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Asking patients about their sexuality
How to take a sexual history (without blushing)
When you address sexuality, you open a window to the patient’s psychology. Talking about sex may illuminate important clues about the individual’s capacity to:
- give and receive pleasure
- love and be loved
- be psychologically intimate
- manage expected and unexpected changes throughout adulthood.1
The opportunity to listen to sexual histories over time will help you become proficient in generating causal hypotheses and using them to help your patients.
Patients think—often erroneously—that all psychiatrists are knowledgeable, skillful, and interested in addressing sexual concerns. But psychiatric practice has turned away from clinical sexuality, and most of us learn on our own how to take a sexual history and to bring up relevant topics during subsequent sessions.
These activities are not particularly difficult,2 but they often bump up against one or more clinician fears (Table 1).3 You can master these apprehensions by:
- identifying them in yourself
- thinking about them rationally
- learning about the broad range of human sexual expression
- understanding professional boundaries.4
Table 1
Clinicians’ 5 worst fears about taking sexual histories
| Personal or patient sexual arousal while talking about sex |
| Not knowing what questions to ask |
| Not knowing how to help with patients’ sexual problems |
| Sudden awareness of one’s own sexual concerns |
| Having the patient see our moral repugnance about certain sexual practices |
| Source: Reference 3 |
Assessing sexual complaints
Sexual behavior—normal and abnormal, masturbatory and partnered—rests upon biological, psychological, and interpersonal elements, and cultural concepts of normality and morality.5 These four components also are the sources of sexual problems (Table 2).6,7
To accurately assess individuals’ and couples’ sexual problems, we must consider the four components’ present and past contributions in every case. We may declare a hypothesis of cause after one or two sessions, but the explanation usually evolves and becomes more complex with time.8
Outside of sexuality clinics, we usually learn about a patient’s sexual complaint during therapy for another problem:
- Individuals may bring up cross-dressing, anxiety about possibly being homosexual, concern about violent sexual fantasies, or other issues of sexual identity. Sexual function concerns may include new difficulty attaining orgasm, aversion to intercourse, painful intercourse, too-rapid ejaculation, episodic inability to maintain an erection, or longstanding inability to ejaculate while with a partner.
- Couples may present with difficulty orchestrating their sexual lives. Their complaints may involve discrepancies in sexual desire, inability to bring a young wife to orgasm, cessation of sex, infidelity, dyspareunia, erectile dysfunction in a newly married couple in their 60s, or a wife’s distress over her husband’s use of Internet pornography.
- Referrals may come from a social agency about an individual whose sexual behavior clashes with social values or laws. Judges, lawyers, state boards, clergy, or medical chiefs-of-staff may request assistance with individuals who cross sexual boundaries at work, are accused of sex crimes, or have been sexually victimized.5
4 components of sexual behavior: Where sexual problems may arise
| Component | Related sexual problems (examples) |
|---|---|
| Biological elements | Congenital androgen receptor disorder,9 undiagnosed prolactinoma,10 medical disorders (such as multiple sclerosis), medication side effects, heroin abuse |
| Psychological elements | Developmental processes (neglect, lack of warmth, or physical and sexual abuse from childhood caretakers) or present states (affect disorder, paranoia) |
| Interpersonal elements | Lack of psychological intimacy, marital alienation, disapproval of spouse’s behavior (such as gambling or excessive shopping), disrespect for spouse’s parenting style, past infidelity |
| Cultural concepts of normality and morality | Inability to free oneself of antisexual religious attitudes, homophobia, or belief that masturbation or oral-genital contact is abnormal sexual behavior |
Ask about sexual identity
By the end of adolescence, most individuals have stably in place the three self labels that encompass sexual identity:
- gender identity—the degree of comfort with the self as masculine or feminine
- orientation—the gender of those who attract or repel us for romantic and sexual purposes
- intention—what we want to do with our bodies and our partners’ bodies during sexual behavior.9
Conventional sexual identities do not pose a countertransference problem for most professionals after they become accustomed to discussing sexual matters. But unconventional identities—such as a gender identity disorder, homosexuality, or a paraphilia—can cause anxiety and avoidance for sexually conventional psychiatrists.
