Jill couldn’t sleep. She desperately wanted to be sleeping before Steve, her husband of 18 years, came to bed.  She felt she couldn’t bear it if he lay close to her, stroking her in the hopes she would be willing to make love.  She was so tired of avoiding him in the evenings.  So tired of feeling trapped in a sexless, distant marriage.  She knew she needed Steve, she believed that she loved him, but she no longer wanted to make love to him.  She willed herself not to cry, because if she started, she wasn’t sure she’d ever stop.

As she lay in bed, Jill’s memories of her life with Steve started to flood her mind. When they met in school, she was 21, he was 19. They met at a large party and went back to her room together that night. The sex was drunken, raw, lusty, explosive and great. He had boundless stamina; her ability to have orgasms also was boundless. Their relationship in the beginning revolved around sex. They couldn’t go for hours, much less days, without tumultuous sex. They had sex everywhere, all the time. In the midst of this lust inspired union, they started to find themselves and each other. Real love blossomed and they were married.

The first years of their married life were filled with passionate, satisfying sex.  However, with the birth of  their daughter Stephanie, the pain from her episiotomy, the piles of laundry, and the overwhelming sleep deprivation, their sex life came to an abrupt halt. Jill found herself angry at Steve more often than not. He didn’t seem to notice how overwhelmed she felt, and he certainly wasn’t making  much of an effort to help her around the house. Jill wondered if he even found her sexually attractive anymore. She felt discouraged by her failed  attempt to lose the extra 16 pounds on her previously thin frame.

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Slowly, as the baby slept more, the discomfort from her episiotomy faded, and her feeling of obligation to Steve grew, they started to have sex again. When they had sex, it was OK  (not great as it use to be) and Jill was still orgasmic. But, Jill never initiated sex, never. Could it be the birth control pill she went on after she delivered? Her doctor said no. As the years passed, their life outside the bedroom became more and more hectic. The demands of their jobs grew, Steph’s soccer games and ballet recitals were the focus of their “free” time, and the piles of laundry never shrank. Jill was happy, but exhausted. Steve was happy too, but he felt neglected. Their sex was confined to the bedroom, it happened once or twice a week…nothing great. When Stephanie was about six, Jill decided she wanted to have one more baby. Steve was not so sure, but when it came to these types of decisions there was no changing Jill’s mind. Besides, sex with Jill, after she got off the pill, was the best it had been in years. Jill noticed it also. She figured it was her “maternal” hormones kicking in. Along came Audrey and again, sex went out the window. Jill and Steve grew increasingly alienated from one another. Over the next few years, sex became an afterthought. They were both so tired. Jill also realized that sex didn’t feel as good. Her nipples were less sensitive -- she used to be able to climax when Steve sucked on them. Her orgasms became more infrequent. It wasn’t only that they had sex less often, it required much more “work” for her to orgasm. Steve’s sexual frustration started to overflow. Arguments became more frequent. It was affecting their marriage. Jill missed the closeness she and Steve used to share. She hated not wanting to make love to him.  Jill confided in her mother, she needed advice. Her mother told her it was all “a part of getting older, you should be thankful that you once had good sex.” She went to her friends. Most of them agreed that their sex lives were getting worse, but no one had any suggestions. Her friend Linda, recently divorced from her second husband, suggested that Jill “have an affair to spice things up.” Jill went to her gynecologist and with great embarrassment confided to her that her sex drive was diminished.  Her doctor seems disinterested in Jill’s “problem” and briefly suggested that she use some vaginal lubricant and  rent an erotic video. Despite feeling brushed off, Jill gamely used the samples of K-Y jelly that she had been given and they watched some terrible actors fake moaning orgasms on a poor quality x-rated video.  They did have sex that night and after Steve fell asleep, Jill lay in bed crying.

