By Dr. Joy Davidson
Dear Dr. Davidson:
I read about hormones and libido every time I open up a magazine. One minute, hormones are the next best things to a diamond bracelet for stirring up desire; next minute, they’re too risky, or aren’t proved effective. I’m 56. My kids are out of the house — finally! — and I’d like to take advantage of a reasonably good 24-year marriage to enjoy my sex life. But the animal urge is weak and there always seems to be something better to do. I’ve read books on how to “rekindle desire” and articles on spicing things up. It all makes sense, and then I think: “I’ll start tomorrow.” Please tell me: What is really going on here.
—Puzzled Reader
Dear Puzzled Reader,
Like you, millions of women are desperate to understand the effects of aging, of hormones, and of long-term love on their sexuality. I’ve decided to focus my inaugural article for NYCPlus entirely on your concerns, because you speak for so many women and their partners.
Think about it: Roughly a third of a woman’s life unfolds after natural menopause. Yet women of the baby-boom generation — the torch-bearers of feminism and sexual freedom — are the first group to stand up and demand an investigation into how that passage affects their health, psyches, and especially their sexuality. Baby Boomers also constitute the first “quick-fix” generation, teeming with bona-fide superwomen who expected for better or worse to have it all—the big job, the loving family, and the comfortable home. So it makes sense that we’d tackle the perplexities of midlife the way we’ve managed just about everything else—speed dialing all the way.
The trouble is that science has not quite caught up with our penchant for quick fixes or beam-me-up therapies, and the fact that we have to slow down in order to tease apart and digest all the accumulated bits of information threatens to drive some of us a little batty.
Ask ten healthcare professionals about hormone therapy for midlife changes and you’re likely to hear at least seven different replies. Meanwhile, it has become common for women to supplement the female hormones, estrogen and progesterone, for symptoms like hot flashes, night sweats, and some of the more troublesome sexual conditions like reduced genital sensation, vaginal dryness, tissue thinning, and bladder problems. At the center of the debate over prescribing E and P for these physiologically identifiable conditions, however, are the effects on women’s long-term health — not enhanced sexual function.
When we consider the androgen hormones like DHEA-S and testosterone, such careful concerns about overall health are replaced by a firestorm of controversy. First of all, symptoms that open women’s minds to the suggestion of supplementing androgen hormones are largely subjective (lowered erotic interest, difficulty with sexual arousal, changing quality of orgasm), and factions within the women’s health movement are at odds over the risks of steroid use. Add to this the larger and even more heated debate over “medicalizing” women’s sexuality, seen by some as a means of capitalizing on questionable sexual “disorders” for the benefit of pharmaceutical marketing.
We know that steroid hormones do play a role in women’s sexual well being, but we don’t know enough about how they act in the body, naturally or as supplementation, to make sweeping claims about how they might benefit postmenopausal women. In fact the latest studies indicate that testosterone (T) is no panacea. Blood levels of androgens fail to predict whether a woman will experience diminishment of sexual desire, and in trials for the testosterone patch, while sexual activity increased for those given T,
it also increased for those given a placebo. Nevertheless, androgens are prescribed “off label” by many practitioners with reported success. In my own sex-therapy practice, I’ve seen good results in selected cases in which T was used in conjunction with psychotherapy. But there is no way for me to know what proportion of those results was attributable to the hormone.
Still, our determination to ask questions and the fact that so many of the researchers in the sexual-health field today are feisty women over 40 has indeed led to progress. For instance, we now know that diminished sexual desire—the most common sexual complaint among middle-aged women — is a more complex, contextual, and nuanced matter than menopausal changes can explain, or that hormone therapy alone can resolve. And that’s the good news, because it means that women needn’t be so quick to rush out in search of prescriptions for anything more elaborate than scrupulous self-examination of their own lives and relationships.
Here, based on some of the most advanced thinking and research, are a few points to consider as you contemplate your situation and work toward illuminating your next step:
There is no such thing as “low libido.”
“Libido” is commonly used to represent innate sexual drive, as though some folks receive more or less of the precious stuff before birth, and as though it can be measured, like blood pressure. Consequently, we worry that we can just use up our libido, or that when we reach a certain age the libido we once had will disappear — poof! This concept of libido as a tangible “thing” breeds the false assumption that our sexual bodies can be understood outside the context in which they live, love, and learn –which is a grave mistake.
Rather than speak about libido, I find it more useful to delineate the facets of our sexual experience that ebb and flow throughout the life cycle. We can speak of sexual desire: feeling it for someone, or wishing we could feel more of it; learning what generates or depletes it. We can explore arousal: the awareness of heightened stimulation and the flow of intensely pleasurable sensation. We can talk about orgasm: having them on our own, changes over time, and what we can do to make them happen with a partner. We should also acknowledge that for many women, desire and sexual satisfaction are not entirely dependent upon orgasm. In fact, unlike men, women are much more likely to report being pleased with their sex lives when sex is reliably pleasurable (with or without consistent O’s), or when it leaves them feeing emotionally connected with their partners – or, better yet, both.
