Episode 400: Women’s Most Common Sexual Problems
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You're listening to the Sex and Psychology Podcast, the sex ed you never got in school and won't get anywhere else. I am your host, Dr. Justin Lehmiller. I am a social psychologist and research fellow at the Kinsey Institute and author of the book, Tell Me What You Want, The Science of Sexual Desire and How It Can Help You Improve Your Sex Life. The most common sexual problems that women experience center around low sexual desire and difficulty becoming aroused.

In the past, low desire and low arousal were considered to be separate issues. However, it has become apparent that women who experience problems with one often experience problems with the other. And that's why the current version of the DSM, which is the psychiatry bible, now lumps them together under a single category called female sexual interest/arousal disorder. In today's show, we're doing a deep dive into this disorder.

We're going to talk about how it's clinically defined, why problems with arousal and desire so often go together, how common this is, and why it seems so difficult for women who have this disorder to get treatment. As we'll discuss, among women seeking help for it, it takes an average of about five years to access treatment, which is a huge problem. We'll also discuss whether there are any drug treatments for it and why it's so hard to create a medication that can stimulate desire on demand.

I am joined by Dr. Lori Brado, an internationally recognized leader in sexual health research. She is a professor in the University of British Columbia, Department of Obstetrics and Gynecology. Lori is a registered psychologist and holds a Canada Research Chair in Women's Sexual Health. She is author of the fantastic book, Better Sex Through Mindfulness, How Women Can Cultivate Desire. This is going to be another amazing conversation. Stick around and we're going to jump in right after the break. ♪

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Hi, Laurie, and welcome back to the show. Hi, Justin. Thanks for having me. Well, thanks so much for joining me. So we're going to be talking all about women's most common sexual difficulties today. And in the next episode, we're going to talk about ways of treating them. So the most common sexual difficulties that women face in the bedroom typically revolve around sexual desire and arousal. And when they become clinically significant, they may be diagnosed as female sexual interest arousal disorder. So

So what can you tell us about this disorder in terms of what it looks like and how it's clinically defined? Yeah, great question. I'm so glad we're having this conversation because as you said, low desire, distressing low desire is the most common of the sexual concerns actually across genders, not just among women. But, you know, if we think about desire as a motivation for sex,

Low desire would be the opposite of that, either a reduction in your interest in sexual activity or for some people, an outright absence of desire for sex. So typically, folks will say, I never think about it. I don't initiate anymore. When my partner initiates, you know, I shrug, I avoid it. I intentionally go to bed at a different time.

really common. And for about 20% of women, those symptoms are really distressing. And so they'll say things like it interferes in my quality of life, it interferes in my relationship, it takes a toll on my mood. So again, really glad we're having this conversation about low desire.

Yeah, so when we're talking about low desire, the key thing that would make it clinically significant would be it's causing a lot of distress in your life or it's causing some significant impairment in relationships or other aspects of life, right? So if you have low desire but you're not bothered by it, it's not really a sexual dysfunction, right?

That's right. Yeah. So if we look at how we formally categorize or classify sexual problems as dysfunctions, there's different systems we use. In mental health, we tend to use the Diagnostic and Statistical Manual, Mental Disorders, or DSM-5.

And so there is a requirement that in addition to experiencing the low desire, that it creates what we call clinically significant personal distress. So that means to you, it's bothersome. Not that society is creating, you know, stereotypes and making you feel like there's something wrong with you. It has to be personally distressing to you. And so it really is that combination. So let's take the case of a person who says, you know, I'm not interested in sex.

I don't have attractions to people. It doesn't bother me. This is who I am. We'd probably say that that person is an asexual person and there's absolutely no reason that we or anyone should attempt to change that person's desires or attractions.

So clinically, and because I'm a clinical psychologist, you know, really important that we ask questions like, how does this interfere in your life? How does it show up for you? Do you worry about it? Do you think about it a lot? Does it impact your sense of self? So that's where we're getting at that clinically significant personal distress part of it.

Yeah, and I totally agree. We shouldn't be creating problems where they don't exist, right? And you can think about this in a lot of different ways. You know, for example, let's say you have a man who ejaculates very quickly, you know, within 30 seconds to a minute. But let's say that he's not bothered by it and his partner isn't either. You know, some people actually find rapid ejaculation to be very erotic because they interpret it

as like their partner has this uncontrollable lust or attraction to them. And so it's not an issue in their relationship, right? So it's one of these things where there has to be that personal distress component in order for it to kind of meet that threshold of a dysfunction.

