Liberating Female Libido

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Women experience natural peaks and valleys in sex drive linked to biology, but there are a few red flags that should prompt a discussion with a health care provider.

Many lists will include a good sex life as a positive health habit, touting benefits such as stress-relief, better sleep and heart health. Though it sounds like simple advice, many women find it a complex topic, and worrying about whether you have low libido may make things even worse.

“Most women would like to have a carefree sexual life, I believe, but it can be hard to access as the natural sexual response gets pushed down in many women’s busy lives,” says Dr. Nicole Cirino, a reproductive psychiatrist and the director of the OHSU Division of Women’s Mental Health and Wellness in Portland.

Women experience natural peaks and valleys in sex drive linked to biology, but there are a few red flags that should prompt a discussion with a health care provider. Cirino defines sexual dysfunction as pain with sex, consistent low libido and/or physical problems with arousal or orgasm.

“To diagnose anyone with a sexual disorder, part of the criteria is that the relevant signs must be present for six months,” she says. “If these symptoms don’t cause distress, we do not define it as a problem or offer treatment. However, if the symptoms affect a woman’s primary relationship and leads to dissatisfaction and conflict in the relationship, then we can offer treatment, often involving the partner as well.”

If a gynecologic or medical cause is ruled out, women may still feel concerned about perceived low libido. For example, a patient reports the experience of sex is fine, but if left up to her, she wouldn’t initiate it because it’s just not on her radar screen, explains Dr. Karen Adams, an OB-GYN and certified menopause specialist at OHSU. Women then may feel guilty or as if they are somehow abnormal or broken, which doesn’t help their sex lives, Adams adds. This is where exploring the concept of brakes and accelerators to sexual interest can be beneficial.

Stressing about libido

“For women generally, sexual behavior doesn’t start with desire; we aren’t walking around hoping we get to have sex today,” Adams says. “Mostly, women are in a sexually neutral state; then, if conditions are right, we might respond to overtures. Emotional receptivity is truer for women than free-floating desire.”

Research shows that there are a few things that accelerate a woman’s interest in sex and a longer list of things that make them hit the brakes, Adams explains. Some of the things that cause women to apply the brakes include fear of pregnancy or sexually-transmitted disease, negative body image and concern for reputation among others. As for turning on the sex drive, Adams says there are four main themes that women report: love/emotional closeness, romance, erotic appeal and visual cues, including personal grooming.

“However, context is so important for women,” Adams says. “When ask we ask women what gets them in the mood, they will say an attractive partner who accepts and desires them in a relationship where they feel trust and confidence, with maybe a dash of something erotic.”

Stress is not sexy. Science has shown that any stimulation in a stressful environment can feel like a threat and slam the brakes on sexual interest, Adams says.

“If you’ve got the flu or you work 70 hours a week, or your mom is staying with you and you have three kids under age 10, having sex may feel like one more demand,” she says. “What sex therapists often do is dig into is the context to help women have a different mindset that is empowering rather than shaming.”

Sex therapy

Cirino is one of fewer than 10 certified sex therapists in Oregon, receiving her credentials through American Association of Sexuality Educators, Counselors and Therapists. She has teamed up with Adams at the OHSU Menopause and Sexual Medicine Program in the Center for Women’s Health to see patients whose primary sexual complaint is low libido.

“Our model in sex therapy is to help the patient identify what is causing their sexual difficulty and try to help them understand how it may be influencing their behavior,” she says. “We address it with various tools, including communication skills, therapeutic interventions like mindfulness or cognitive behavioral therapy, sexual education and awareness of sexual devices available that may be helpful.”

This type of therapy is generally focused and short-term.

“If someone has longstanding marital issues, a mental health condition or something that requires long-term therapy, such as chronic PTSD or addiction, we generally recommend they address these with a general psychotherapist,” Cirino says.

Biology comes into sex drive in many ways, including chemical reactions in the brain.

“There are hormones and neurotransmitters involved in female sexual response that are more pronounced in the beginning of relationships,” Cirino says. “These can lead to increased libido in new relationships, lasting four to 18 months. There is a decrease in the reward system for a sexual encounter as time progresses in long-term monogamous relationships. Thus, libido is higher early on and tends to die down the longer a woman is with her partner.”

Rather than trading in your spouse for a new model, Cirino helps couples consider what would help.

“This can be addressed in several ways, such as introducing novelty into a long-term relationship,” she says. “Novelty increases these neurotransmitters and can stimulate libido. This could be something as simple as a new scent, different lighting, candles, a new location or role play. Also, you must set up the sexual encounter for success. For example, keep the kids and pets out of the bedroom. Make the location inviting.”

One of the primary drivers for women to continue to have sex in long-term relationships is the emotional intimacy they report feeling with ongoing sexual engagement with their partner, Cirino says.

“Oxytocin is a hormone that is released during s sexual encounter and it is implicated in bonding in mammals,” she says. “Oxytocin is released primarily during breastfeeding and sex – two periods of time that mammalian species can benefit from bonding activities.”

Healthy sex

For Adams, the definition of “healthy sex” starts from a consensual decision between adult partners. After that, the rest is largely the opinion of the individual.

Cirino also won’t be pinned down.

“There is no ‘normal’ in terms of frequency, orgasm intensity or satisfaction,” she says. “That is up to the individual.”

Adams also points out that it isn’t a problem health-wise to not have sex, if that’s an acceptable choice for the woman.

“It’s only a problem if there is a mismatch in what partners want,” she adds. “Personally, I think sex is one of those things that promotes vitality and connection. We know that social connection is life-promoting and that people who have social support live longer and have better quality of life.”

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3 factors for feeling sexy

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Dr. Karen Adams, an OB-GYN and certified menopause specialist at OHSU says there are three things that are predictive of an active and healthy sex life in women:

  • Physical health: “Overall physical health is very important in terms of sex. A lot of medical conditions negatively impact women’s sexual response, including chronic pain, obesity and diabetes. Make sure you are getting appropriate medical attention to maximize your health and modify physical activity. It doesn’t have to be anything fancy, just walk around the block a few times a day. Research shows a high correlation with women who walk daily and healthy sexual behavior.”
  • Mental health: “There is a high correlation between low libido and anxiety, mood disorders and depression. If you seek treatment for one, the other may improve. Not all solutions involve medication; some could include meditation or mindfulness, as examples.”
  • Freshness: “A woman’s sexual interest tapers off in a long-standing relationship, so it’s about how to change things up to reconcile the erotic with the domestic, keeping novelty alive in a long-term relationship.”

No gain in pain

Underlying physical and mental health conditions can negatively impact sex life. Dr. Karen Adams, an OB-GYN and certified menopause specialist at OHSU, wants women to know they don’t have to settle.

“You don’t have to accept painful sex,” she says. “It’s totally sane not to want to do things that hurt. Pain can come from many sources, such as nerves, muscles and hormones. We can look for sources of pain and treat them.”



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