Dr. Goldstein writes:

Jill came to my office about a year later. She was changing doctors, not because of dissatisfaction with her prior gynecologist, but because her insurance changed. As I had just recently started my practice, I was not too busy. I had time to actually talk to my patients. Along with the basic questions about pap smears, birth control, and menstrual periods, I added some questions that most gynecologists don’t ask. “ Do you have pain when you have sex?” “Do you have trouble reaching orgasm?” “How’s your sex drive?”

Jill’s response to that last question was “Frankly, I’d rather be gardening.”

I was intrigued by her answer. On the surface it was funny. Deeper down, I knew there must be more. “Did you ever have a good sex life?” With that question came her tears. Years of frustration poured out. We talked for about half an hour, I asked a few more questions, but mainly I just listened. (To this day I thank Jill for her openness and willingness to trust me with the most intimate details of her life.) On that day, I had few answers. Years of medical school and an internship and residency in obstetrics and gynecology left me ill prepared to deal with even the most basic questions about sex and libido. I promised Jill, that I would find her some answers.

About the same time as I began my search for a solution to Jill’s loss of libido, two remarkable events occurred in the treatment of sexual dysfunction (for simplicity’s sake I include a loss of libido in the realm of sexual dysfunction--though it is much more complex than that): Viagra was released as a treatment for male erectile dysfunction. To say it caused quite a stir is a vast understatement. Thirteen million prescriptions were filled in the first six months. No one knew what a large problem erectile dysfunction is. Women started to call me asking for prescriptions, not for their partners, but for themselves! (We will talk much more about Viagra later in the book).

Secondly, Dr. Judith Reichman, the Today show gynecologist, appeared on Oprah to discuss testosterone cream for decreased libido. Her appearance caused such a stir that she came back on a couple of months later to answer more questions and to defend herself from the attacks of the medical establishment. And I thought that I had gotten a lot of requests for Viagra! My patients were beating down the doors to get “the cream.”

Even though I knew that Jill wasn’t alone, I was astonished to find that experts estimate that over 40 million women suffer from a loss of sexual desire. In addition, approximately 50% of women will, at some point in their life, have a problem  with their sexual functioning -- libido, difficulty in arousal, or inability to achieve orgasm. I asked myself, why wasn’t I taught this. If not in medical school, surely this should be a part of every ob/gyn’s training.

I first starting reading the “real medical literature” from respected journals like the New England Journal of Medicine, JAMA,  and the American Journal of Obstetrics and Gynecology. The number of articles and research on the subject of sex drive and libido was underwhelming. I then went to the mass-market literature. There were dozens of books about sex. Each author, each sexpert, claimed to find a new area of the vagina that was the key to sexual fulfillment: The G spot, The X spot, The Cul De Sac. There were books about orgasms, yeah, there were a lot of books about orgasms. They promised Orgasm in Five Minutes, Prolonged Orgasm, Liberated Orgasms, Multiple Orgasms, Natural Orgasm, Museum Quality Orgasms (I am not joking), and even Stock Market Orgasms (I’m still not joking-- I guess you shout “Buy, Buy, Buy” when you climax.) However, there were surprisingly few books devoted to libido and sex drive. The authors of these books believe that if you didn’t have a strong libido it was because you didn’t know the “special place” in your vagina or you didn’t have their “special” type of orgasm.

As I sifted through the voluminous amount of misinformation and pseudoscience, I came to one simple conclusion. For most women , a loss of libido cannot be attributed to one  single cause. Almost always, there are several contributing factors. While knowing your testosterone level and finding your G spot is important, knowing how to make time to make love (and to relax for that matter) is equally important. Any  treatment for decreased libido that is only a “a pill” or “a cream,” is bound to fail for most women. This is not to say that hormones, medications and herbs are not useful. They can be very useful, but only when combined with self-exploration, time management, stress relief, and couples therapy.  This point became very clear as I began to work with Dr. Marianne Brandon, a clinical psychologist specializing in relationship counseling, body image issues, and sex therapy.  Together, we worked with hundreds of women with one unifying complaint: they have lost their libido. Inevitably, we found that our efforts were much more successful when we combined our biological  and psychological approaches to treatment.  We came to recognize one very important fact: A woman’s sex drive is influenced by many physical and emotional variables.