Absolutely. And Justin, I'm going to give you another example where that early or rapid ejaculation is actually a positive thing. And this is among those women who have pain with sex, right? So those are the women who say, oh, I want sex to go as quickly as possible. I enjoy it for a short period of time, but I don't want it to last, you know, 30, 40, 50 minutes. So yeah, again, thanks for highlighting the distress part of it. Yeah, it really depends on the context.

So female sexual interest arousal disorder is actually a relatively new diagnosis. It's only been around for a little over a decade. And prior to that, it was actually split into two different diagnoses in the DSM. There was one that covered low sexual desire and a separate one that covered difficulty becoming or staying aroused.

So I wondered if you could tell us a little bit about this shift in terms of why arousal and desire problems were kind of merged into one category instead of being treated as separate entities like they were in the past.

So thanks to a lot of really good sex research that we've been seeing, thanks to Viagra and certainly women's sexuality, the research studying women's sexual health. I mean, it was almost non-existent prior to Viagra's approval in 1998. And so what happened is Viagra was approved and then people started saying, huh,

What about women? What does women's arousal look like? Could Viagra work for women? And it really ushered in this just explosion of research into women's sexuality, including the nature of desire and the nature of arousal. And there's been many different studies, you know, looking at people who have clinically difficulties with desire and arousal or in the laboratory studies. And I know you've talked about it a lot on the podcast, Viagra.

you know, studying the sexual response when people are watching erotica. And I think one of the quite consistent findings that we've seen in the research is for self-identified women that arousal and desire, they can emerge at the same time. They're often indistinguishable. And even when you ask people to describe desire and arousal, ask women to describe desire and arousal, they tend to describe them in almost the same way.

And that's quite different from some of the research that we see with men where we can almost quite easily differentiate, you know, the motivation desire for sex versus arousal, which often corresponds with erection and physiological response.

So in the DSM-5, and I had the opportunity to be one of the folks on that committee that was looking at the diagnoses, we really looked at the literature, which said, even for a lot of those women with low desire, they have these concurrent problems.

arousal difficulties. They have trouble getting aroused in their body. They have trouble reaching orgasm. They're not feeling pleasure. And so it made a lot of sense to kind of bring those both into the same condition, recognizing that different women might experience it in different ways.

And so the formal diagnosis, as you said, sexual interest arousal disorder, a woman needs to experience three of six symptoms and then have significant distress by that. So you might have a woman where the problem is really specifically focused on desire. She's not interested. She's not initiating. She doesn't have erotic thoughts and she's distressed. That would fulfill the criteria. And then you might have another woman who,

Who, in addition to the low desire, she's not feeling pleasure in the body. She's not getting aroused. She's not having, you know, lubrication and the other signs of arousal. And she too would meet criteria for sexual interest arousal disorder. So that was the real shift from the former DSMs to the current one.

Yeah. And that makes sense. But it also highlights how this is a complex disorder in terms of the fact that the presentation might be very different across different individuals in terms of whether it's more focused on desire or arousal or both. Yeah.

So how common is this? I think you mentioned earlier that we're talking about roughly 20 to 30 percent who might find it distressing at a given point in time. But are there certain ages or stages of life where this becomes more problematic or where it's a bigger issue?

So if we look at just desire and not including the distress criterion for both women and men, and there's a tiny bit of data on gender diverse people. So pretty much across the board, across genders, desire decreases with age fairly consistently. With men, it's very much associated with the decline in testosterone levels that happen every year. And around the age of 50, it declines to a level that might impact their sexual function.

But interestingly, in women, if we also look at, okay, they have low desire, are they distressed by it? We see this trend and a number of studies have found this, that actually with age, the distress lessens over time. So the peak of low desire and being distressed by it in women is at about age 51, which perhaps coincidentally is the same age of menopause in North America. Right.

But I know you've done research on menopause and it's an interest to you and probably to a lot of your listeners. And so, you know, I think the important thing is that what's happening in those older ages that they're no longer distressed by is, is it that they kind of get used to it? Is it that they find other ways of experiencing sexual fulfillment and satisfaction? Yeah.

that doesn't hinge upon having a level of desire. I think that's one of the big research questions that we really don't know. But again, that peak age of about 51 in women is when you're going to see the highest levels of low desire that are distressing.