Table 3
Ask about 3 components of sexual identity
| Component | Sample questions |
|---|---|
| Gender identify | Are you happy that you are a male (female)? |
| Do you privately feel sufficiently masculine (feminine)? | |
| Orientation | Are you sexually and romantically attracted primarily to males, females, or both? |
| Intention | Are your sexual fantasies focused on unconventional images involving sadism, masochism, exhibitionism, voyeurism, clothing, animals, or children? |
Paraphilia. The most upsetting paraphilia to learn about is pedophilia. The patient typically is nervous about revealing his (or rarely her) fantasy focus on boys, girls, or both. Pedophiles may be exclusively interested in particular age groups—such as preschoolers or grade school children—or be preoccupied with children while also having more conventional adult sexual interests.
Learn to ask about erotic fantasies, knowing that occasionally you will encounter behaviors or thoughts that are contrary to your own values. Knowing that you will encounter paraphilia enables you to anticipate and work through any private moral outrage before you meet the patient.3
Ask about sexual function
Desire, arousal, and orgasm are the three dimensions of sexual function listed in DSM-IV-TR. Sexual dysfunction may be classified as lifelong (since onset of sexual activity) or acquired (after a symptom-free period). If a patient’s sexual dysfunction is acquired, determine whether it occurs in all sexual encounters or is situational (with only one partner or present sometimes with a partner). These distinctions allow you to rationally pursue the cause (Table 4).
If a patient complains of loss of desire for sex, determine if it is manifested by:
- absence of sexual thoughts, fantasies, attractions, or masturbation (as might be seen in acquired hypogonadal states)
- lost motivation to approach his or her partner for sex (as commonly occurs when partners become alienated).10
Common sexual dysfunctions such as premature ejaculation, female anorgasmia, hypoactive sexual desire disorder, and arousal dysfunctions often have no significant genital findings. Erectile dysfunction in middle-aged and older men indicates the need to do a workup for early vascular disease and metabolic syndrome.
Desire versus arousal. Differentiating sexual desire and arousal can be complicated because they overlap, particularly during middle age or as individuals settle down with a consistent partner. Desire is also complicated by a vital gender difference.11 Most women in monogamous relationships eventually notice that the arousal stimulated by sexual behavior precedes their intense desire for sex, whereas most men report that their desire for sex precedes their arousal through much of the life cycle. Understanding these concepts will shape your follow-up questions about desire and arousal experiences.
Table 4
Ask about 3 components of sexual function
| Component | Sample questions |
|---|---|
| Desire | Are you ever “horny”—that is, have spontaneous feelings of mild sexual arousal? |
| Tell me what motivates you to have sexual behavior with your partner | |
| Arousal | Explain what is it like for you during lovemaking. |
| Do you get excited? Do you stay excited? | |
| Orgasm | Please tell me about your concerns about attaining orgasm |
Adult Sex Life: 6 Stages
Sexual dysfunction symptoms may be the same throughout the life cycle, but their meanings to patients vary dramatically. For example:
- A psychological stress that creates erectile dysfunction in a 60-year-old might not affect a 25-year-old because biological capacities for arousal are different at these life stages.
- Anorgasmia in a 22-year-old does not have the same psychological and biological sources as anorgasmia in a 62-year-old.
Stage 1: Sexual unfolding usually corresponds with adolescence and single adulthood. It is characterized by growing awareness of individual identity and functional characteristics and experiments in managing sexual drives, sexual opportunities, and relationships through masturbation and partner sex. It ends when a person depends on one partner for sexual expression.
Stage 2: Sexual equilibrium is established as part of a monogamous partnership. This equilibrium, which shapes the couple’s unique pattern of sexual expression, is formed by the interaction of their individual identity, desire, arousal, and orgasmic attainment characteristics.