Women’s sexual responses are different than men’s. (No, it’s not just you!)
The original Masters and Johnson model of human sexual response was based on a linear, male pattern. Because men are known to experience desire (i.e., horniness) like a bolt from the blue, M & J supposed that women, too, usually first felt surges of desire, then proceeded to glide through stages of arousal and orgasm — just like men. Now we know that women’s sexual patterns are actually more circular.
It wasn’t until the late 1990s that Dr. Rosemary Basson, a Canadian researcher, suggested a women-centered model of sexual response, reflecting what women already knew from long experience: that we sometimes feel desire only after beginning to engage in pleasurable sexual activity. That is, desire does not necessarily come crashing over us like a tidal wave; we have to splash about in the waters of erotic sensation before we feel its gravitational tug. This helps to explain why women with reduced desire may also complain of difficulty becoming aroused. If a woman isn’t getting the kind of stimulation — mental, emotional, or physical — that excites her, then desire may never happen at all.
Lack of arousal and/or desire is first and foremost a relationship and social issue.
When we look at studies of sexual desire and satisfaction, we discover that hormones are actually the least potent factors when weighed against psychological, cultural, and relational variables.
The onset of menopause often coincides with decades of wedded bliss — or blistering. It also corresponds with the effects of partner-aging on health, sexual performance, sexual self-image, and overall self-esteem. Lessening of desire and/or arousal may be primarily owing to lack of sufficient (or sufficiently skilled) erotic touch, lack of knowledge or willingness to seek satisfaction, poor attention to one’s own sexual feelings, sexual desires or fantasies that are incompatible with a partner’s or produce guilt, negative emotions about sex, rancor toward a partner, and the effects of a partner’s illness or sexual dysfunction.
Ideas about age-appropriateness can also thwart women’s sexual experience and squelch permission to be unabashedly sexual. Pummeled on a daily basis by magazine and television ads that set up a tyrannical standard of beauty, women are constantly being reminded that truly sexy sex belongs only to the young and the lovely. No surprise, then, that in one study of 500 women over the past three years by Deborah Nedelman, Ph.D., and Leah Kliger, MHA, 51 percent of middle-aged women said that they’d lost desire because they were unhappy with their bodies. To regain sexual power, women have to recreate and redefine the very concept of sexy sex over 50.
Past experience predicts satisfaction.
Unlike a mutual fund, a woman’s past sexual performance actually predicts future erotic returns. Our prior experiences have strong influences on our expectations and attitudes toward pleasure and love in mid-life. While it appears that in younger women, hormonal output partially protects against the damaging effects of painful events (including early sexual abuse), middle-aged woman tend to lose that benefit. However, a longstanding, hearty sense of sexual vitality can override the influence of hormonal changes.
Unmarried middle-aged women may be more sexually satisfied. (Uh-oh!)
“HRT should stand for Husband Replacement Therapy,” said one of my clients. She told me that she’d been taking hormones for three years with the hope of rekindling desire before she realized that what she really needed was “Henry replacement.”
A Japanese study presented at the World Association for Sexual Health this past June assessed sexual satisfaction in married and unmarried people over 40. Male satisfaction seemed to be unaffected by marital status, while for women, satisfaction was greater among the unmarried. Unmarried women felt their sexual relationships were rich, fulfilling and—perhaps most importantly — they saw themselves as key players in the relationship. These women, in contrast to their married counterparts, felt that their partners understood and responded to their needs. Other studies indicate that women who lost desire in long-term relationships were able to reawaken their erotic feelings in new relationships, although there’s no doubt that at different stages of life we have different needs, and may seek different qualities in a partner. I see this all the time in my practice. At one stage, women are looking for somebody who will be first and foremost a good father or provider—at another stage, a good lover and companion. I am not extrapolating from this data that the solution to dwindling desire is to dump an old partner and get a new one, but we do see once again how the power of experience affects the dialogue between our physical and emotional selves.
There’s no doubt that women can remain sexually vital, excited, and exciting at any age so long as we continue to “own” and embrace our sexuality, or in some cases, learn to celebrate it fully for the first time. Some women need help pushing through the accrued psychological and relationship barriers to sexual excitement and pleasure, perhaps with the aid of a sex therapist. But merely waiting for the magic of a patch or pill is not the answer now, nor may it ever be. We’re complicated creatures, we women. Science is not likely to find a cure for that — nor should we want one.
