Low Libido, with Anastasia Hallisey, MSN, CNM

Please enjoy my interview with Anastasia Hallisey, a full scope, certified nurse midwife with advanced training in sexual health and pelvic pain. She practices at St. Francis Hospital in Hartford, CT.

Jane: Thank you for talking with me today about low libido in women. What exactly does that term mean?

Anastasia: Low libido or low sex drive means low sexual desire. It is a common issue among the women who visit my sexual health clinic. Desire is one part of sexual response, which also includes arousal, orgasm and the resolution after orgasm. Low desire is a complex issue; the solutions are rarely quick and easy.

Jane: Tell me how you counsel women who are having issues with low sexual desire?

Anastasia: First, I want to know if the woman is defining her perfectly normal sex drive as abnormal. Many women do not understand that their sex drive can differ from that of men.* Men usually have a spontaneous sex drive- their feelings of desire and arousal lead to sex. But women often have a responsive sex drive. In this model, a woman chooses to engage in sex from a place that is so sexually neutral she might just as soon do the dishes. Sexual stimulation usually leads to arousal and desire. So desire happens after she starts the sexual stimulation, not before. Just because she does not experience spontaneous desire does not mean something is wrong with her or her libido. This model also acknowledges that emotional intimacy that can come from a sexual experience acts as a motivator to choose to have sex, rather than doing those dishes.

Second, I want the woman to know that sexual response is not just a biological on/off switch. Our thoughts, feelings and fantasies apply brakes and accelerators to our physical arousal and desire. Here is how it works: Our subconscious brain is constantly scanning the environment for relevant sexual stimuli. For example, you see a cute barista and the accelerator increases arousal. However, you know you’re in a public coffee shop, and that activates the brakes to inhibit the arousal. These brakes and accelerators are fiercely personal. Like for some people, being in a public space might be a total turn on. There’s no judgement about your turn-ons and turn-offs.

Understanding libido means paying attention to what turns you on (your accelerators) and what turns you off (your brakes.) This comes from one of my favorite books, Come As You Are, by Emily Nagoski. The book has a sexual temperament questionnaire that will give you a bit of a script to discuss with your partner.

Jane: Can our conscious thoughts act as accelerators and brakes, too?

Anastasia: Most definitely. And the good news is that if you want to change your experience and your feelings, you can address your thoughts. Specifically, you can influence your sexual desire by changing your thoughts. Obviously, I am not suggesting that you use your thoughts to try to change your sexual orientation. But you can use your thoughts to change your experience.

For example, when a woman tells me that she is just not attracted to her spouse any more, I ask her, “What are your thoughts when you are engaging in sex with your partner?” She may have thoughts like, “This isn’t any fun. It used to be better. I’d rather not have sex.” If those are her thoughts, then that is what her experience will be. She could change her thoughts to, “I feel closer to my partner when we connect sexually,” or “I am open to feeling pleasure when my partner’s hands are on me.” I am not suggesting that she convince herself that she is attracted when she is not. I am suggesting she change her thoughts while still staying with her truth. Addressing your thoughts is something that you can control. And your thoughts affect your physical response.

If you want to feel empowered by changing your thoughts, check out the podcast, Unf*ck Your Brain, with life coach Kara Loewentheil.

Kara Loewentheil describes another way that our brains get in the way - by being an object vs. the subject of desire. If you are a woman, or you’ve been socialized as a woman, you have been trained to attract, to be an object of desire. By contrast, men, and people socialized as men, are trained to pursue, to be subject to desire. The great news is that this is all mumbo jumbo, and you don’t have to think this way. You can divorce yourself from the idea that your sexuality exists for other people and reframe your sexuality as something that exists for you.

Jane: I assume that our thoughts about our body can act as a big brake. Can we change those thoughts?

Anastasia: Body image is huge. Two thirds of women report that body image negatively impacts their sexual experiences. Poor body image has been shown to decrease desire, lower arousal and blunt pleasure. The self-criticism pulls us out of connection to ourselves and to others.

Recently I saw a patient who made an appointment for low libido. When I asked her how she felt about her body, she answered, “I’ll feel great once I lose 20 pounds.” I asked her if her husband was bothered by it, and she said, “Oh, no, no, no. He doesn’t care. He’s fine.” So, she was striving for an attraction from a person who was already attracted to her! She needed to change her thoughts to feel attractive for herself. Her 20-pound goal was a trap. Twenty pounds now might later become, “I wish my butt was higher. Then I will feel attractive want sex again.” Or whatever. It’s an endless cycle. This is really complex. There’s no pill or quick fix to deal with body image.

But you’re asking, Jane, what we can do about this kind of thinking. Mindfulness can help. There is a great book, Better Sex through Mindfulness, by Laurie Brotto. If you have issues with your body, you can change your self-critical thoughts by making a daily practice of focusing on one or two things you really do like about your body. She suggests that you start this practice in a safe space, maybe outside the bedroom, because focusing on self-love thoughts might be harder when you are naked with your partner. Another practice involves focusing on sensations in the body to get you out of your brain. It can begin with scanning the body to notice sensations and advance toward the practice of attending to the physical sensations when someone touches you.

On the subject of touch, try focusing not on giving touch but on taking touch. When you put your hands on someone’s body, what do you take in? Mindfulness of taking touch during sex can bring you into the present moment where you can learn to experience pleasure.

If you need support around these ideas, get it. In addition to the resources I mentioned, I recommend sex therapists. Go to AASECT.org to find certified sex therapists in your area. A sex therapist can also help with communication. You cannot underestimate the value of having open and honest conversations about sex. If you’re not willing to say, “That’s not doing it for me” to your partner, it’s unlikely you’ll ever derive much pleasure from the experience. You’ll never get from Point A to Point “O.”

