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Low Sexual Desire and Difficulties with Arousal: Origins and Interventions
Abnormal Psychology · Chapter 17: Sexual Health, Gender Identity, and Atypical Sexual BehaviorsSection 17.2 · lesson 61 of 9712 min · free with a free account
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In this lesson
Origins, a contested classification, and treatment aimed at the person's own goals.
- Describe the desire and arousal categories, and the debate about them
- Distinguish responsive from spontaneous desire
- Explain the contributors, and the cycle that maintains the difficulty
- Describe treatment, and what the evidence supports
Transcript
Everything said in the video, section by section (1,624 words). Read along, or search it.
Sexual Health, Gender Identity, and Atypical Sexual Behaviors
Low Desire and Arousal Difficulties
This section covers low sexual desire, and difficulties with arousal. We look at how the categories are drawn, and at a genuine debate about how they are divided. We separate responsive desire from spontaneous desire, which does more clinical work here than anywhere else in the chapter. Then we look at the contributors, the cycle that keeps these difficulties going, and what treatment can honestly offer.
Before You Begin
2 Ideas, Hard to Separate
As before, this is educational and clinical material, not a basis for diagnosing yourself or anyone else. Concerns belong with a qualified professional, and medical assessment is part of that. Two terms first. Desire means interest in, and motivation toward, sexual activity. Arousal means the physiological and subjective response once activity has begun. They are distinct in concept, but hard to separate in practice. Interest that is not followed by response tends to fade. And response that occurs without interest is often experienced as absence, rather than presence. One principle runs through the whole section. Treatment aims at the person's own goals, never at meeting someone else's expectation of them.
The Current Categories
3 Categories, Described in Paraphrase
Three categories occupy this territory. We describe them in paraphrase. The first is defined by persistently deficient or absent sexual thoughts, and desire for activity, and is classified in men. The second is defined by difficulty obtaining or maintaining an erection during activity. The third is a combined category in women, covering reduced interest, reduced arousal, and reduced responsiveness together. Each carries the shared requirements from the last section. Duration, most occasions, distress to the person, and the exclusions. And the specifiers apply throughout. One requirement does a great deal of work here. Asexuality must be excluded before any desire diagnosis is made. A person with little sexual attraction who is not distressed by that fact does not have a dysfunction. The classification says so explicitly.
The Classification Controversy
Combined for Women, Separate for Men
Notice something about those categories. Desire and arousal are combined into one category for women, and kept separate for men. The reasoning offered is empirical. Research on women's reports suggests the two are less separable in experience than the linear model assumed. People often cannot tell them apart when asked. On that reading, the combined category describes experience more accurately. There are two criticisms. First, if the argument holds, it should apply to everyone. Keeping separate categories for one group encodes an assumption about difference, not a finding. Second, combining categories hides which aspect of function is actually affected, and that is the information the classification exists to convey. This question should not be resolved in either direction at this level. What you should take away is that the asymmetry exists, that it is contested, and that both sides argue from evidence, not only from politics.
Table 17.2.1
The Dispute Is About Shape, Not Existence
Here are the three categories side by side. The separate desire category assumes that desire and arousal can be distinguished in what people report. Erectile difficulty is the most physiologically visible of the categories, and that shapes how it tends to be investigated. And the combined category is defended as more accurate to report, and criticized as an asymmetry without a stated principle. Notice what the dispute is about. It concerns the shape of the categories, not whether the difficulties exist.
Patterns of Desire
Spontaneous and Responsive Desire
Now the distinction from the last section that does the most work here. Spontaneous desire arises before an encounter, and prompts it. Responsive desire arises after arousal has begun, in response to context and stimulation. Both are ordinary patterns. If you traced them across an encounter, one would rise before it begins, and the other after. But both reach the same place. The difference is timing, not capacity. Neither is a stage of development that the other has failed to reach. The clinical consequence is a false positive that is common, and avoidable. A person with a responsive pattern compares themselves with a spontaneous norm, absorbed from media portrayals and casual conversation, and concludes something has gone wrong. And a clinician who shares that norm agrees with them. Psychoeducation that corrects this is often the most useful early intervention there is. It is not a consolation prize. It corrects an actual error.