The power of this interaction can be seen in previously functional men and women who quickly become dysfunctional in a new equilibrium because they discern their partner’s displeasure, lack of satisfaction, or lack of interest in particular sexual acts. Their perception of their partner’s unhappiness can quickly induce performance anxiety during sex, anger about sex, or a sense of hopelessness about getting one’s needs met.
The sexual equilibrium’s power is evident in previously dysfunctional individuals who quickly become comfortable and capable when they sense that their partners are pleased with them as partners. Inhibitions gradually lessen, and the couple’s sexual life begins on a good footing.
Stage 3: Preservation of sexual behavior refers to maintaining partnered sexual activity as life becomes more complex because of expected events such as pregnancy, rearing children, new job responsibilities, illness in parents, etc. The couple’s ability to preserve their sexual relationship rests on their capacity to:
- manage disappointment over emerging knowledge of the partner’s character
- resolve periodic nonsexual disagreements
- re-attain psychological intimacy
- understand how important sex is as a means to erase anger, reduce extramarital temptation, reaffirm the couple’s bond, and have fun.
Stage 4: The physiologic downturn in midlife for women begins during perimenopause and is characterized by diminished drive, vaginal dryness, and reduced vulvar and breast erotic sensitivity.12 Men’s physiologic decline—usually apparent to them by their mid-50s—is characterized by reduced drive and less-firm penile tumescence.13
Stage 5: Aging effects emerge gradually as individuals move into their 60s. Both sexes usually find orgasm more difficult to attain. Women may say they have sex primarily to please their partners, and men may notice less consistent potency.
Both sexes rely on motivational aspects of desire to have sex, not on sex drive per se. A man may say he wants to have sex, for example, because “it is normal to want to have sex as long as the body is willing; it makes me feel manly.” Women who maintained natural vaginal lubrication during their 50s often now use lubricants.14
Stage 6: The era of serious illness—whether psychiatric or physical—can occur any time in the life cycle. Illnesses ranging from congestive heart failure to complicated grief can limit a person’s sexual activities. Some changes can increase the frequency of sex—such as hypomania or mania, the new appreciation of a now-impaired spouse, or substance abuse that decreases sexual restraints—but most serious illnesses diminish the patient’s or partner’s sexual desire and arousal.
When death, divorce, or other separations disrupt relationships and individuals find themselves unattached, they return to stage 1: unfolding. With new partners, they will have different desire, arousal, and orgasmic characteristics than they did when last unattached. Their next sexual equilibrium will be different from the one before.
Related resources
- Levine SB. Sexual life: a clinician’s guide. New York: Plenum; 1992.
- Risen CB. Listening to sexual stories. In: Levine SB, Risen CB, Althof SE (eds). Handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003:1-20.
1. Levine SB. Sexuality in mid-life. New York: Plenum; 1998.
2. Maurice WL. Sexual medicine in primary care. Philadelphia: Mosby; 1999.
3. Risen CB. Listening to sexual stories. In: Levine SB, Risen CB, Althof SE (eds). Handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003:1-20.
4. American Psychiatric Association. Principles of medical ethics with annotations especially applicable to psychiatry (pamphlet). Washington, DC: American Psychiatric Association; 1993.
5. Levine SB. A reintroduction to clinical sexuality. Focus 2005;III(4):526-31.
6. Diamond M, Watson LA. Androgen insensitivity syndrome and Klinefelter’s syndrome: sex and gender considerations. Child Adolesc Psychiatr Clin North Am 2004;13(3):623-40.
7. Schlechte JA. Prolactinoma. N Engl J Med 2003;349(21):2035-41.
8. Gabbard GO. Mind, brain and personality disorders. Am J Psychiatry 2005;162(4):648-55.
9. Kafka MP. The paraphilia-related disorders: nonparaphillic hyper-sexuality and sexual compulsivity/addiction. In: Leiblum SR, Rosen RC (eds). Principles and practices of sex therapy. New York: Guilford Press; 2000:471-503.
