Generation X and older millennials came of age in the 1990s and early 2000s, a time of ecstasy, Lil’ Kim, Sex and the City, and sex-positive feminism. It was not an era free of misogyny, but still, there was a sense that sex was something women enjoyed, not simply endured or navigated. They are arguably the first North American cohort to be steeped from puberty onward in a culture that allowed for the idea that women might be entitled to, and entitled to be public about, their own sexuality.
These women are also the first to reach maturity in the age of Viagra, which initiated a cultural revolution when it first hit the market, in 1998. Former presidential candidate Bob Dole went on TV and made it okay to talk about impotence—which had been given a new, less stigmatizing name: “erectile dysfunction.” Sales of Viagra (sildenafil citrate) hit nearly $2 billion (US) annually by 2008. Viagra normalized both public discussion of sexual function in old age and the idea that medical science could provide a lifetime of satisfying sex.
Now, Gen X women are in or approaching menopause, with all its attendant complications—which, for many, includes the loss of the sexual desire and arousal they have always taken for granted. They are also starting to be more vocal about the toll that vanishing sex drives and medical indifference are taking—and to demand better. The force of these demands, and growing interest in the field from medical researchers, many of whom are themselves women of this generation, is spurring a new and far more nuanced understanding of sexuality and of what may be happening when desire goes missing.
Diminishing sexual desire (an interest in sex) and arousal (the physical changes that happen when we are turned on) are difficult to understand and diagnose: there is no single cause, and it is not one type of thing. Diminished desire and arousal can be traced to everything from the physiological changes of menopause to the stress and lack of sleep that often characterize a busy mid-life to iron deficiency to the side effects of prescription drugs.
This can make it difficult for doctors to even know how to begin isolating why a woman may be experiencing frustrating changes in her desire. Doctors are not often deeply educated about the subject—nor is there a formal medical specialty dedicated to its study—and many do not take the loss of libido seriously. The lack of care is further compounded for transgender and nonbinary people, whose experiences are not generally included in the medical research that does exist about desire. Solutions for women are, correspondingly, difficult to come by. The few treatments that do exist are confusing, costly, ineffective, and in some cases, potentially harmful. Many GPs advise women to seek out sex therapy, which—though it includes some of the most research-supported approaches available—may or may not be appropriate for their particular situations, is difficult to access, and is not a well-regulated field of practice.
Distressingly low desire or arousal—that is, desire or arousal that are significantly lower than one wishes—is the most prevalent sexual complaint among women. As many as 40 percent of women experience low desire, and up to 10 percent are distressed enough for it to be a diagnosable condition, called female sexual interest/arousal disorder (FSIAD). The problem isn’t isolated to any particular demographic—it affects single women as well as those in decades-long marriages, queer women as well as straight women, nonbinary and trans people as well as cis women—and it becomes more common after menopause: a 2018 survey of Canadians in mid-life in The Journal of Sexual Medicine found postmenopausal women much more likely to report low desire.
The effect on quality of life can be profound. One study of 1,100 women found lack of desire comparable to the toll of chronic conditions such as diabetes, asthma, or hypertension. These women were also more likely to experience depression.
Some women are so frustrated by the limited options available to them that they are trying anything—including unproven remedies. A recent study of women with pelvic pain (one of the major, oft-ignored factors that rob women of desire) found that half were using a cannabis product such as CBD oil for relief and that, of those who weren’t, 80 percent wanted to try one. One woman I interviewed for this article told me that she and her husband want to try the psychoactive Amazonian plant ayahuasca as a “reset.” On the internet, topical creams with questionable ingredients are available. Some Canadian providers even offer women the “O-Shot,” a clitoral injection purported to boost arousal that is not recommended by the American College of Obstetricians and Gynecologists.
