Sex Therapy: Low Libido

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    Dr. Pacik

    Anita Hoffer is a certified sex therapist who practices in Boston. She has helped my patients who struggle with low libido, difficulty with orgasm and relationship problems. Some of these problems persist even after a successful outcome of treatment using the Botox multimodal program. I asked her to share her thoughts on the Forum. For out of town patients she is effective using Skype to communicate.
    If you would like to speak to her please contact my office for her information.

    Loss of Libido in the Aftermath of Vaginismus

    Dr. Pacik has asked me to comment on the heartfelt postings of many women on the Forum about loss of libido and I am honored to have that opportunity. I have thought a great deal about this subject, have had the privilege to work with many of his patients and also have helped other women with low desire that does not stem from vaginismus.

    What I hear in each of these posts on the Forum is incredible pain. Usually of very long standing. Usually deep disappointment that “sex” didn’t end up being what you had always imagined. Despite your love for your partner and the intimacies you have shared, the actual act intercourse has been unreachable by many of you. Many of you were celibate or at least ‘technical virgins’ until you were married and then, at that point, you found yourselves having painful sex or no sex at all. Heartbreaking. And certainly not what you had always expected and dreamed about.

    I wish I had an easy answer to the problem. There is hope but unfortunately, there is no such thing as a quick fix. Please know that you are not alone and the loss of libido that often arises during the struggle with vaginismus and persists after Botox treatment is not uncommon. Getting back your desire is possible but it takes time, work and commitment to the process. This should not be surprising for a number of reasons. First, for many of you, vaginismus, and all the complications that derive from it, has been persistent, usually for an extended period of time (in some cases for many years). Whereas the mechanical obstacles to intercourse were solved under Dr. Pacik’s careful hands and wise care, the emotional and psychological consequences may not resolve so quickly. Sexual problems that have been in the making for years seldom resolve overnight. Secondly, even after the Botox therapy has been “successful”, ironically the tension is worse because the stakes are higher. Now, at long last, intercourse “should” be possible and so each failure adds to the stress and makes the frustration and despair worse. Couples naturally feel pressure to perform. There is a strong urge to make up for lost time and considerable guilt (usually on the part of the woman) for being unable to give back all the love that was missed.

    Stress is toxic to libido. So naturally, what used to be, or should be, satisfying foreplay and rewarding lovemaking loses its appeal. Countless studies have been published which show that increased psychological stress results in diminished interest in sex and decreased desire – this is not only true for vaginismus patients. That’s why it is important not to get discouraged and to take the steps necessary to manage the anxiety by recognizing the many, often subtle, ways it influences your sex drive and robs you of your sexual energy. Stress control methods vary widely according to the individuals’ circumstances and there is no one-size-fits-all remedy. Basic approaches include, but are not necessarily limited to, life style changes, intimacy and sensuality exercises, mindfulness practice, improved sexual communication tools and, less commonly, medications and nutritional supplements (the latter only under the supervision of a physician and/or a nutritionist).

    The way we think about desire is an important key to the libido problem. Much has been written on this subject. Until recently, a common misconception has been that normal female desire precedes arousal. This throws a real monkey wrench in the works for couples who are dealing with the aftermath of vaginismus. The source of this outdated belief is the 20th century sexual arousal model developed by sex researchers Masters and Johnson. They proposed a uni-sex linear model consisting of a sequence of events that started with desire and moved on to excitement, orgasm and resolution. However, the fact of the matter is that for many women, arousal comes before desire and only then, is desire triggered (by becoming aroused!) If you stop to think about it, you can appreciate how women who strictly believe this paradigm (especially those whose confidence is already a little shaken) are likely to be confused and very self-critical when intense desire doesn’t emerge de novo and propel them to the bedroom. When lovemaking is burdened by lingering fears of painful penetration, dilation procedures which may be unnecessarily elaborate (see Dr. Pacik’s post on August 17th), and guilt (and even resentment), it is easy to see why couples get discouraged.

    A more modern, woman-friendly, understanding comes from Dr. Basson (2001), a female sex researcher in Canada who has developed the concept of a circular, triggered arousal cycle built on responsive desire.. In her research, she found that women more often make a conscious decision to engage in sex, allow themselves to become aware of and experience their partner’s touch, relax into the pleasure of it and feel aroused – and only then recognize their desire and libidinal awakening. The cycle intensifies and then results in full engagement.

    It is noteworthy that loss of desire and sex drive are NOT the same thing as loss of the capacity for arousal and orgasm (although they are easily and frequently equated in our minds). The good news is that there are many things we can learn to do in lovemaking that fuel arousal. Good lovemaking is a skill that needs to be learned and practiced. It does not happen overnight – except in Hollywood movies. No one is born ”knowing how” to do it well. Lovemaking should be a time of relaxation and focus on pleasure – not a death-march to the finish line of intercourse. The pressure which survivors of vaginismus put on themselves in this regard is counter-productive, and goal-oriented foreplay deadens the senses.

    So it is important to focus on how we can best nurture and intensify our arousal in order to enable it to blossom into full-fledged desire. After all, for sex to be worthwhile, it must be worth having! Each of us has our own unique arousal style. Every couple is different, and meaningful generalizations are hard to come by. Attitudes and beliefs you may have been raised with, religious or philosophical lessons you were taught or picked up from your environment, messages about sex you learned in school or from your family, attitudes about pleasure and how (or whether) to enjoy it, traumatic or sexually abusive experiences you may have had along the road to becoming a sexually mature adult — all these will play a role as will the amount of basic sex education you received about your body and how it functions. The only right answer is the one that works for you. So long as your explorations are consensual, and no one is getting hurt, there are no rules. Now that Dr. Pacik has helped you to arrive at this important threshold, this is your opportunity to grow and follow the path ahead that is uniquely yours.

    Counseling can be extremely helpful at these times for learning how to manage the anxiety, gain insights and build skills to address the complicated issues that underlie loss of libido, and learn new tools to rebuild desire. It is often said that our most important sex organ lies between our ears – this is true in my experience, provided we are otherwise in good sexual health.

    May you travel safely and may your journey be fulfilling.


    Hi all. Low libido so often co-occurs with vaginismus. On their site, Maze Women’s Sexual Health group has an excellent section recommending several books that address low libido, including:

    The Sex Starved Marriage – A Couple’s Guide to Boosting Their Marriage Libido
    By M.W. Davis, 2003

    Mating in Captivity: Reconciling the Erotic and the Domestic
    By Esther Perel, 2006

    Secret Female Hormone: How Testosterone Replacement Can Change Your Life
    By L. Maupin, 2014


    Helen Leff, LCSW

    Hi everyone,
    I think it’s really worthwhile to read Anita Hoffer’s info on low libido post vaginismus as well as Heather’s book list. Most importantly know that there is help and support available and stay positive.


    This is a great post Helen. I was just looking over the site and noticed Live Blogcast for the first time! How absolutely cool and amazing is this! Ladies, if you want to check it out, there is a ton of very, very helpful and useful discussion in a q&a type format all about low libido and how to treat this. It was hosted by Dr. BatSheva and Nicole Tammelleo.


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