10. Basson R. Sexual desire and arousal disorders in women. N Engl J Med 2006;354(14):1497-1506.
11. Basson R. Human sex response cycles. J Sex Marital Ther 2001;27(1):33-43.
12. Dennerstein L. The sexual impact of menopause. In: Levine SB, Risen CB, Althof SE (eds). The handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003.
13. Schiavi RC, Schreiner-Engel P, Mandeli J. Healthy aging and male sexual function. Am J Psychiatry 1990;147(6):766-71.
14. Kellett JM. Older adult sexuality. In: Szuchman LT, Muscarella F (eds). Psychological perspectives on human sexuality. New York: John Wiley & Sons; 2000:355-82.
When you address sexuality, you open a window to the patient’s psychology. Talking about sex may illuminate important clues about the individual’s capacity to:
- give and receive pleasure
- love and be loved
- be psychologically intimate
- manage expected and unexpected changes throughout adulthood.1
The opportunity to listen to sexual histories over time will help you become proficient in generating causal hypotheses and using them to help your patients.
Patients think—often erroneously—that all psychiatrists are knowledgeable, skillful, and interested in addressing sexual concerns. But psychiatric practice has turned away from clinical sexuality, and most of us learn on our own how to take a sexual history and to bring up relevant topics during subsequent sessions.
These activities are not particularly difficult,2 but they often bump up against one or more clinician fears (Table 1).3 You can master these apprehensions by:
- identifying them in yourself
- thinking about them rationally
- learning about the broad range of human sexual expression
- understanding professional boundaries.4
Table 1
Clinicians’ 5 worst fears about taking sexual histories
| Personal or patient sexual arousal while talking about sex |
| Not knowing what questions to ask |
| Not knowing how to help with patients’ sexual problems |
| Sudden awareness of one’s own sexual concerns |
| Having the patient see our moral repugnance about certain sexual practices |
| Source: Reference 3 |
Assessing sexual complaints
Sexual behavior—normal and abnormal, masturbatory and partnered—rests upon biological, psychological, and interpersonal elements, and cultural concepts of normality and morality.5 These four components also are the sources of sexual problems (Table 2).6,7
To accurately assess individuals’ and couples’ sexual problems, we must consider the four components’ present and past contributions in every case. We may declare a hypothesis of cause after one or two sessions, but the explanation usually evolves and becomes more complex with time.8
Outside of sexuality clinics, we usually learn about a patient’s sexual complaint during therapy for another problem:
- Individuals may bring up cross-dressing, anxiety about possibly being homosexual, concern about violent sexual fantasies, or other issues of sexual identity. Sexual function concerns may include new difficulty attaining orgasm, aversion to intercourse, painful intercourse, too-rapid ejaculation, episodic inability to maintain an erection, or longstanding inability to ejaculate while with a partner.
- Couples may present with difficulty orchestrating their sexual lives. Their complaints may involve discrepancies in sexual desire, inability to bring a young wife to orgasm, cessation of sex, infidelity, dyspareunia, erectile dysfunction in a newly married couple in their 60s, or a wife’s distress over her husband’s use of Internet pornography.
- Referrals may come from a social agency about an individual whose sexual behavior clashes with social values or laws. Judges, lawyers, state boards, clergy, or medical chiefs-of-staff may request assistance with individuals who cross sexual boundaries at work, are accused of sex crimes, or have been sexually victimized.5
4 components of sexual behavior: Where sexual problems may arise
| Component | Related sexual problems (examples) |
|---|---|
| Biological elements | Congenital androgen receptor disorder,9 undiagnosed prolactinoma,10 medical disorders (such as multiple sclerosis), medication side effects, heroin abuse |
| Psychological elements | Developmental processes (neglect, lack of warmth, or physical and sexual abuse from childhood caretakers) or present states (affect disorder, paranoia) |
| Interpersonal elements | Lack of psychological intimacy, marital alienation, disapproval of spouse’s behavior (such as gambling or excessive shopping), disrespect for spouse’s parenting style, past infidelity |
| Cultural concepts of normality and morality | Inability to free oneself of antisexual religious attitudes, homophobia, or belief that masturbation or oral-genital contact is abnormal sexual behavior |
Ask about sexual identity
By the end of adolescence, most individuals have stably in place the three self labels that encompass sexual identity:
- gender identity—the degree of comfort with the self as masculine or feminine
- orientation—the gender of those who attract or repel us for romantic and sexual purposes
- intention—what we want to do with our bodies and our partners’ bodies during sexual behavior.9
Conventional sexual identities do not pose a countertransference problem for most professionals after they become accustomed to discussing sexual matters. But unconventional identities—such as a gender identity disorder, homosexuality, or a paraphilia—can cause anxiety and avoidance for sexually conventional psychiatrists.