So interesting. Now, something I wanted to get your take on is the distinction between female sexual interest arousal disorder and responsive desire. I've seen some lively discussion about this on social media, where some people seem to think that these are just one and the same. So for example, some people argue that responsive desire is just a way of repackaging low sexual interest and arousal, while others seem to think that this disorder is

pathologizes responsive desire, which for many women is the primary way that they feel desire. So are we talking about two different sides of the same coin here or are female interest arousal disorder and responsive desire two totally separate things?

Yeah, my view is that they are two totally separate things. First off, it's important to recognize that the kind of contemporary ways that we think about desire as something that strikes you out of the blue and you're kind of minding your own business and suddenly you're horny and you must have sex with someone. That's a really outdated view of desire. Not

totally absent altogether. Because again, if you're in a brand new relationship or you're suddenly away on a vacation somewhere beautiful or someone really turns you on in a way that only works for you, you're probably going to have those spontaneous, seemingly spontaneous feelings of desire. But as you appropriately said, Justin, for a lot of women and for people in general in long-term relationships,

the much more common way that desire shows up is it kind of emerges during a sexual encounter. So maybe at the outset of an encounter, you have some motivation to engage in sex, but that motivation doesn't have to be that you're feeling in the mood for sex per se, right? But you still need to be motivated. Maybe it's to get that orgasm. Maybe it's to get that emotional closeness. Maybe it's to be able to fall asleep. Maybe it's to celebrate a birthday, what have you, lots of different reasons, right?

But then as the encounter continues, and as long as the kinds of touches, the kinds of stimulations are the ones that work for you, right? They elicit your excitement. They elicit your pleasure and arousal. Guess what? Your motivation for that is going to grow over the encounter. And so we call that responsive desire because it's that wanting that emerges in response to arousal and touch and stimulation. Right?

So we don't want to pathologize this. We don't want to say that this is a sexual dysfunction. In fact, we want to celebrate it. And clinically, because I see so many women with low desire, as soon as I explain responsive desire to them, they suddenly feel empowered. They suddenly feel like, oh, I thought desire was something that was totally out of my control. And I just had to accept that at a certain stage of my relationship or age that I had lost it.

And this has given me hope and confidence. And, you know, I feel sensual again that actually there's a lot I can do. I can focus on the kinds of stimulation that I want that bring out my pleasure. I can focus on being present and being mindful and concentrating on the arousal. I can, you know, influence other things in my environment that can cultivate this responsive desire. Yeah.

So we don't want to pathologize it or say that it's a disorder. In fact, we want to say this is a wonderful way to continue to have desire for decades, right? For the rest of your relationship, for the rest of your life. There's no reason why someone, you know, can't have this kind of desire well into the older years.

Yeah, so responsive desire is a totally different thing than this sexual interest arousal disorder. Although some people may be convinced that they have a disorder of low desire simply because they don't experience spontaneous desire. So you can see how some people might confuse these things if their understanding of desire is that it's supposed to be this thing that hits you out of the blue. And if you don't experience that, that there's something wrong. And the reality is we need to normalize that different people experience desire in different ways.

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So what do we know about the causes of low sexual interest and arousal? You know, is this biological? Is it psychological? Is it a bit of both? What's the underlying mechanism?

Yeah, so the answer is yes, Anne. It usually always is. It usually always is. I mean, we in sex research, we generally accept that the brain is the biggest sex organ. So because the brain is the biggest sex organ, there's all sorts of brain-related things that can interfere with desire, biologically, psychologically, and socially. So biologically, if you're taking a medication...

let's say, like an antidepressant that can interfere with the brain's processing of sexual cues, we know that that can impact sexual function and sexual desire.

But on the more psychological side, we also know that other things that impact the brain psychologically, like chronic stress or depression or worries or ruminating about how the sex is going to go, et cetera, those can also directly impact sexual desire. And all of these examples I'm giving you, I think, bring to life a lot of the amazing research that our colleagues in the field have shown. On the kind of social and cultural front, we also know that societal or cultural beliefs

or religious beliefs, or if you belong to a particular ethno-cultural groups that has certain messages around when you're allowed to have desire and when you're not allowed to have desire, that too can impact your desire for sex. So as an example, if you grow up in a household, whether it's from religious influence or cultural influence that says,

absolutely no sex until marriage and you find yourself having libidinal influences as a teenager, but you're very afraid of the repercussions of that, that's going to take a toll on your sexual desire even later on in life.

So I think first and foremost, we want to look at the brain's influence on desire, but also other facets of sexual response. And then, of course, the body plays a role, right? So if you have heart disease or any sort of concurrent medical issue that's going to impact the blood vessels of the body, a very clear example in men would be, you know, heart disease and high blood pressure and having difficulties with erections. But you can see the same thing in women, right?