“That’s what happens when medicine has these gaps,” says OB-GYN Jen Gunter. “These voids get filled by people who are offering an easy solution.” Her 2021 book, The Menopause Manifesto, which includes chapters on libido and vulval health, argues that women deserve better. Gunter is on a mission to banish stigma and misinformation around menopause and women’s health, and she says women today are more open about sexuality and hungry for real facts. “The more the words are spoken, the less mystifying it is.”
The study of women’s sexual disorders is still in its infancy, long dwarfed by the brighter spotlight on men’s sexual health. A huge market would exist for an effective medication for low desire in women. But, while drug companies have touted one-size-fits-all fixes, experts such as Gunter say there is no single solution to lower desire because there isn’t one single problem.
Change hovers on the horizon. Mindfulness-based therapies developed at the University of British Columbia (UBC) have had the most clinically significant results, in part because of their ability to ease not just low desire but many of its causes, such as stress. Meanwhile, in the Netherlands, a small research company called Emotional Brain says two of its drugs in development could usher in a new “personalized approach” to low libido. The hope is that we are on the cusp of a greater understanding not just that women are entitled to their desire but that pop culture and politics are not enough to secure it—that, to truly support women and their sexualities throughout their lives, we need to learn more, to research more creatively, and to develop a full range of treatments to address desire in all its complexities.
Viagra’s success at the turn of the twenty-first century kicked off a gold rush to cash in on a female version. On the one hand, this ignited some much-needed research on women’s sexual disorders. But the “little blue pill” skewed expectations of what a solution for sexual challenges could or should look like.
The science of women’s sexualities has always been shaped by cultural forces, whether prurience about the notion of women having desire in the first place or the tendency to use men’s sexualities as a benchmark. Until the mid-twentieth century, physicians generally believed that women naturally had less desire for sex. Then, the human sexual-response cycle developed by sex researchers William Masters and Virginia Johnson asserted that the way men’s and women’s bodies responded to arousal was similar. The publication of their book, Human Sexual Response, in 1966, was a breath of fresh air for feminists tired of patriarchal norms that said women simply did not, and should not, enjoy sex as much as men did. But the influential model—particularly its 1977 update by researcher Helen Singer Kaplan, which emphasized desire—dictated that desire looked exactly the same for women and men: it arose spontaneously, triggering sexual activity and physical arousal, then a plateau, then a single orgasm. As traditionally understood by medical science, desire leads to sexual activity, which in turn produces increasing arousal.
We now know that map isn’t quite right—it may capture what the experience is like for some women, some of the time, but it certainly isn’t the whole story. For decades, however, it sent researchers astray, and that confusion shaped theories of what an approach to low desire required. It should go without saying that, if you’re designing treatments to rev up women’s sex drives, it helps to understand how those sex drives work.
In 2001, UBC psychiatrist Rosemary Basson published a paper that shared what she saw in her patients: although a small group of women felt desire spontaneously, it was more common for women to feel physically aroused and even begin sexual touching first, and then feel desire. The traditional sequence was reversed.
Basson’s paper described a nonlinear, “responsive” model of female desire: women often begin by being open to sexual talk or touching, which in turn helps them get aroused and then generates desire, which makes them decide to continue. She argues that women pressuring themselves to feel spontaneously “in the mood”—to have desire first—without enough time or stimuli to help them get there, produces anxiety that, ironically, quashes desire. While the responsive model has been characterized as saying women have sex “in response” to their male partners’ advances, Basson has said that’s a misunderstanding—and many men have responsive desire too.
Women’s arousal, too, may work differently than has long been believed. From a physiological standpoint, arousal is a blood-flow event: increased blood flow to the pelvis readies our bodies for sex. Less blood flow equals less arousal. Simple, right? Yet even this basic description has become dotted with asterisks by newer research. Canadian sex researcher Meredith Chivers’s surprising studies at Queen’s University have shown that a rush of blood to the pelvis is sometimes just . . . blood flow. That is, it isn’t necessarily correlated with desire. An increase in vaginal blood flow doesn’t always mean one feels subjectively turned on or is even particularly aware of any sensation.