Table 3
Ask about 3 components of sexual identity
| Component | Sample questions |
|---|---|
| Gender identify | Are you happy that you are a male (female)? |
| Do you privately feel sufficiently masculine (feminine)? | |
| Orientation | Are you sexually and romantically attracted primarily to males, females, or both? |
| Intention | Are your sexual fantasies focused on unconventional images involving sadism, masochism, exhibitionism, voyeurism, clothing, animals, or children? |
Paraphilia. The most upsetting paraphilia to learn about is pedophilia. The patient typically is nervous about revealing his (or rarely her) fantasy focus on boys, girls, or both. Pedophiles may be exclusively interested in particular age groups—such as preschoolers or grade school children—or be preoccupied with children while also having more conventional adult sexual interests.
Learn to ask about erotic fantasies, knowing that occasionally you will encounter behaviors or thoughts that are contrary to your own values. Knowing that you will encounter paraphilia enables you to anticipate and work through any private moral outrage before you meet the patient.3
Ask about sexual function
Desire, arousal, and orgasm are the three dimensions of sexual function listed in DSM-IV-TR. Sexual dysfunction may be classified as lifelong (since onset of sexual activity) or acquired (after a symptom-free period). If a patient’s sexual dysfunction is acquired, determine whether it occurs in all sexual encounters or is situational (with only one partner or present sometimes with a partner). These distinctions allow you to rationally pursue the cause (Table 4).
If a patient complains of loss of desire for sex, determine if it is manifested by:
- absence of sexual thoughts, fantasies, attractions, or masturbation (as might be seen in acquired hypogonadal states)
- lost motivation to approach his or her partner for sex (as commonly occurs when partners become alienated).10
Common sexual dysfunctions such as premature ejaculation, female anorgasmia, hypoactive sexual desire disorder, and arousal dysfunctions often have no significant genital findings. Erectile dysfunction in middle-aged and older men indicates the need to do a workup for early vascular disease and metabolic syndrome.
Desire versus arousal. Differentiating sexual desire and arousal can be complicated because they overlap, particularly during middle age or as individuals settle down with a consistent partner. Desire is also complicated by a vital gender difference.11 Most women in monogamous relationships eventually notice that the arousal stimulated by sexual behavior precedes their intense desire for sex, whereas most men report that their desire for sex precedes their arousal through much of the life cycle. Understanding these concepts will shape your follow-up questions about desire and arousal experiences.
Table 4
Ask about 3 components of sexual function
| Component | Sample questions |
|---|---|
| Desire | Are you ever “horny”—that is, have spontaneous feelings of mild sexual arousal? |
| Tell me what motivates you to have sexual behavior with your partner | |
| Arousal | Explain what is it like for you during lovemaking. |
| Do you get excited? Do you stay excited? | |
| Orgasm | Please tell me about your concerns about attaining orgasm |
Adult Sex Life: 6 Stages
Sexual dysfunction symptoms may be the same throughout the life cycle, but their meanings to patients vary dramatically. For example:
- A psychological stress that creates erectile dysfunction in a 60-year-old might not affect a 25-year-old because biological capacities for arousal are different at these life stages.
- Anorgasmia in a 22-year-old does not have the same psychological and biological sources as anorgasmia in a 62-year-old.