So you can see difficulties reaching orgasm, being associated with heart disease or being associated with high cholesterol, high blood pressure. And although I'm talking about arousal and orgasm, if sex doesn't feel good and you're not having pleasure, that's going to take a direct toll on your sexual desire.

So really important that whether you're a psychologist or a mental health provider or you're a physician that focuses on the body, that you're kind of looking at all different organ systems. I like to start with the brain, but that you're really looking at what might the different organ systems or the skeletal system or the muscular system, et cetera, and problems in those systems be contributing to the problems with low desire.

Yeah. And so as you've described here, desire is complex. And I think that's one of the reasons why it can be difficult to treat in many cases, because there might be a lot of different factors that are at play here. And, you know, there could be something on the sociocultural side, like your religious background and upbringing and the cultural environment in which you're embedded, but there can also be relational factors.

It could be due to age-related changes and going through menopause and so many other things. So yeah, desire is complex.

Now, despite being incredibly common, female sexual interest arousal disorder is something that a lot of women never get help with. And something I read in one of your papers is that even among women who are seeking help, it takes an average of about five years to actually enter treatment. So what's up with that? You know, why does it seem so hard for so many women to get help with this problem?

Yeah, so there might be reasons on the part of the individual seeking treatment themselves, right? They're embarrassed. And I think despite the fact that we feel like we live in a sex-saturated society, there's still rampant taboos and stereotypes and

You know, I myself feel a bit embarrassed when I want to talk to my own primary care doctor about sex or, you know, difficulties I might be having. And so on the part of the person themselves, whether it's embarrassment or shame or fear of this taking too much time or frankly, not having access to treatment and not knowing where to go or maybe not having the resources or what have you live in, you live in a rural community and there's no care providers around you.

And then there's a whole set of, I think, a much longer list of reasons on the part of care providers. So if we look at medical schools, for example, and I do a lot of teaching in our own medical school at University of British Columbia, almost none of them have training in medical school focused on sexual function. Right. So here we have, we're producing these incredible doctors and the vast majority don't even know how to ask a person about, you know, how's your sex life?

Or are there any difficulties relating to your sexual health you want to talk about? So they're not getting trained. Doctors themselves have their own taboos, right? So just as we as individuals or care seekers might be feeling shame and stigma, guess what? Doctors are not immune to that. So they might feel like, oh gosh, I can't bring this up with my patient. You know, we focus on your diabetes and we focus on the other important parts of your life. I can't suddenly derail this and talk about sex.

I think all of these problems we can change on the part of people themselves. The more we have good sex education at the youngest possible age and we normalize sexual health as a part of health, then people will grow up feeling like, okay, in the same way that I talk about my knee pain or my diabetes, I also talk about my sexual health.

And then on the provider front, it's not that hard to include some curriculum in medical school in addition to other healthcare provider curricula on sexual health. So it's all within reach.

Yeah. And I think so much of this issue really does stem from inadequate sex ed for our healthcare providers. You know, the statistics I've seen suggest that in U.S. medical schools, physicians in training are getting about 10 hours total of sex ed across their four years of med school, which is not quite enough time to cover everything they need to know about sexual health, sexual dysfunction, sexually transmitted infections, right? Gender and sexual diversity and all these other sorts of things. So...

you know, we're not really equipping them with the tools and skills they need. And then when they have patients who come in with sexual health problems and issues, oftentimes they just don't really feel equipped or prepared with how to deal with them. And I think that's a big part of the reason why one of the most common pieces of sex advice that doctors give to women, whether they're dealing with pelvic pain or issues with desire or arousal, is they tell them to just relax and have a glass of wine, right? Like that alcohol is the solution for all of women's sex problems.

Yeah. Not to mention that alcohol at higher doses can directly interfere with arousal and make it harder to feel pleasure. And so, yeah, the messaging is, you know, not only wrong, it's totally dismissive. And then so women will feel, wow, like it took so much courage for me to talk to a healthcare provider. And then I was told, you know, it's all in my head, have a glass of wine. You must not care for your partner. There's going to be very little motivation to get a second opinion.

Yeah. It's like you build up the courage to tell your doctor about this and then they want to give you a prescription for boxed wine. You know, it's like, yeah, just wrong. Just wrong.

So in the eyes of many, the solution to all of this would be to have some type of pill or medication to treat the issue because it could be widely and easily accessed and have immediate effects. And pharmaceutical companies would love this. You know, they'd love to have a blockbuster medication for women's most common sex problem that would rival the sales of Viagra, which treats men's most common sex problem.

