Igniting the Spark

Q: Several of my female clients have reported a decrease in sexual desire. I’m not a sex therapist, but I’d like to help them. Where do I start?

A: What you’re seeing is common. According to recent research, the number of women reporting diminished desire right now is extremely high. Diminished sexual desire affects an estimated 40 percent of American women, cutting across race, sex, sexual orientation, and gender identity—although there’s a dearth of research on this problem in trans and nongender-conforming individuals. Diminished desire is the number-one issue women bring to sex therapists, but I’ve learned from personal experience that you don’t have to specialize in sex therapy to do good work with these clients.

My own foray into the sexual health arena occurred almost 20 years into my practice, inspired by my own loss of desire. I did a deep dive into the clinical and research literature and found solutions, albeit ones that are not well-known by the public, or even by most therapists. Using what I learned, I published A Tired Woman’s Guide to Passionate Sex, a self-help book on low desire in women. This led to four randomized clinical trials that found that women who’d read the book enhanced their desire and other aspects of sexual functioning. Since then, I’ve immersed myself in the sexual health field. I wrote a second book, on orgasm issues, became a certified sex therapist, and now provide trainings for therapists on helping clients with sexual concerns. If you’re looking to help your clients with sexual issues, specifically diminished desire, here’s how.

Desire, Arousal, and the Sexual Roadmap 

The first step in working with women experiencing diminished desire is to become more comfortable asking clients directly about sexual issues. Many clients won’t bring sex up unless you do, but you’ll soon realize that treating sexual issues is a skill you can learn without having to reinvent yourself as a therapist. 

You might begin by saying something like, “More than one-third of women in long-term relationships say their desire has diminished, and many of them are bothered by this. Is your level of sexual desire a concern for you?” However the client answers, you need to acknowledge that this concern is common—and treatable. With female clients who experience diminished desire, it’s important to assess the possible causes. Undiagnosed, untreated sexual pain—often, but not always, with penetration—is one of the most common causes. Many women don’t know intercourse is not supposed to hurt, and too many have been told by physicians that the solution is to have a glass of wine and relax. In these cases, diminished desire is the presenting clinical concern, but the source of the problem is the pain. Because sexual pain is commonly a physiological or medical issue (e.g., pelvic floor dysfunction or endometriosis), referring to a physician who specializes in sexual medicine is essential. These physicians help rule out medical causes that can contribute to diminished desire, such as thyroid issues or medication side effects. They can also treat sexual pain with medicine, or in extreme cases, with surgery.

Assessing the psychological causes of diminished desire is equally important. As many as 95 percent of sexual issues can be solved by providing information and suggestions. Some issues, such as affairs, infertility, deep-seated anger, trauma, loss of attraction, and body dissatisfaction require intensive individual or couples therapy, while others related to stress, exhaustion, and relationship-stage issues can be addressed with psychoeducation and specific strategies.

To understand the cause of a client’s diminished desire, first differentiate issues with desire from issues with desire and arousal together. For instance, my client Liz told me, “I never feel horny anymore.” This loss of interest in sex indicated issues with desire on its own. Concerns around arousal, however, generally focus on the absence of sensation or pleasure during sex. This was the case with my client Angie, who told me, “I don’t feel excited during sex. I feel dead down there.”

To assess whether a client is having issues with desire or with both desire and arousal, ask if they have sex despite not feeling horny. Then, follow up by asking if they enjoy sex once it gets going. Many women will say that they have sexual encounters despite lacking desire and derive no physical satisfaction from them. These clients have issues with both desire and arousal. Research shows that while these women have similar desire-killing stressors as those with only desire issues, they tend to have more serious past and present psychiatric symptoms, more negative early childhood histories, and more negative sexual histories. Clients with both desire and arousal issues often need more intensive therapy than those with only diminished desire, so the best course of action is to refer these clients to a specialist if you don’t feel equipped to treat their more deeply entrenched issues.