Stage 1: Sexual unfolding usually corresponds with adolescence and single adulthood. It is characterized by growing awareness of individual identity and functional characteristics and experiments in managing sexual drives, sexual opportunities, and relationships through masturbation and partner sex. It ends when a person depends on one partner for sexual expression.
Stage 2: Sexual equilibrium is established as part of a monogamous partnership. This equilibrium, which shapes the couple’s unique pattern of sexual expression, is formed by the interaction of their individual identity, desire, arousal, and orgasmic attainment characteristics.
The power of this interaction can be seen in previously functional men and women who quickly become dysfunctional in a new equilibrium because they discern their partner’s displeasure, lack of satisfaction, or lack of interest in particular sexual acts. Their perception of their partner’s unhappiness can quickly induce performance anxiety during sex, anger about sex, or a sense of hopelessness about getting one’s needs met.
The sexual equilibrium’s power is evident in previously dysfunctional individuals who quickly become comfortable and capable when they sense that their partners are pleased with them as partners. Inhibitions gradually lessen, and the couple’s sexual life begins on a good footing.
Stage 3: Preservation of sexual behavior refers to maintaining partnered sexual activity as life becomes more complex because of expected events such as pregnancy, rearing children, new job responsibilities, illness in parents, etc. The couple’s ability to preserve their sexual relationship rests on their capacity to:
- manage disappointment over emerging knowledge of the partner’s character
- resolve periodic nonsexual disagreements
- re-attain psychological intimacy
- understand how important sex is as a means to erase anger, reduce extramarital temptation, reaffirm the couple’s bond, and have fun.
Stage 4: The physiologic downturn in midlife for women begins during perimenopause and is characterized by diminished drive, vaginal dryness, and reduced vulvar and breast erotic sensitivity.12 Men’s physiologic decline—usually apparent to them by their mid-50s—is characterized by reduced drive and less-firm penile tumescence.13
Stage 5: Aging effects emerge gradually as individuals move into their 60s. Both sexes usually find orgasm more difficult to attain. Women may say they have sex primarily to please their partners, and men may notice less consistent potency.
Both sexes rely on motivational aspects of desire to have sex, not on sex drive per se. A man may say he wants to have sex, for example, because “it is normal to want to have sex as long as the body is willing; it makes me feel manly.” Women who maintained natural vaginal lubrication during their 50s often now use lubricants.14
Stage 6: The era of serious illness—whether psychiatric or physical—can occur any time in the life cycle. Illnesses ranging from congestive heart failure to complicated grief can limit a person’s sexual activities. Some changes can increase the frequency of sex—such as hypomania or mania, the new appreciation of a now-impaired spouse, or substance abuse that decreases sexual restraints—but most serious illnesses diminish the patient’s or partner’s sexual desire and arousal.
When death, divorce, or other separations disrupt relationships and individuals find themselves unattached, they return to stage 1: unfolding. With new partners, they will have different desire, arousal, and orgasmic characteristics than they did when last unattached. Their next sexual equilibrium will be different from the one before.
Related resources
- Levine SB. Sexual life: a clinician’s guide. New York: Plenum; 1992.
- Risen CB. Listening to sexual stories. In: Levine SB, Risen CB, Althof SE (eds). Handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003:1-20.
When you address sexuality, you open a window to the patient’s psychology. Talking about sex may illuminate important clues about the individual’s capacity to:
- give and receive pleasure
- love and be loved
- be psychologically intimate
- manage expected and unexpected changes throughout adulthood.1
The opportunity to listen to sexual histories over time will help you become proficient in generating causal hypotheses and using them to help your patients.
Patients think—often erroneously—that all psychiatrists are knowledgeable, skillful, and interested in addressing sexual concerns. But psychiatric practice has turned away from clinical sexuality, and most of us learn on our own how to take a sexual history and to bring up relevant topics during subsequent sessions.
