I have been writing and teaching about healthy sexuality for decades, and consistently, the number one sexual concern of my students and my patients is low libido. I would define low libido as a lack of spontaneous desire for sex (alone or with another), including sexual thoughts and fantasies. The Global Study of Sexual Attitudes and Behaviors (GSSAB) found that 26 to 43 percent of women experienced low sexual desire worldwide. As both a doctor and a woman, I find this alarming, since satisfying sex has so many benefits—it can be a positive force for health, producing important chemicals in our bodies and important bonds in our relationships. So why are so many of us lacking in desire?
Sexual desire is an expression of vibrant health, of creative fire
If you were sitting in my office concerned about having low sex drive, you would see me make a large circle with my hands and arms, while saying, ‘libido for women lives in the complex web of our lives and is influenced by our past experiences, our general health, our current relationships, and our hormonal balance.’ In other words, women don’t separate sex from any other important part of their health and well-being. Which, honestly, is as it should be. Sexual desire is an expression of vibrant health, of creative fire. And, we all deserve to have a life that supports that vibrant expression of life-affirming desire.
Here are some of the factors that can cause trouble with your libido and what you can do to help.
1.Your family suppressed sexuality
The earliest influences on our sexuality are the household and societal sexual norms that we grow up with. If you were raised in a place where most folks, for religious or cultural reasons, felt that sex is bad or to be feared, you might suppress your own early sexual exploration. Early fears of sexuality remain with us once we are adults and can be difficult to shake. Sometimes it can be therapeutic to flaunt those rigid norms by yourself or with friends or a lover that you trust. In other words, as a very wise woman once said to me, ‘shake your hips, like your mama told you not tah,’ …. And enjoy it. You get to reclaim your body and your joy in it for yourself.
2. You have low body confidence
Ask any woman-loving man or woman. They like breasts. All breasts. All sizes and shapes
If you were raised in a family or culture that had strict definitions of what a sexy woman should look like, you may feel inadequate in comparison. It is infuriating that the image of what is considered sexy in the media is so impossibly out-of-step with what women actually look like. The great majority of potential lovers are interested in you because you are physically attracted to them. Not because you fit some perfect ideal of the female form. Ask any woman-loving man or woman. They like breasts. All breasts. All sizes and shapes. And hips . . . and those lovely derrieres. And particularly in a woman that they care about and find interesting.
We can be brutal with ourselves about our bodies, but our lovers typically just want to love us. And in case you were concerned that being overweight might affect your ability to be sexual, real studies of this show that women who are overweight or obese have just as much sexual libido and orgasmic ability as other women.
If it is difficult to overcome all those voices in your head that keep you from your pleasure (your mum, your priest, your imam, your mean childhood girlfriends, your asshole ex-boyfriend, the magazines in the news stand), it can be helpful to practice “Body-Love”. Stand in front of a mirror in as little clothing as you can, and still feel comfortable. Now hold each part of your body, your breasts, your belly, your thighs, and say out loud, in your own words, everything you appreciate that this part of your body does (e.g. nurses babies, or digests your food, or climbs stairs). Finish by expressing your love for that body part. And when the negative voices run through your head, just let them pass.
3. You’ve had previous trauma or bad sex – even long ago
When most women experience sexual trauma, they shut down sensations in their genitals and their sexual feelings
The incidence of sexual trauma—incest or rape—before the age of 18, worldwide is 1 in 4 to 1 in 5. In some countries, it is as high as 50 percent. This is tragic in so many ways. Add to this the number of women having sex too young, sex under the influence, sex that they ‘shouldn’t’ have had, sex that was painful, and insensitive and violating medical pelvic exams—that’s a whole lot of women who have had negative sexual and genital experiences. Our genitals are our most private and vulnerable area of our bodies. Of course, trauma can affect any part of our bodies, but when most women experience sexual trauma, they shut down sensations in their genitals and their sexual feelings, in general. Perhaps even while becoming extremely sexually active. This is true for sexual violence, but it can also be true for a woman who has just had bad sex, or has been shamed for being sexual.
Begin healing and developing trust in your sexual instincts, by only having sex when you truly want to. Your desire will emerge when your body anticipates that sex only happens when your body is ready.