Also, check out the Rosy App. It’s a wealth of information There are videos on everything from “Finding Your First Vibrator,” to “Islam and Sexuality.” Once a month they have a live feed. And there’s tons of erotica.

Jane: So, Anastasia, we’ve talked about ways to become aware of our thoughts and to change our negative thoughts. What about the physical practices of sex? I assume that experiences of pleasurable sex create a positive feedback loop that will lead to more desire in the future.

Anastasia: Good question. I definitely want to talk about masturbation, but first let’s talk about the difference between the penile and the clitoral anatomy. The penis is a pretty straightforward organ. You do a few basic motions and soon, woop, you get a prize. By contrast, our genitals are hidden. Even with a mirror, we can only see a very small part of the clitoris that is on the outside. On the inside, the two crura extend for about 7 cm on each side and the bulbs can enlarge. So, the clitoris is difficult to find. And what feels good changes day to day. Women need to be raised to know that about themselves. They need to be told.

As for masturbation, there is a double standard. It is a societal norm for people with penises to masturbate and to talk about masturbation. Men learn so much about their sexuality through masturbation. By contrast, many women look to their partners, often male partners, to discover their own sexuality rather than discovering it through masturbation.

Jane: That is so true and so frustrating to hear about from my patients.

Anastasia: We’ve had generations of women never speaking about orgasm. It is time to close that. Women need to be told to prioritize their own pleasure. Thankfully, we are coming around and talking more about the clitoris and orgasm and pleasure than even in the boomer generation.

Jane: I did not feel comfortable teaching masturbation to my adolescent patients; I pointed them towards online resources. How do you do it?

Anastasia: I have pretty frank conversations with women. But I also use resources. My favorite is OMGyes.com, which has two seasons of videos. The first season is geared towards masturbation. The second season is more about learning how to find pleasure during sex with a partner. The videos show close-up, full Monty vulvas while the women, ages 21 to 81, explain and demonstrate their techniques with clitoral stimulation, masturbation and intercourse. Each season costs about $50. Another resource is BodySex, started by Betty Dodson, which offers online workshops that teach masturbation. Betty Dodson has been a sex advocate since the 70’s and doing these workshops for a very long time. She died recently but her partner has taken over the workshops. Then there are sex shops that sell lube and vibrators and more. Know that not all sex shops are the same. There are some real tacky ones. You walk in and think, “Oh my gosh, this is not for women.” If you’ve gone to one and didn’t like it, try another. Or shop on-line: Adam and Eve. Good vibrations. Oh My, in Northampton, Massachusetts.

Jane: I’ll add Self-Serve in Albuquerque, which has on-line classes and merchandise.

Anastasia: And, Middlesexmd.com has information and products geared towards sexuality during menopause.

Jane: Many women who know how to pleasure themselves during masturbation still have difficulty having an orgasm with a partner, especially if they do mostly penis-in-vagina (PIV) sex. Too many people don’t know that only about 25% of vulva owners will reliably orgasm with PIV. And, a woman may feel uncomfortable using her hand or a vibrator to self-stimulate her clitoris during sex.

Anastasia: Oh my god, let’s talk about the huge limitations of PIV sex. Women need stimulation and sensation on top, on the vulva. When the penis goes in the vagina, it misses the whole thing completely! If women are only having PIV sex, if that’s the only sex they know, then they likely think, “What’s the big deal about sex? I guess I’m different from women who like sex. I guess something is wrong with me.” And there is nothing wrong with them. They’ve just got to go find the stimulation and the movement. As I say to my patients, “PIV are just three letters in the alphabet of sex.”

 Jane: You must also see women who are having not just decreased desire and arousal but decreased, or more infrequent, orgasms. What do you tell them?

 Anastasia: Again, many of these women want a quick fix, like a pill. But our sexual response is complicated. For women having difficulty with orgasm, I start with masturbation. But if the issues only occur with a partner, we talk about all of the factors that influence the sexual response beyond what you and I have already talked about. I’ll list them.

1. Stress. Stress can affect our ability to orgasm. The practices of mindfulness and of changing negative thoughts can help.

2. Relationship problems. I had a patient who said her libido problem started seven years ago. When I asked her about what happened back then, she said her partner had had an affair. So, what she thought was her problem with her libido, was a problem in the relationship.

3. Trauma. Unresolved trauma can create problems to experience pleasure.

4. Poor technique. One patient said when her partner wants to have sex, he taps her on the shoulder until she relents. Ain’t no pill that’s gonna help that! That’s poor technique!

5. Lack of adequate arousal. It can take women 20 minutes to get properly aroused.

6. Anxiety about loss of control.

7. A partner’s sexual dysfunction. Erectile dysfunction itself is actually less of an issue for partners than how the man deals with his erectile dysfunction.

8. Cultural and religious messages about sex and pleasure. The Rosy app is helpful for women with religious based issues, as are sex therapists.

9. Medical issues. Nerve injury. Pelvic floor dysfunction – either too much tension or too much relaxation. Medications, especially antidepressants. Infection, chronic illnesses and cancer treatments. A whole host of hormonal changes, like those occurring with breastfeeding and menopause. Hormonal birth control can cause difficulty with orgasms and also pain with sex.

Jane: Thank you, Anastasia. Is there anything else that you want to add?

Anastasia: Depending on the source of the problem, there are so many solutions to get women back on the track of desire and pleasure. Change your stinkin’ thinkin’ from judgmental to curious. Use the plentiful resources. Develop healthy practices.

Jane: Thank you, Anastasia. Your patients are lucky to have you!!

*In this article, “women” refers to persons with vulvas and “men” refers to persons with penises. We acknowledge that gendered terms do not indicate genital anatomy.