All that is just the physiology of sex, which researchers are still learning about. (The internal clitoris was only fully mapped in 2005.) When it comes to subjective sexual experience—why desire, arousal, and release feel the way they do—there is even more we don’t know.
Most of sex, and 100 percent of the enjoyment of sex, takes place in the brain, an overwhelmingly complex organ and one that is notoriously difficult to study. Researchers have begun to explore the importance of the neurotransmitters serotonin, norepinephrine, and dopamine in the sexual response cycle, but measuring these in the human brain and creating a precise model of what they’re up to during sex is a major challenge, says Lori Brotto, UBC’s Canada Research Chair in Women’s Sexual Health. (This may be why loss of arousal is among the common side effects of some antidepressants that affect serotonin.)
The complexity of sexuality thus makes low desire vexing to fix. The situation becomes even more complicated during the menopause transition, when multiple changes can impact sexuality. The body’s production of estrogen and other sex hormones wanes, but the effect of this on desire isn’t direct. Lower estrogen levels can reduce the flow of blood to the pelvis, causing the genitourinary syndrome of menopause, which means less lubrication and tissue changes that can cause dryness, irritation, pain, and diminished sensation. All of that can shut down desire for sex. Luckily, says Gunter, hormonal creams and estrogen tablets can work to restore blood flow and ease these symptoms; she calls them equivalent to a Viagra for women. But lowered estrogen also produces hot flashes, waking women multiple times at night. Lack of sleep is a huge indirect desire killer that is often missed by doctors, she says. “For many women, the menopause transition can trigger a mild depression, and depression can affect your libido,” she adds. “So you have to think about this as a whole-body, whole-mind, whole-cultural-experience thing.”
Other changes in menopause can include decreased muscle mass in the pelvic floor, especially in the levator ani, the muscles that contract during an orgasm. Physiotherapy and exercises can help in these cases.
It’s important for GPs to be better educated about these basics, says Gunter, since they’re typically women’s first point of contact in their quest for help. The differential diagnosis should look widely at a person’s life. “Is it estrogen in the tissues? Is it your pelvic floor muscles not contracting? Is it a relationship problem? Is it the fact that you’ve been stuck at home because of the pandemic with three kids?”
“We are not simply beings that respond to hormones,” Gunter says. “We are far more complex than that.” Consider testosterone cream, a drug sometimes prescribed to women with low interest in sex, with side effects and mixed results. Studies have failed to establish a clear relationship between the hormones in our blood and the desire we feel in our bodies—meaning you can have high natural testosterone and still have low desire. In a 2010 study by UBC’s Basson and others comparing blood levels of androgens (such as testosterone) in a group of women with clinically low desire and in a group with no sexual dysfunction, few significant differences were found.
It’s also important to ask a patient what she means by low desire, says Gunter. It’s normal to have ebbs and flows in desire over a relationship spanning decades. “This idea that you’re going to have exactly the same libido throughout your whole lifespan is a very destructive message,” she says, alongside the images we see on TV of (still mostly heterosexual) lust: women and men embracing at exactly the same time, desire perfectly choreographed.
Given that there is no single biological cause for low desire, and given how partial our understanding of sexuality still is, it should be no surprise that attempts at finding a one-size-fits-all cure have failed. Many of the drugs we do have were discovered by accident. Viagra was supposed to be an angina drug. Flibanserin (marketed under the name Addyi), the only pill on the market for female low desire, was supposed to be an antidepressant. “The pharmaceutical companies have tripped over these things,” says Stephen Holzapfel, who founded the Sexual Medicine Counselling Unit at Women’s College Hospital.
