BJOG: an International Journal of Obstetrics and Gynaecology

April 2002, Vol. 109, pp. 357 –363

REVIEW

Rethinking low sexual desire in women

Introduction clarify medical, including psychiatric and gynaecological
history, confirm normal genital and pelvic anatomy and
The apparent high prevalence of low sexual desire in state that nothing organic is amiss. The relevance of a
women leads to a questioning of the traditional view of normal pelvic exam is frequently over-emphasised. Often
women’s sexual response and the nature of their sexual the woman is then dismissed with the conclusion: ‘‘your
desire. Is the traditional model of sexual arousal and problem must be psychological’’. Indeed, being an emo-
potential orgasmic release, initiated by sexual desire (as tion, sexual desire is a psychological entity, but it also has a
manifested by sexual thinking, fantasising and conscious biological and interpersonal basis and women expect their
sexual neediness), actually true for women? Are other gynaecologist to accept their sexual difficulties as a legi-
cycles of response more common and would their acknowl- timate women’s health issue and be prepared and able to
edgement clarify causes of apparent low desire and thereby address it. This aspect of gynaecological care is clearly
facilitate management? This review compares the tra- stated in Guidelines of National Regulatory Bodies5 and the
ditional model of the human sexual response cycle with website of the International Federation of Gynaecology and
an alternative model whose component parts are frequently Obstetrics.
faulty or entirely missing in the experiences of women
complaining of low sexual desire. Continuous modulation
of this cycle occurs as feedback is obtained from genital
What is meant by low sexual desire
and non-genital physical responses, as well as from emo-
tions and perceptions. The new model illustrates the dif-
The presence of sexual thoughts, fantasies and an innate
ficulty experienced by most women in distinguishing
urge to experience sexual tension and release, alone or with
between desire and arousal and the common lack of both.
a partner, have been considered the markers of desire6. The
There are implications for the management of low desire in
traditional model of the human sexual response cycle of
the context of chronic dyspareunia, chronic infertility,
Masters, Johnson and Kaplan, as shown in Fig. 1, depicts
gradual reduction of ovarian androgen from midlife the stage of desire leading on to arousal, a plateau of
onwards, and for the management of sudden complete loss
heightened arousal which peaks briefly and releases in
of ovarian androgen in premature, surgical or medical
the experience of orgasm(s) to be followed by resolution6.
menopause.
Management has been unclear when the woman is com-
plaining of lack of these presumed markers of desire, but is
neither depressed nor medically unwell, and not taking
medication likely to interrupt her desire.
Prevalence of low sexual desire in women
If women are asked the reasons for agreeing to or
instigating a sexual experience with their partner, their list
Community studies of women point to a 33% – 39%
is extensive7,8. Reasons include wanting to be emotionally
prevalence rate of self-diagnosed low sexual desire1,2 and
close, to show love and affection, to share physical pleasure
low desire is the most common problem for women attend-
for the sake of sharing, to increase a sense of attractiveness
ing sexual therapy clinics3. Of 964 North American women
and attraction, to increase a sense of commitment and
attending for routine gynaecological care from family
bonding, but only sometimes to satisfy a truly ‘sexual’
practitioners and gynaecologists, 67% reported problematic
need. These intimacy-based reasons appear particularly
low sexual desire4. It is accepted that whether studies are
important in the longer term monogamous relationship.
by interview or questionnaire only those women willing to
Even the need for masturbation has varied causes, includ-
be questioned about an extremely private area of their lives
ing to soothe and comfort, to relax, and to sleep but only
will be included. Rather than concluding that some one-
sometimes primarily to release sexual tension.
third of women have a ‘disorder’, the reasons for this
apparently common perception of failing to meet some
sexual standard must be sought. To date, clinicians, includ-
ing gynaecologists, have found management of low sexual Alternative model of women’s sexual response
desire to be highly challenging. Women speak of their lack
of an ‘emotion’ (sexual desire) that they once had or feel A recently proposed alternative intimacy-based model
they should have. The medical response has been largely to appears to be relevant to women by clarifying the com-
D RCOG 2002 BJOG: an International Journal of Obstetrics and Gynaecology
PII: S 1 4 7 0 - 0 3 2 8 ( 0 2 ) 0 1 0 0 2 - 9 www.bjog-elsevier.com
358 REVIEW