These activities are not particularly difficult,2 but they often bump up against one or more clinician fears (Table 1).3 You can master these apprehensions by:
- identifying them in yourself
- thinking about them rationally
- learning about the broad range of human sexual expression
- understanding professional boundaries.4
Table 1
Clinicians’ 5 worst fears about taking sexual histories
| Personal or patient sexual arousal while talking about sex |
| Not knowing what questions to ask |
| Not knowing how to help with patients’ sexual problems |
| Sudden awareness of one’s own sexual concerns |
| Having the patient see our moral repugnance about certain sexual practices |
| Source: Reference 3 |
Assessing sexual complaints
Sexual behavior—normal and abnormal, masturbatory and partnered—rests upon biological, psychological, and interpersonal elements, and cultural concepts of normality and morality.5 These four components also are the sources of sexual problems (Table 2).6,7
To accurately assess individuals’ and couples’ sexual problems, we must consider the four components’ present and past contributions in every case. We may declare a hypothesis of cause after one or two sessions, but the explanation usually evolves and becomes more complex with time.8
Outside of sexuality clinics, we usually learn about a patient’s sexual complaint during therapy for another problem:
- Individuals may bring up cross-dressing, anxiety about possibly being homosexual, concern about violent sexual fantasies, or other issues of sexual identity. Sexual function concerns may include new difficulty attaining orgasm, aversion to intercourse, painful intercourse, too-rapid ejaculation, episodic inability to maintain an erection, or longstanding inability to ejaculate while with a partner.
- Couples may present with difficulty orchestrating their sexual lives. Their complaints may involve discrepancies in sexual desire, inability to bring a young wife to orgasm, cessation of sex, infidelity, dyspareunia, erectile dysfunction in a newly married couple in their 60s, or a wife’s distress over her husband’s use of Internet pornography.
- Referrals may come from a social agency about an individual whose sexual behavior clashes with social values or laws. Judges, lawyers, state boards, clergy, or medical chiefs-of-staff may request assistance with individuals who cross sexual boundaries at work, are accused of sex crimes, or have been sexually victimized.5
4 components of sexual behavior: Where sexual problems may arise
| Component | Related sexual problems (examples) |
|---|---|
| Biological elements | Congenital androgen receptor disorder,9 undiagnosed prolactinoma,10 medical disorders (such as multiple sclerosis), medication side effects, heroin abuse |
| Psychological elements | Developmental processes (neglect, lack of warmth, or physical and sexual abuse from childhood caretakers) or present states (affect disorder, paranoia) |
| Interpersonal elements | Lack of psychological intimacy, marital alienation, disapproval of spouse’s behavior (such as gambling or excessive shopping), disrespect for spouse’s parenting style, past infidelity |
| Cultural concepts of normality and morality | Inability to free oneself of antisexual religious attitudes, homophobia, or belief that masturbation or oral-genital contact is abnormal sexual behavior |
Ask about sexual identity
By the end of adolescence, most individuals have stably in place the three self labels that encompass sexual identity:
- gender identity—the degree of comfort with the self as masculine or feminine
- orientation—the gender of those who attract or repel us for romantic and sexual purposes
- intention—what we want to do with our bodies and our partners’ bodies during sexual behavior.9
Conventional sexual identities do not pose a countertransference problem for most professionals after they become accustomed to discussing sexual matters. But unconventional identities—such as a gender identity disorder, homosexuality, or a paraphilia—can cause anxiety and avoidance for sexually conventional psychiatrists.
Table 3
Ask about 3 components of sexual identity
| Component | Sample questions |
|---|---|
| Gender identify | Are you happy that you are a male (female)? |
| Do you privately feel sufficiently masculine (feminine)? | |
| Orientation | Are you sexually and romantically attracted primarily to males, females, or both? |
| Intention | Are your sexual fantasies focused on unconventional images involving sadism, masochism, exhibitionism, voyeurism, clothing, animals, or children? |
Paraphilia. The most upsetting paraphilia to learn about is pedophilia. The patient typically is nervous about revealing his (or rarely her) fantasy focus on boys, girls, or both. Pedophiles may be exclusively interested in particular age groups—such as preschoolers or grade school children—or be preoccupied with children while also having more conventional adult sexual interests.