These drugs have all faced criticism. Flibanserin, which received US approval in 2015 after a media campaign by its maker, Sprout Pharmaceuticals (Health Canada approved it in 2018), has been criticized by doctors because it must be taken daily, patients must curtail alcohol intake to use it, and it produces, at most, only one more satisfying sexual event per month over placebo—in exchange for a risk of unsexy side effects such as dizziness and nausea. (Sprout did not respond to requests for comment.) Bremelanotide, approved by the US Food and Drug Administration in 2019 for the treatment of low desire in premenopausal women, must be injected into the leg at least forty-five minutes before sex—not sexy either—and side effects may include nausea, headaches, or vomiting. In testing, some subjects preferred a placebo. Robert Jordan, a senior vice president of Palatin, the maker of bremelanotide, counters that no one in its drug trials dropped out because of the injection and that side effects wear off quickly.
Viagra also made it seem as though quick and effective treatment for sexual dysfunction is the norm and women are, as always, the unlucky exception. That’s not true. Patient data have long shown drug companies’ well-kept secret: Viagra has a high dropout rate. Almost half of men taking phosphodiesterase-5 inhibitors like Viagra, Levitra, and Cialis quietly stop refilling their prescriptions after one year, according to a comprehensive review of multiple studies published in 2016 in the journal Andrology. Reasons cited included lack of efficacy, side effects, and “marital problems”—in other words, sexual complexities that a pill couldn’t fix.
The notion that men always have strong sex drives despite emotional, psychological, or relationship factors and only require a boost to their hydraulics just isn’t true, says Sarah Hunter Murray, a Winnipeg therapist and the author of the 2019 book Not Always in the Mood: The New Science of Men, Sex, and Relationships. “I see the men that Viagra doesn’t work for,” she says. “Viagra is not a desire drug at all,” says Holzapfel. It’s an arousal drug: it boosts blood flow to the pelvis. That’s it. Sometimes, that sensation of blood flowing can spur feelings of desire. But, in many cases, an erection by itself doesn’t address the deeper desire issues that many men find it hard to talk about.
Viagra’s barrage of marketing, then, may have set up a mythical standard of what to expect in a drug for women: a pharmaceutical bypass for sex’s complexities and insecurities. Hearing Big Pharma’s line that men have a cure but women don’t, Gunter says, can compound women’s distress.
Lori Brotto does research with the urgency of someone trying to make up for lost time. Women’s concerns have long been excluded from medicine in general. “Up until the year 2000, women weren’t even included routinely in clinical trials” for heart or diabetes drugs, says Brotto, the director of UBC’s influential Sexual Health Laboratory. Sexuality has also been sidelined. “We haven’t known as much, scientifically, about sex function, especially desire, for men and women until really the last thirty years,” says Holzapfel.
You might imagine that a condition both multifaceted and widespread in the population would attract a proliferation of specialists similar to those who study nutrition or sports medicine. Yet the number of professionals truly qualified to treat complex sexual health issues is low. Studying sexuality, particularly in women, has never been a priority in Western medicine owing to deep-seated biases and doctors’ discomfort. “We don’t have a formal specialty called sexual medicine” in Canada or, indeed, in most places in the world, says Holzapfel. For example, while there is an organization, the Board of Examiners in Sex Therapy and Counselling in Ontario (BESTCO), that certifies Ontario sex therapists, membership is voluntary. A list of sex therapists certified by BESTCO shows only fifty-one for the entire province, most clustered in Toronto. That’s one for approximately every 291,000 people. (By contrast, according to the Canadian Medical Association, there are 835 OB-GYNs in the province.)
Until recently, Brotto says, medical research in this area has also been constrained. “Because pharmaceutical companies were the primary source of funding for research, it really steered the kinds of questions that got asked,” she says. The lion’s share of funding has gone to drug trials rather than to psychological or sex education treatments or even to testing how to combine new drugs with therapy, she says. Her own research focuses attention elsewhere: she’s interested in how a woman’s overall state of mind might affect her ability to experience arousal.
On the basis of her research, Brotto has developed a mindfulness-based sex therapy, which she hopes will both give women a more holistic approach to their sexualities and, by being something they can do on their own (an at-home guide will be out next year, and an online video series is in the works), expand access to care.