stimuli are related more to the behaviour of the partner

during the day, than specifically at the moment of physical
interplay. However, heterosexual women frequently
express a wish both for more non-genital and genital non-
penetrative stimuli, but without sexual intercourse.
Many psychological factors negatively influence the
processing of sexual cues in the limbic centres. Included
are non-sexual distractions, feeling sexually substandard,
past negative or painful experiences, previous discrediting
of the woman’s sexuality, and fears of infertility, preg-
Fig. 1. Traditional human sex response cycle of Masters, Johnson and nancy, sexually transmitted diseases, or fear for her emo-
Kaplan. Reprinted with permission from the American College of tional or physical safety. Sometimes there is a dysphoric
Obstetricians and Gynecologists (Obstetrics and Gynecology, 2001, Vol.
reaction to any physical arousal that takes place, perhaps
98, pp. 350 – 353).
more commonly when there has been past abuse11.
Biological factors are only just beginning to be clarified.
ponent parts of their response cycles that may be faulty or Some neurotransmitters that appear to be ‘prosexual’
absent9. A woman frequently begins a sexual experience include dopamine, oxytocin, noradrenaline, and serotonin
sexually neutral. She, for the intimacy-based reasons via 5HT1A receptors. Some that are sexually negative
described, deliberately finds or receives sexual stimuli that include serotonin acting via 5HT2 and 5HT3 receptors,
potentially could move her from neutrality to a state of prolactin, and gamma amino butyric acid. The production
sexual arousal (Fig. 2). An attempt to include this ‘recep- of prosexual neurotransmitters is decreased with androgen
tivity’ component of women’s sexual desire has been made deficiency. Depression distorts the balance of neurotrans-
in the new definitions and classifications of female sexual mitters, as do anti-depressants and anti-psychotics. How-
dysfunction by the American Foundation of Urological ever, the possibility that some women (and men) may have
Disease10. a stronger ‘inhibitory tone’ that itself may be to some
Many psychological and biological factors may poten- degree innate, is only recently being investigated12,13.
tially preclude arousal, but if the processing of the stimuli in Infrequently, low thyroid or hyperprolactinemic states
the woman’s limbic and paralimbic centres is such that a affect the limbic areas so that arousal is not reached.
degree of arousal is experienced, she can potentially con- Despite achieving arousal and subsequent desire, if the
tinue to focus on the stimuli. Further arousal follows and in outcome is negative, the woman’s cycle is broken and her
time, in addition to her original intimacy-based motivation, intimacy with her partner is not enhanced. Examples include
she achieves definite desire in order to continue the experi- chronic dyspareunia, partner’s sexual dysfunction, effects of
ence for the sake of the sexual tension and sexual enjoyment. medication (e.g. serotonin re-uptake inhibitor-induced
In this cycle, departing from the traditional one, sexual orgasmic disorder or deficient oestrogen or testosterone).
stimuli are integral; arousal is experienced before desire Lack of oestrogen, by reducing the bioavailability of nitric
and orgasm is not mandatory for a normal or healthy oxide, can lead to insufficient smooth muscle relaxation in
response. The power behind the cycle is the couple’s the vulval, bulbar, spongiosal and clitoral erectile tissue,
emotional intimacy and this power or ‘motor’ may be limiting their engorgement. Similarly, vaginal, vascular
enhanced or diminished by the experience itself.

Potential breaks in women’s alternative cycle

The emotional intimacy may be so minimal that the

woman is not motivated to -find or receive sexual stimuli
that could allow her sexual response. Gynaecologists may
not wish to address the intimacy problems themselves, but
they can clarify the normality of the woman’s low desire in
this context. This in itself is therapeutic since the woman no
longer feels that she is labelled as sexually dysfunctional. If
the partners are motivated to improve their emotional
intimacy, professional counselling can be suggested: the
problem is not inherently sexual but to do with the non-
sexual interpersonal relationship.
Frequently, sexual stimuli are entirely absent. The day
is filled with non-sexual interactions. Often the needed Fig. 2. Alternative model of women’s sexual response.

