexually without neces-
Volume 171 July 1999 w m 43