4. Sex is painful
I know it seems obvious, but why in the world would someone want to have sex if it hurts? The most common reason for pain with intercourse or penetration are the hormonal changes of menopause. Women can also experience early menopause from surgical removal of the ovaries and/or uterus at any age or from chemotherapy or radiation for cancer treatment.
Lower circulating oestrogen levels result in the vaginal and vulvar tissues becoming thinner, drier, and more vulnerable to injury
Nursing a baby can also induce a menopause-like state of the hormones. Lower circulating oestrogen levels result in the vaginal and vulvar tissues becoming thinner, drier, and more vulnerable to injury. In this environment, penetrative sex, especially without enough lubrication, can cause many microtears of the vulva and vagina—ouch! I call this vaginal road rash, and it burns and hurts, sometimes severely.
The excellent news is that in almost all cases, this can be helped with topical estrogens. This is not hormone replacement; it is local estrogen for the tissues and is safe in all women, with the exception of those who have had breast, uterine, or ovarian cancer.
5. You don’t have enough testosterone
Testosterone is the major driver of libido in women
Perhaps the most important physiological influence on libido is the availability of estrogen and testosterone. Estrogen contributes to sexual receptivity— that Marilyn Monroe, hair flip kind of sex drive. But studies have found that testosterone is the major driver of libido in women, increasing desire for sexual behavior and increasing genital arousal, sensation, and lubrication. When testosterone is low, in addition to lack of libido and less pleasure, it is common for women around menopause and women who have lost their ovaries, to have low testosterone. Europe has approved a ‘woman-sized’ testosterone patch for the treatment of low libido in women, and it can work wonders if your testosterone measures are low (a blood test you can ask your GP for).
6. You have underlying medical issues
A variety of health issues can interfere with libido, including any chronic disease, thyroid malfunction, chronic pain, cancer and cancer treatment, and a large variety of medications— including oral contraceptives, anti-depressants and blood pressure medications.
I recommend having your doctor do the following tests to see if your libido is being affected by a medical condition:
- Optimal thyroid function: TSH, free T3, free T4
- Total and free testosterone levels, or total testosterone and sex hormone binding globulin (SHBG)
- Consider other hormone testing if you are peri-menopausal, menopausal, or have stopped having menses (blood or discharge during menstruation) for unknown reasons: estradiol, progesterone, DHEA-S
- If you have pain with sex, a good gynecologic exam should be able to identify any skin conditions or infections contributing to the pain.
7. Stress and busyness
Because we are complex beings, we can have plenty of testosterone, be comfortable with our bodies, have great sexual partners, and still have no sex drive. My observation is that many women are, literally, too busy for sex. Which is very sad, as sex, if you pay attention to your body and cultivate your sex drive, gives back in spades what you put into it. Sexual activity (including self-pleasuring) has been found to reduce mortality and rates of illness, improve your hormonal profile, and substantially reduce the risk of depression.
Get enough sleep; fatigue may be the number-one killer of sex drive for the average female
The keys to inviting your sex drive back into your life include using your body, physically, on a regular basis. Walk, bike, hike, dance the tango, or play badminton. Be active and in your body. Eat or rest when needed. Get enough sleep; fatigue may be the number-one killer of sex drive for the average female. Make time for pleasure. This is a big one. If you don’t fit sex, with yourself or with another, into your schedule, it will not spontaneously appear. One of the ways to invite sex back into your life is to use fantasy in ways that are fun. This could be spontaneously imagined fantasies, romance novels, erotica, erotic films, or role play. Letting your fantasy life flourish is a fast way to stoke your libido.
Libido, like many aspects of the body, has a positive feedback loop. You make time for self-pleasure and increase the number of sexual thoughts that you have, and you are more likely to want to have sex again sooner. Sex begets sex. So put it on your calendar, and make it happen.
8. Lack of trust
I have often said, ‘sex is just a mirror of the relationship itself’. And after decades of working with couples, I really believe that to be the case. If you do not want to have sex because you are mad at your partner, it has nothing to do with your health or being rested or having enough testosterone. It has to do with your relationship. And contrary to what you may have seen in novels or movies, fighting and lack of trust do not lead to a better sex life. Trust is the number-one ingredient necessary for a happy, healthy sex life. If you do not trust your partner, either emotionally or physically, it will be very difficult to have a hot sexual life. Exploring the relationship and trying to establish trust is the fundamental piece necessary to support your libido.