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 REVIEW 359

men, the subsequent physical tumescence itself constitutes

an additive or compounding second level sexual stimulus.
The engorgement is accurately detected and enjoyed. Only
men with chronic situational erectile dysfunction typically
under-rate their physical response16. By contrast, women
in good health typically under-rate their physical
response17. Psychophysiological data of objective increase
in the vaginal blood flow in the laboratory in response to
erotic stimulation repeatedly shows lack of correlation
with the woman’s subjective arousal17 – 19. Thus, women
typically do not have this genital confirmation of their
arousal in any direct way. Many women need direct
stimulation to their congesting vulval structures to receive
that second level confirmatory stimulus20. Clearly, some
sexual styles, particularly intercourse-focused, may pre-
Fig. 3. Blended sexual response cycles. clude this.
There is also moment-to-moment feedback from the
and non-vascular smooth muscle relaxation is impaired emotions21. This feedback may be positive: one of enjoy-
reducing vaginal lubrication and accommodation, respec- ment, pleasurable mood, self-affirmation, or it may be
tively. The action of vasointestinal polypeptide is also negative: one of embarrassment, shame or guilt. Feedback
influenced by oestrogen, and is most likely the major from the genitalia and from the emotions are depicted in
neurotransmitter. It is possible that testosterone is also Fig. 4.
involved in the congestion of the vulva and vagina by Although the term sexual response cycle has been in
regulating a1 adrenergic responsiveness as is postulated common use since Masters and Johnson’s publications, the
for penile cavernosal smooth muscle14. true cyclicity comprises physical, emotional and cognitive
feedback. This is not appreciated in the traditional linear
model.
Blending of traditional and alternative cycles If the emotional response to any perceived physical
arousal is negative (dysphoric arousal), the sexual centres
Clearly, some women, spontaneously or cyclically or may cease to transmit excitatory input to the lumbar sacral
even frequently, experience innate apparently spontaneous centres. For some women, it appears that excitatory neuro-
sexual hunger or need as in the traditional model. The two transmission does continue: the genitalia remain engorged
cycles may blend as shown in Fig. 3. Cyclical spontaneous but the woman does not feel sexually aroused. This
desire may well be related to the mid-cycle peaks of response is typically shown by women diagnosed with
testosterone and androstenedione. arousal disorders, who in the laboratory setting, dem-
Interestingly, many women report easy spontaneous onstrate a normal genital congestive response to erotic
desire early on in a relationship3. However, careful ques- stimuli but feel no subjective arousal18. Similarly, in
tioning clarifies that many sexual stimuli and deliberately clinical settings, women will report that their fingers can
organised sexual contexts were all part of the ‘dating’ detect some genital swelling and lubrication, but massaging
atmosphere such that ‘spontaneity’ was perhaps more
apparent than real. The newness itself, the unpredictability,
even the lack of commitment or legitimacy, may be potent
stimuli in a new relationship.

Modulation of the cycle from somatic and emotional

responses

In men, mental sexual arousal alters the descending

neurotransmission from limbic centres to the lumbar sacral
centres of the spinal cord. Probably this involves increas-
ing oxytocinergic signalling from the paraventricular
nuclei of the hypothalamus with concurrent reduction of
inhibitory serotonergic input, particularly from the nucleus
paragigantocellularis in the medulla15. When this balance
of signalling to the pelvic autonomic outflow occurs in Fig. 4. Somatic (genital) and affective feedback cycles.

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360 REVIEW

scious sexual thinking and sexual needs initiates the sex

response.

Women with chronic dyspareunia

Sharing this alternative model with women allows them

to recognise the multiple consequences of their chronic
dyspareunia. The woman has learned to avoid many sexual
stimuli; any that remain are unlikely to lead to arousal
because of the mindset associated with the anticipated
painful outcome. The couple’s emotional intimacy has
suffered because of the repeated feelings of being hurt,
being used, even abused. Confusion, resentment, anger,
sadness replace feelings of closeness. The needed therapy is
Fig. 5. The repercussions of chronic dyspareunia on the woman’s sex
clearly more than pain management (Fig. 5).
response cycle.