Dr. Brandon and I have developed a new approach to help women find their lost libido, to feel sexy again, to reinvigorate their marriages. We call this approach sexual wellness. Our concept of sexual wellness is a holistic one.  It encompasses four primary components of health: physical, emotional, intellectual, and spiritual.  These four components must be present and in balance, in order for a person to feel sexy and to have a great libido.  In addition, we believe that it is essential to use this holistic concept of wellness to evaluate and treat women who are having problems with their sex lives.

In order to have a great sex life and a healthy libido, a woman must have good physical health.  Her hormones of desire (estrogen, testosterone, dopamine) must be present and in balance.  The skin and nerves of her vagina, clitoris, and nipples must be healthy and sensitive.  She must be able to have sex without pain.  She must know her body, her erogenous zone, and what brings her to climax.

In addition to having physical health, a woman must have the emotional health necessary to allow herself to feel lustful, empowered, desired, vulnerable, open, and loved.  Being emotionally healthy refers to a woman’s ability to acknowledge and experience her full range of feelings; both sexual and non-sexual, good feelings as well as those we might classify as uncomfortable or negative.  Emotional health allows a woman to move between, and experience, a wide variety of emotions without fixating on one, or avoiding others.

A woman who is intellectually healthy feels stimulated and useful in her life.  It is  not a matter of level of education or IQ per se.  Rather, a woman who experiences herself as competent and appropriately challenged is functioning in an intellectually healthy way.  These feelings enable a woman to experience herself as confident and capable in her sex life as well.

We believe that libido is enhanced from spiritual health as well.  Spiritual health means something different to every woman. It may, or may not, revolve around a relationship with God.  It is very personal and specific to each woman’s unique psychology and belief system.  It may be broadly defined as the way each woman finds meaning, and worth in herself, and her life.  For most women, bringing spiritual health and identity into the act of making love enhances their desire and over-all sexual experience.

The combination of physical, emotional, intellectual, and spiritual health are the essential components of sexual wellness.  When they are in balance, a woman can experience the joy and fulfillment in her life, and in her sexual relationships, that she craves.

When we focus on women who have come to sexual maturity after the sexual revolution of the 1970s, we find that as a group, they have been able to develop a less restrictive approach to their sexuality. This sexual freedom allowed them to have great sex, and great sex lives.  They have known lust; they are comfortable with a strong libido.  They know their bodies and they know how to reach orgasm. However, due to the countless physical and emotional hurdles a woman inevitably encounters (marriage, career, and childbirth to name a few) the four components of her sexual wellness fall out of balance.  That is when her sexual desire, her libido, and her lust diminish.  While this is unfortunate, it is very common – almost universal.  While most psychiatrists and psychologists believe that decreased sexual desire is a psychiatric illness known as Hypoactive Desire Disorder, we believe that this decreased desire is neither a diagnosable, nor a pathologic condition.  We prefer to think of decreased libido as one of life’s great challenges. The challenge is to regain what women know is inherently naturally for them – a healthy sex drive. At the same time, a woman can use this challenge to search for a deeper understanding of herself, her relationships, and her sexuality. This is the essence of  our book Reclaiming Desire.

Reclaiming Desire, which incorporates traditional medicine, naturopathy, herbal therapy, and individual and couples psychotherapy, will help a woman who once had a very fulfilling sex life recapture the balance that is necessary for a great sex life and libido.  In this book, we attend to the “whole” woman, including body, mind, and spirit.  We have found this holistic approach to be essential to help women reclaim their sexual passion.