To treat desire issues, however, you don’t need to be an expert. Many low-desire clients may have stopped having sex, believing that feeling horny is a prerequisite. They’ll often report that they enjoy sex when they engage in it, even reaching orgasm. If they happen to be in a long-term relationship, I often educate them about the “we can’t keep our hands off each another” stage of a relationship—also known as the limerence phase—which usually involves intense desire. This is the earliest stage of a relationship, and it lasts, on average, between six months and two years. Although many long-term couples come to miss this stage when everything feels thrilling, the level of intensity that accompanies it isn’t sustainable. How would anybody permanently in this state raise kids or hold a job?! The solution, I tell my clients, is to create a sexual roadmap for their current relationship stage, rather than trying to get back to how they used to feel.

Part of this treatment step involves education about the two types of desire: spontaneous and responsive. Spontaneous desire is what most clients mean when say they’ve lost their desire. In the words of my client Liz, it’s “feeling horny.” Spontaneous desire occurs simultaneously with the initial signs of physical arousal—genital tingling, swelling, and lubrication—making it a powerful feeling that women may miss and even grieve when it wanes. Responsive desire is being receptive to the idea of sex for reasons other than being horny, such as to please a partner and enhance closeness, and, importantly, because they realize that if the conditions are conducive—such as if they receive consensual, pleasurable stimulation, take time to build arousal, and quiet their minds to focus on the sensations—the encounter will become pleasurable.

Most women in long-term relationships and under stress will experience diminished spontaneous desire, but they don’t have to rely on this as a cue for sexual encounters. Instead, they can reverse the equation and have sex to get horny, rather than waiting to be horny to have sex. If you encounter clients who’ve been belittling themselves for doing this, calling it “duty sex,” congratulate them for using a well-established sex-therapy technique! Tell them, “If it’s fun, it’s not duty sex!”

Ways to Reignite the Spark

To reignite the sexual spark for diminished-desire clients, it helps to get them thinking about sex. Encourage them to fantasize about sex regularly, and give them permission to enjoy their fantasies, even if they’re about things they’d never do in real life. This was the only suggestion my client Andrea needed. After I asked her to set her alarm and take a two-to-five-minute fantasy break every hour, she returned to therapy telling me, “Now I have the opposite problem. I can’t stop thinking about sex and want it all the time!” Of course, for most clients, regaining desire isn’t so simple, and additional suggestions are needed.

You can also use the cognitive-based technique of helping your client develop a personalized sex mantra. This entails identifying their negative thoughts about sex and substituting positive thoughts in their place. My client Liz realized she’d been telling herself, “Sex is a chore I do for my husband,” so she substituted the mantra, “Sex is for my pleasure!” She used her mantra multiple times a day. Thinking positively about sex outside the bedroom helped her begin the process of reinventing her sex life.

Some women struggling with diminished desire often have trouble focusing during sex. They’re bothered by intrusive thoughts about tasks and responsibilities. Some are overly focused on their bodies or on whether they’re “performing” sexually according to unrealistic expectations they’ve internalized. These clients need practice turning off their busy brains during sex. Mindfulness is one empirically supported method to facilitate this.

I encourage clients to practice mindfulness in their daily lives and then transfer it into the bedroom. Liz realized she had intrusive thoughts during sex, usually about tasks she’d left unfinished or about how long it was taking her to orgasm. She began doing short, daily mindfulness meditations using an app on her phone and practiced mindfulness while focusing on the sensations in her mouth while brushing her teeth. Then, she applied this mindful focus to the bedroom. Initially, she tried using a saying I suggested, “Bed Not Head,” but it didn’t work for her. Once, she’d mentioned in passing that she loved her partner’s scent, so I suggested that when she got distracted during sex, she should breathe deeply while focusing on her partner’s smell. This helped her come back to the moment.

Behavioral Strategies

Techniques focused on thinking positive thoughts outside the bedroom and turning off one’s busy brain inside it can help clients with diminished desire, but additional behavioral strategies are essential.