these engorging structures is not appreciated as pleasurable Women with sudden complete loss of ovarian androgen
sexual arousal. The genital physiological response would
appear to be an involuntary reflex mediated by the (uncon- The woman with premature, surgical or medical meno-
scious) autonomic nervous system3 (note the occurrence of pause is more distressed by her inability to respond to
genital response in situations of genital assault and rape)3. formerly effective sexual stimuli than her lack of sponta-
Clearly, the subject of sexual arousal and any lack thereof neous sexual thoughts and fantasies. The androgen needed
is highly complex, with the result that the role of genital for processing the stimuli in generating subjective arousal
vasoactive medication in women complaining of arousal is insufficient. She may also suffer the consequences of
difficulties is far from clear20,22,23. To date, the only lack of peripheral testosterone action on the smooth muscle
large placebo controlled studies of sildenafil given to response involved in vulval and vaginal congestion. The
women have failed to show benefit over placebo23. Of couple’s emotional intimacy may suffer from both the lack
note, these studies (one on oestrogenised and one on non- of rewarding physical times together and the confusion and
oestrogenised women), included women with a broad misunderstanding as to its cause. The breaks in her cycle
range of sexual dysfunction which included lack of arousal. are shown in Fig. 6. In one study28 47 consecutive couples
The arousal disorder was not analysed in any way (e.g. to referred for female low sexual desire were assessed.
determine whether the women were complaining of lack of Although lack of testosterone was felt to be a factor in
subjective arousal or lack of both subjective and genital some 20%, many other breaks in the women’s (alternative)
arousal)22. Current research is attempting to focus on the cycles were also apparent. Of note, in a recent placebo-
use of vasoactive drugs in women with an acquired reduc- controlled study of transdermal testosterone replacement in
tion in genital response and a smaller placebo controlled
study showing benefit of sildenafil in premenopausal
women has been recently published24. The traditional view
that vaginal lubrication constitutes sexual arousal in
women is thus not only restrictive but misleading when
arousal disorder is under discussion. Women tend to focus
mostly on how mentally exciting they find the stimulus
when they rate their sexual arousal18. Future research may
profitably focus on those women who reliably respond
genitally throughout the experience of sexual stimulation
but have no subjective arousal. In other words, there is a
need to identify the mechanisms of the disconnection
between mind and genitalia.
These models of blended intimacy-based and ‘drive-
based’ sexual response cycles with ongoing modulation
from emotional, cognitive and physical feedback include
many concepts of previous authors3,6 – 8,25 – 27. However,
the traditional model familiar to gynaecologists still Fig. 6. The repercussions of sudden complete loss of ovarian androgen on
remains that of Kaplan, Masters and Johnson where con- the woman’s sex response cycle.