Diana Firican is one of the women Brotto has worked with: she participated in eight weeks of mindfulness-based therapy, part of a five-year randomized controlled study designed to test whether a mindfulness-based approach would be more effective than existing approaches to sex therapy. One group received sex education along with traditional group therapy; Firican’s group learned mindfulness-based techniques as well as the sex ed.
The sex ed, which included learning about responsive desire, helped; Firican loved knowing she could start having sex for nonsexual reasons, or “start from zero desire,” she said. But mindfulness, by helping focus attention first on the breathing, then on the whole body, and then on genital sensations, resulted in sexual feelings intensifying as distracting thoughts fell away. The key is not just noticing but fully accepting each sensation exactly as it is, a mindfulness skill called “equanimity.” As women notice more pleasant sensations, desire to have sex increases because there is more incentive to do so. The mindfulness group also saw greater reductions in distress and rumination and more relationship satisfaction. This held for up to a year after the therapy ended.
Gunter, who says Brotto’s therapies should be among FSIAD’s first-line treatments, nevertheless understands why all these steps might be frustrating. “You wait four months to see your GP and then you get in and they ask you about your sleep and they ask you about your depression, and you’re like, Ugh . . . . It’s hard for people to understand how something like talk therapy or mindfulness-based practices can improve this big problem. You know what you need for a big problem? You need a high-powered drug or an injection or a surgery.”
Mindfulness-based therapy is showing promise for many—in particular, for those who experience lowered desire due to stress, distraction, or distress related to physical health and for those who aren’t sure what the cause is. Those who don’t see improvement after trying mindfulness or talk therapies and who have ruled out other factors such as vulval changes and general health issues may still benefit from medication, says Gunter. This is especially true if researchers can refine their approaches and target drugs to the specific causes that underlie FSIAD.
If women ever do get a libido pill, Kim van Rooij may have something to do with it. In her job as a GP in Amsterdam, she often sees patients with sexual difficulties. As a researcher, she has been working on a treatment with huge market potential.
“I think the mistake [pharmaceutical companies] make is that they want to develop something for all women,” she says. “That’s not possible.” Until recently, Van Rooij was chief medical officer of Emotional Brain, which has developed two separate desire drugs—with the working names Lybrido and Lybridos—tailored to what its researchers believe are two subtypes of sexual brain chemistry. Although phase-two trials were promising and the drugs were initially expected to come to market in 2016, the company hit difficulty attracting funding for costly, much larger phase-three trials that would involve thousands of subjects in multiple countries. Emotional Brain is now in the process of being sold, and the new owners will be moving ahead with those more expensive trials.
Taking Lybrido or Lybridos would go like this: patients struggling with low desire would get a blood test. It would reveal whether they have a genetic predisposition to be sensitive to some of the neurotransmitters and hormones that play key roles in regulating pleasure, desire, and sexual satisfaction—oxytocin, androgens, and serotonin, respectively. Based on the results, they would get a prescription for either Lybrido or Lybridos—on the theory that each drug will be more effective if it’s targeted to the right kind of brain chemistry. Both drugs are taken on-demand, just like Viagra, and take effect within a few hours. Both have a coating containing a tiny quantity of testosterone to induce a heightened sensitivity to sexual feelings and suggestions.
If the pill is Lybrido, what’s beneath the coating is the drug sildenafil citrate (that is, the medication marketed as Viagra), which would send blood flow to the pelvis at the same time. The interplay of these drugs would work for about half of patients with FSIAD—those with less sexual sensitivity. “The first group of women don’t have as much sensitivity to oxytocin or androgens,” says Van Rooij. “They never flirt. If they see a very attractive person, they don’t think about sex.”
For roughly the other half, however, taking Lybrido would be an extreme turnoff. The failure of an early trial led to this discovery. Researchers were testing Lybrido on a pilot group when they noticed some women responding worse to the new drug than to placebo. “And then they looked at the interviews,” says Van Rooij. The screening interviews with participants who reacted negatively revealed histories of sexual abuse.