So what happened to Jill and Steve?  We started by making a “game plan” based on our holistic concept of sexual wellness.  The first step was to have Jill and Steve meet with Dr. Brandon.  Initially, they were reluctant to see a therapist -- they felt uncomfortable with the idea of sharing the intimate details of the marriage with a stranger. In addition, they were afraid of what they might learn about themselves and their relationship in therapy. What if they decided they were no longer a good match?  They struggled with these questions, and others, for a while. Initially, they sorted through conflicts about family, money, and parenting. Real progress was made, however when both Jill and Steve discussed their emotional, intellectual, and spiritual needs. Jill mustered up the courage to tell Steve that she felt that she barely knew him anymore. She felt that all of their energy went into raising their children and they had fallen out of touch with their feelings. Steve became angry and responded that he had to work hard to pay for the cost of raising the children in an environment they both valued. He felt that he didn’t have the time, or the desire, to be the “perfect” man Jill was asking for. In time, however, both Jill and Steve became less combative and more focused on positive change. They began to enjoy tackling the issues that had eroded their emotional connection.  Jill and Steve were able to rebuild the foundation of their relationship. The result was a renewed sense of intimacy and excitement in their sex lives.

Secondly, we advised Jill to stop the birth control pills that she had been on for the majority of the last 10 years. Briefly (we address this in the booking more depth), birth control pills lower the amount of testosterone – one of the hormones that control sex drive. Jill told me later that she had never felt “like herself” since starting birth control pills. Concurrently, Steve got the vasectomy that he had been promising he would have for about three years. (It is important not to minimize Steve’s role in this treatment plan. While the primary goal of Steve’s vasectomy was permanent birth control, his willingness to fulfill his promise and to have a role in this treatment plan should not be underestimated.) Within a few weeks, Jill started to notice some improvement in her libido (just like the time when she went off birth control pills to conceive her daughter Audrey). After Steve recovered from his vasectomy, they went away for a romantic weekend to, as they put it, “check out the plumbing.” After the weekend, they gave each other rave reviews. Jill told me that they “felt so relaxed, so in love. The great sex was just a natural extension of the way we were feeling.”

A few months later, however, Jill called. She said that although her libido had improved, and Steve was much more considerate, having an orgasm still took much more work than it had in the past. She said her nipples and clitoris felt “almost numb.” I tested Jill’s total testosterone and free testosterone blood levels and performed a special type of pelvic sonogram called a doppler ultrasound. As I had guessed from her symptoms, Jill’s  total testosterone was low, and her free testosterone level-- the active form of the hormone--was so low, it was undetectable. In addition, the ultrasound showed that blood flow to Jill’s pelvic organs was decreased.  I gave Jill a testosterone cream that she was to rub on her vulva -- near her clitoris-- every night for three weeks and then to the inside of her thigh three times a week. In addition, I recommended that Jill start taking L-Arginine, a nutritional supplement that increases blood flow to a woman’s vagina and clitoris. Within a month, Jill called to tell me, “I feel great, completely alive. I haven’t felt this good in 10 years. It’s not just the sex or the orgasms. Our relationship is great. And I feel like my old self. I’ve found my lost libido.”

Jill told me this story, about coming home after a hectic three day company regional meeting.

You may think that Jill’s story of sexual reawakening may be too generic, too suburban, too mainstream.

It isn’t. After Dr. Brandon and I learned to ask the right questions, we have encountered hundreds of women with the same complaint: they have lost their libido.  Many women of Jill’s mother’s generation, never had, nor did they expect, great sex lives.  Jill, however, and millions of women of her generation, once had fantastic sex. Yet, when their sex lives fade they found few explanations and even fewer solutions from their mothers, friends, and doctors. Our book, Reclaiming Desire, changes that. There are answers to the questions: “Where is my sex drive?”  “Why doesn’t sex feel great anymore?” “What happened to my orgasms?”  “How can I feel sexy again?” And most important,  “How can I find my lost libido?” These answers are available in our book Reclaiming Desire!

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