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 REVIEW 361

women whose surgical menopause was thought to be the associated with dyspareunia38. Tibolone’s androgenic
cause of acquired low sexual desire and response, benefit activity is thought to account for increased sexual desire
only was seen in the older women and only if they achieved and responsiveness in women receiving tibolone, compared
high normal (as opposed to mid-normal) premenopausal with those receiving either conjugated oestrogen plus
testosterone levels29. No therapy other than testosterone medroxyprogesterone acetate39, or oestradiol plus norethis-
replacement was given. terone40,41. Also, tibolone allowed comparable increases
Little detail is known about the exact role of testosterone in sexual responsiveness compared with oestradiol plus
in either innate sexual need or in the processing of sexual dihydro-androsterone, the latter causing untoward lipid
stimuli. Post mortem evidence of uptake of androgen (and effects42. Of note, these studies were of otherwise healthy
oestrogen) in various areas of the brain has shown highest postmenopausal women rather than women complaining of
levels in the medial preoptic area, medial and basal hypo- sexual dysfunction.
thalamus and the substantia nigra30. Whether testosterone Women of all ages are currently requesting (and in some
needs to be converted in brain cells to both dihydrotestos- centres being given)43,44 testosterone supplementation in
terone via 5a hydroxylase and aromatised to oestradiol to various forms, without safety and efficacy data, and with-
exert its action, as is necessary in rodents, is not clear. The out the documentation that sexual desire and responsive-
practice of giving women aromatase inhibitors after a ness correlate with testosterone (or any other androgen)
diagnosis of breast cancer, may clarify this question. levels, other than those in the supraphysiological range.
Adrenal androgen is nevertheless sufficient for many Additional basic requirements include a testosterone assay
women. Clearly, the sensitivity of androgen receptors sensitive and accurate in the female range. More data are
(currently not measurable in clinical practice) is likely as needed of androgen levels in women of different ages (and
important as blood levels. health status), who do not have sexual dysfunction. Scien-
tific studies of testosterone replacement in peri and na-
turally postmenopausal women are needed, including the
Women with gradual loss of testosterone use of local testosterone in restoring vulval congestion
without necessarily achieving high normal premenopausal
The usual slow decline in testosterone levels from the testosterone levels systemically. Replacing testosterone in a
early 40s onwards appears to be far less often associated pattern that varies through the four-week period to mimic a
with unresponsiveness to formerly effective stimuli31. younger premenopausal ovulating cycle would be a useful
Beginning in the early 40s, some but not all studies strategy to study.
indicate testosterone levels decline progressively but not Discussion of the alternative cycle is helpful in identify-
usually to undetectable levels32,33. Although this slow ing the subgroup of menopausal women who previously
decline appears often to be asymptomatic, certainly some experienced conscious intrinsic sexual desire, and were less
peri and naturally postmenopausal women do complain of aware of beginning a sexual experience from a state of
loss of genital response and mental response comparable sexual neutrality. This particular subgroup acknowledges
with the loss experienced by some women with surgical that their sexual response can still occur but they are
menopause. For both groups of women, loss of energy may dissatisfied; they mourn the loss of their former ‘hunger’,
also be linked to the androgen lack34. Unfortunately, that appeared to be spontaneous rather than triggered.
scientific study of androgen replacement therapy in women Fortunately, adaptation to the need for creating a sexual
is minimal35. We lack both efficacy and safety data. Prior
to the study by Shifren et al.29, there were minimal data on
physiological as opposed to pharmacological doses of
prescribed androgen. Sexual benefit was seen in the oes-
trogen versus oestrogen plus testosterone controlled study
by Davis et al.36 using testosterone implants designed to
give high normal premenopausal testosterone levels; but
interestingly, the women were recruited for bone density
reasons rather than sexual dysfunction. Non-physiological
androgen administration (i.e. methyl testosterone), acting
via the androgen receptor and via reduction of sex hormone
binding globulin (SHBG), has also been associated with
sexual benefit in postmenopausal women but the dose
needed (2.5mg) is associated with unwanted reduction of
high density lipoprotein cholesterol37. Tibolone has oes-
trogenic properties as well as some androgenic activity via
its D4 metabolites and its ability to reduce SHBG. It also
has been shown to improve the effects of lack of oestrogen Fig. 7. The repercussions of infertility on the woman’s sex response cycle.

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362 REVIEW

context (and removing their often self-imposed label of A much-needed area of psychosexual research is the dis-
dysfunction) is possible. connection between subjective arousal and genital conges-
tive response.

Women with chronic infertility

Acknowledgements
Emotional intimacy frequently suffers due to the stres-
sors of multiple medical appointments, investigations, The author would like to thank Dr P. M. Rees for his
adverse effects of fertility drugs, failed cycles, and failed editorial comments and Mrs M. Piper for her secretarial
in vitro fertilisation. The experience of intercourse being skills.
required on certain days, can lead to mechanical emotion-
ally unrewarding experiences. The woman’s sense of sex-
Rosemary Bassona,b
ual self-confidence and attractiveness may suffer, thereby a
University of British Columbia Departments of Psychiatry
inhibiting the processing of any stimuli. The outcome can
and Obstetrics and Gynaecology, Vancouver Hospital,
remain unrewarding owing to the limited psychosexual
Canada
interaction, the focus for so long being on the mechanical b
B.C. Centre for Sexual Medicine, Vancouver Hospital,
act of intercourse, dispensing with erotic play.
Vancouver, Canada
Illustrated in these common clinical situations is the
multifactorial nature of the complaint of low sexual desire
(Fig. 7). Careful integration of any future libido enhancing
medication will be critical20. References

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