In a separate study of women without histories of sexual trauma, Van Rooij recalls, company researchers scanned women’s brains to see how they responded to the medication and found that, while they had expected testosterone to activate the limbic system in most women, for some, it instead activated the prefrontal cortex, which is involved in inhibition. They hypothesized that a subtype of people with FSIAD were perfectly sensitive to testosterone but also had strong inhibitory reactions—an overactive serotonin system, which is involved in telling the brain you’ve had enough of something and it’s time to stop.
“It’s not only sexual abuse but people who had a very strict [upbringing], with parents who never told them about sex, or there was always a taboo,” Van Rooij says. “Their first boyfriend or girlfriend experience was not what they expected it to be. Those kinds of experiences you take with you, of course, to other sexual activities.” This group would be prescribed Lybridos (a placeholder name which will be changed to prevent confusion, says Van Rooij), which has the same testosterone coating but with a very small dose of the antianxiety medication buspirone underneath.
Less serotonin during the testosterone’s active window would take the foot off the brain’s “brakes,” according to the dual-control model of desire, which Lybridos is based on. It’s the theory that much of human behaviour, including sex, depends on balancing excitatory and inhibitory patterns in the brain. Sex educator Emily Nagoski has described desire as having gas and brake pedals. We often focus on our turn-ons, trying to hit the gas harder, but equally important to desire is eliminating what turns us off, like stress or distractions.
Not all women with low desire have experienced sexual violence. But desire difficulties may be more common in those who develop PTSD, according to a study by Brotto and sexual health researcher Julia O’Loughlin in 2020. It found that women with low desire were significantly more likely than a control group to meet criteria for having ptsd even though people in both groups had experienced comparable traumatic life events.
The idea of a pill that could soften the body’s learned resistance to sex, whether from sexual trauma or just the general anti-aphrodisiac of being a woman navigating the world’s dangers and judgments, invites obvious reasons to be uncomfortable. Would women be pressured into taking it by partners? Would they pressure themselves into taking it?
Ultimately, the ideal course of treatment will involve choosing from a suite of options, personalized to the individual.
Lybridos works only if taken under the tongue—it wouldn’t work if dropped in someone’s drink, so it couldn’t be used as a date-rape drug, says Van Rooij. Nor does it have mind-altering effects: taking the medication would, if it worked, increase desire for something that a woman wanted—it wouldn’t make her amenable to something she didn’t. It would still be important to have frank conversations about potentials for partner pressure if these drugs came to market. Yet, with some women already turning to cannabis, wine, MDMA, or other ways of self-medicating in order to achieve the relaxation required to give pleasure a chance, a medically researched alternative would be welcome.
Ultimately, says Brotto, the ideal remedy for distress about desire will not be just one pill or one mindfulness technique for all, because these struggles don’t manifest in the same way for everyone. The ideal course of treatment would involve choosing from a suite of options, personalized to the individual.
Gunter isn’t sure if a game-changing pharmaceutical treatment for desire is in the cards or if desire is too complex to be addressed with medication. “Would it be good for us to have more solutions for people? I think so! Because the ones we have aren’t really very good. But I don’t know if that’s because there isn’t a medical option for that, if it’s a far more complex thing, or if there is a medical option and we haven’t come upon the research yet to shine a light on it.”
And, even if we did find a new pill, bigger-picture cultural change would still be needed. “I think the biggest thing that could be changed is at the ground level, everyone having a better understanding about normal sexual functioning,” Gunter says. “So often I hear people say, ‘There’s no female Viagra.’ Well, no, actually, there is. Taking estrogen in menopause is the same as taking Viagra. Estrogen increases blood flow to the tissues. It improves how the tissues can function. Viagra just improves how the penis can function. It doesn’t change libido. So I think it’s important that we make sure that people are also having the right conversations.”