However, finding an effective medication for this issue has proved to be pretty elusive. You know, it seems to be pretty darn difficult to create a pill that instantly creates desire. So what are your thoughts on this? Should we be pursuing a pharmacological solution here, or do you think the disorder is better treated in other ways?

Yeah. So, you know, I am a psychologist, which means my methods involve talk therapy. But at the same time, I'm a big proponent of having as many different options as possible so that people can make the decision that's right for them. And while we've got great evidence for psychological treatments for not just low desire, but really all of the sexual problems, there may be really good reasons why people are not accessing that psychological treatments. Again, some of the reasons that we talked about earlier, but also cost.

So a lot of these more psychologically based healthcare providers are not in systems where it's covered by insurance or their medical services plan. So I do think that there's a real need to have a variety of different options, including sexual pharmaceuticals. The problem, however, is that here we are in 2025, we have two approved sexual pharmaceuticals for low desire in pre-menopausal women only, not post-menopausal women.

And they're frankly terrible. I can give you a concrete example, a client of mine, a female patient with low desire. And we had spent quite a bit of time using all of the evidence-based psychological tools in my toolbox. And we realized that for her, you know, there was a real advantage in trying a sexual pharmaceutical approach. So one of the medications we can't even access in British Columbia, and that's the injection medication called brimelanotide,

You inject yourself under the skin before planned sexual activity. It travels up to the brain. It impacts the melanocortin A receptors in the brain. So we can't even get it where I live. The other medication, flubanserin, which is a pill that women take daily in the clinical trials show that they had to use it regularly daily for eight weeks before we started to see any benefits of

Even there, it's really expensive. So again, where I live, it's about $300 a month, right? And so think about it. If the first two months you're not even seeing any benefits, there's $600 you've spent without any benefit. And then about a third of the women have side effects and the side effects become really untenable for a lot of people because it impacts concentration and nausea and dizziness and sleepiness and all these sorts of things. So I think we can do better. I know that there's lots of companies that are trying to find people

a much better medication for women. And part of that hinges on our understanding of how does the brain impact desire so that we can develop those targeted treatments, but we're just not there yet. And then for postmenopausal women, there's off-label use of testosterone. So off-label means that it's not approved by the FDA, but doctors and their patients can, after having a conversation about the benefits and the downsides,

can elect to use that. And there, there's actually some pretty good data in favor of topical testosterone and boosting low desire in women. But again, it's not approved. So trouble accessing it, you know, you worry about side effects because it's not approved and doctors themselves may be reluctant to prescribe it. Yeah. And, you know, I've talked to some menopausal women who have tried testosterone therapy and have said that it's life-changing in terms of the way that it stimulates desire for them. So I think, you know, for some people that is...

hormonal solutions is something that can often help with them, but certainly something we need more research on and more physician awareness in terms of helping them to figure out which patients it's going to be most helpful for. But yeah, I'm totally on board with you in terms of like more options is usually better. But I think before we're going to have a drug that really works in treating low desire, we have to really understand how desire works in the brain first in order to develop a drug treatment that actually works for it. Yeah. Couldn't agree more.

More research is needed. More research is always better. So thanks for sharing all of this information with us, Lori. I'm looking forward to continuing our conversation in the next episode and diving into a new online platform you created for treating arousal and desire problems in women. Can you please tell my listeners where they can go to learn more about you and your work?

Yeah, for sure. So you can find me on Instagram at Dr. Lori Brado. I mentioned our eSense URL is just eSense.health. And anyone who's interested in participating in research studies in my lab, again, our Instagram handle is UBCSHR, which stands for University of British Columbia Sexual Health Lab. Well, great. I'll be sure to include thanks to all of that in the show notes. Thank you again so much for your time. I really appreciate having you here. Thanks, Justin. Thank you.

Thank you for listening. To keep up with new episodes of this podcast, visit my website, sexandpsychology at sexandpsychology.com or subscribe on your favorite platform where I hope you'll take a moment to rate and review the show. If you listen on Apple Podcasts, please consider becoming a Sex and Psychology Premium subscriber to enjoy ad-free listening for just $3.99 a month.

You can also follow me on social media for daily sex research updates. I'm on Blue Sky and X at Justin Laymiller and Instagram at Justin J. Laymiller. Also, be sure to check out my book, Tell Me What You Want. Thanks again for listening. Until next time.