Communication. There’s a strong relationship between talking about sex and having satisfying sex. It’s important to teach clients to talk about sex before, during, and after sexual encounters. I’m fond of telling clients that it’s easier to learn to talk about sex than it is to read minds, or to expect their partner to read theirs. I teach clients general communication skills, which they can extend to the bedroom. Once my client Ali learned to talk to her partner, Dan, about responsive desire, she explained that she wanted to have sex to feel close, but that it’d take a lot of warming up to get her in the mood. She also told him what she needed during sexual encounters. “Once I learned to talk during sex, including giving Dan directions, it got better,” she told me. Better sex motivated her to engage in it. She now knew that even if she wasn’t horny at the beginning, her partner’s touch would lead her there.

Time- and Self-Care Strategies.  Because women struggling with diminished desire are often exhausted and stressed, I suggest clients keep a time log, which we analyze together, to find pockets of time they can carve out for themselves. Jill discovered she was spending over an hour a day on her hair and decided to get a haircut she didn’t need to blow-dry. This freed up time for a brisk walk every morning. Another client, Amy, realized that instead of eating lunch with a work colleague whose complaining she found irksome, she could do 45 minutes of online yoga. Both Jill and Amy came to later sessions reporting greater sexual energy.

It’s also important to help clients carve out quality time with their partners. Many busy, low-desire women give their partners the dregs of their day. Others avoid spending quality time with their partners, fearing it may lead to sex. Helping clients connect in nonsexual ways is especially useful. Liz and her partner, Jim, took dance classes. Jackie took drives in the country with her partner, Rachel, singing their favorite songs. Also, helping clients and their partners find strategies to divide tasks, like weekly meetings or shared email calendars, can be helpful. Because research suggests that inequitable division of labor is one of the major driving forces of low desire, dividing tasks equitably can help enhance one’s sex life.

Touch-Based Suggestions. Turning toward an affectionate partner takes a concerted just-do-it type of effort when your knee-jerk response to your partner’s affection has become to brush off their touch with annoyance. Many clients may need help using mindfulness to enjoy pleasureful or playful moments. They may also need reassurance that not all touch has to lead to a sexual encounter. Couples may benefit from touching each other erotically several times a day when engaging in sex isn’t possible—a practice I call drive-by eroticism. Erotic, suggestive touch can be done in quick, stolen moments, such as rubbing legs together under the dinner table. Engaging in lengthier erotic connection, such as making out in the car in a driveway, can enhance desire, especially if it’s done without pressure for it to lead to a sexual encounter.

Novelty. Couples often develop sexual routines that work for them; however, even if these routines result in pleasure and orgasm, they can get monotonous. In suggesting novelty, I often remind clients that when they got a new toy as a child, they felt driven to play with it. I explain that the same is true of adult sexuality: when something new is introduced, such as sex toys, erotic books, visual erotica, sexy board games, lubricants, arousal oils, role-playing, and kinky accoutrements, we’re more driven to play with these things. My client Liz experimented with mild restraints and blindfolds and found it arousing. The blindfolds even supported her in being more mindful of sensations.

Scheduled Sexual Encounters. Scheduled sexual encounters, which I prefer to call trysts, can help women with diminished desire save, and even stoke, energy for a sexual encounter. It helps alleviate the “are we going to do it tonight?” tension that plagues many couples. Trysts can occur on a specific day and time. For Liz, it was Sunday mornings when her children went on outings with their grandparents. Other trysts can be for special occasions and might involve resources and planning, such as hiring a babysitter, booking a hotel room, and bringing along music, food, and drinks, instead of just going out to dinner or a movie.

We therapists are in the business of enhancing our clients’ feelings of wellness, and research shows that sexual satisfaction is a good predictor of life satisfaction. Yet many clients’ sex lives are often a hidden pocket of pain and shame, even in the therapy room. It doesn’t have to be this way! You don’t have to be a sex therapist to let clients know they’re not alone and what they’re experiencing is common. A colleague at a workshop I recently gave confessed to me, “If I’d known about this stuff earlier, I could’ve helped a lot more clients—and to be honest, myself too.” 

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