Desire Discrepancy
A Relationship Matter, Not a Disorder
A difference in the level of desire between partners is a relationship matter. It is not a disorder located in the partner with lower desire. That should be stated as plainly as that. And because it is the most common presentation in this area, the point is practical, not theoretical. Two things follow. The first is diagnostic. The classification requires distress belonging to the person. So a person untroubled by their own experience does not meet the description, however dissatisfied their partner is. The second is therapeutic. Suppose the goal of treatment is to make someone want, what another person wants them to want. That is not treatment. A clinician who accepts that goal has taken a side in a relationship dispute, while appearing to be neutral. What is offered instead is a reframing at the level of the couple, where the difficulty actually sits, with work on communication, pressure, and expectation. That is often a relief to both partners. The person with lower desire stops being the patient, and the other stops being the complainant.
Biological Contributors
Medical Assessment Is Required
On the biological side, hormonal, vascular, and neurological factors, chronic illness, fatigue, and sleep disruption all bear on desire and arousal. So do medication class effects. A person who notices a change after a change in treatment is describing something real. The right response is a prescriber-led review, not a private decision either way. Medical assessment is required, not optional, and a psychological formulation never replaces it. Life-stage factors belong here too. Postpartum periods and the menopausal transition both change sexual response for many people. These are normal transitions, not pathologies. The clinical question is whether the person is distressed, and what would help. It is not whether their response matches an earlier stage of their life.
Psychological, Relational, Sociocultural
Attention, Belief, and Obligation
Psychological contributors run mainly through anxiety and spectatoring, which the last section explained. Depressive presentations reduce interest and response directly, and when that is the case, treating the depression is the intervention. Stress and body image concerns also turn attention inward. Beliefs are often the most tractable contributor. Early restrictive or shaming messages, expectations about what should happen, and beliefs about what a difficulty means about the person. Relationally, conflict, resentment, and loss of closeness reliably reduce interest. And poor communication compounds everything, because partners who cannot talk about a difficulty usually infer something worse than the truth. One relational contributor deserves its own name. Obligation. A sense that activity is owed, or that refusal will bring a consequence, is among the most effective suppressors of desire there is. Culturally, scripts, media expectations, and religious frameworks matter. They are worked within, not against. And distress may come from the gap between experience and framework, not from the experience itself.
Figure 17.2.3
The Cycle That Maintains the Difficulty
Whatever starts a desire or arousal difficulty, a recognizable cycle usually maintains it. A difficulty occurs. Anticipatory anxiety then attaches to the next occasion. Attention turns inward, and self-monitoring replaces engagement, which reduces response further. Then sexual situations are avoided. That prevents any disconfirming experience, and raises tension in the relationship, which makes the next occasion harder still. Look at the avoidance step in particular. It converts a difficulty that might have resolved on its own into one that persists. It is the same avoidance mechanism described in chapter eleven. And it is why treatment does not start by trying to restore function directly. The cycle has to be interrupted first.
In the Clinic
Formulate at the Couple Level - After Medical Assessment
Two notes from the clinic. First, a couple often arrives with the problem already framed. One of them has a problem, and the other has brought them. Accepting that framing is the most common error in this area. What helps is to establish early, with both present, whose distress is at issue. And what each person thinks the difference means, about them and about the relationship. The meanings are usually the painful part. Reframing it as belonging to the couple is not a diplomatic maneuver. It is the accurate formulation. Second, medical assessment comes first, even when the story sounds psychological, and especially when the person talks articulately about stress. A difficulty with a physical or medication-class contribution will not respond to psychological work aimed at the wrong target. And the person will conclude that they have failed at treatment.
Treatment
Principles, Not Steps
Treatment is described here by principle and rationale. The specific methods are delivered by trained clinicians, and are not set out as steps. Psychoeducation and expectation correction come first. They are often sufficient on their own where the difficulty rests on the spontaneous-desire assumption. Cognitive-behavioral work targets anxiety, spectatoring, and the beliefs that sustain both. Attention, rather than performance, is the target. Couple-focused work addresses communication, pressure, and obligation, including non-demand intimacy, meaning contact with no expectation that it leads anywhere. Mindfulness-based approaches target the attentional part. The evidence supports them as a useful component, rather than a complete treatment. And medication and hormonal approaches are described by class only. Decisions rest with a prescriber, and combined approaches generally do better than any single one.
On Outcome
Honest Goals: Satisfaction and Distress
On outcome, honesty is required. Desire difficulties are among the harder presentations in this area to treat. Outcomes are better when goals are set in terms of satisfaction and reduced distress, rather than in terms of frequency. A treatment that leaves a person less distressed, better informed, and no longer avoiding has achieved something worth having. That holds even where frequency has not changed. So, to draw the section together. Responsive desire is ordinary, and mistaking it for a deficit is a common false positive. Desire discrepancy belongs to the couple. Medical assessment comes first in every case. And treatment interrupts the cycle, targets attention rather than performance, and aims at the person's own goals.
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