Learn to ask about erotic fantasies, knowing that occasionally you will encounter behaviors or thoughts that are contrary to your own values. Knowing that you will encounter paraphilia enables you to anticipate and work through any private moral outrage before you meet the patient.3
Ask about sexual function
Desire, arousal, and orgasm are the three dimensions of sexual function listed in DSM-IV-TR. Sexual dysfunction may be classified as lifelong (since onset of sexual activity) or acquired (after a symptom-free period). If a patient’s sexual dysfunction is acquired, determine whether it occurs in all sexual encounters or is situational (with only one partner or present sometimes with a partner). These distinctions allow you to rationally pursue the cause (Table 4).
If a patient complains of loss of desire for sex, determine if it is manifested by:
- absence of sexual thoughts, fantasies, attractions, or masturbation (as might be seen in acquired hypogonadal states)
- lost motivation to approach his or her partner for sex (as commonly occurs when partners become alienated).10
Common sexual dysfunctions such as premature ejaculation, female anorgasmia, hypoactive sexual desire disorder, and arousal dysfunctions often have no significant genital findings. Erectile dysfunction in middle-aged and older men indicates the need to do a workup for early vascular disease and metabolic syndrome.
Desire versus arousal. Differentiating sexual desire and arousal can be complicated because they overlap, particularly during middle age or as individuals settle down with a consistent partner. Desire is also complicated by a vital gender difference.11 Most women in monogamous relationships eventually notice that the arousal stimulated by sexual behavior precedes their intense desire for sex, whereas most men report that their desire for sex precedes their arousal through much of the life cycle. Understanding these concepts will shape your follow-up questions about desire and arousal experiences.
Table 4
Ask about 3 components of sexual function
| Component | Sample questions |
|---|---|
| Desire | Are you ever “horny”—that is, have spontaneous feelings of mild sexual arousal? |
| Tell me what motivates you to have sexual behavior with your partner | |
| Arousal | Explain what is it like for you during lovemaking. |
| Do you get excited? Do you stay excited? | |
| Orgasm | Please tell me about your concerns about attaining orgasm |
Adult Sex Life: 6 Stages
Sexual dysfunction symptoms may be the same throughout the life cycle, but their meanings to patients vary dramatically. For example:
- A psychological stress that creates erectile dysfunction in a 60-year-old might not affect a 25-year-old because biological capacities for arousal are different at these life stages.
- Anorgasmia in a 22-year-old does not have the same psychological and biological sources as anorgasmia in a 62-year-old.
Stage 1: Sexual unfolding usually corresponds with adolescence and single adulthood. It is characterized by growing awareness of individual identity and functional characteristics and experiments in managing sexual drives, sexual opportunities, and relationships through masturbation and partner sex. It ends when a person depends on one partner for sexual expression.
Stage 2: Sexual equilibrium is established as part of a monogamous partnership. This equilibrium, which shapes the couple’s unique pattern of sexual expression, is formed by the interaction of their individual identity, desire, arousal, and orgasmic attainment characteristics.
The power of this interaction can be seen in previously functional men and women who quickly become dysfunctional in a new equilibrium because they discern their partner’s displeasure, lack of satisfaction, or lack of interest in particular sexual acts. Their perception of their partner’s unhappiness can quickly induce performance anxiety during sex, anger about sex, or a sense of hopelessness about getting one’s needs met.
The sexual equilibrium’s power is evident in previously dysfunctional individuals who quickly become comfortable and capable when they sense that their partners are pleased with them as partners. Inhibitions gradually lessen, and the couple’s sexual life begins on a good footing.
Stage 3: Preservation of sexual behavior refers to maintaining partnered sexual activity as life becomes more complex because of expected events such as pregnancy, rearing children, new job responsibilities, illness in parents, etc. The couple’s ability to preserve their sexual relationship rests on their capacity to:
- manage disappointment over emerging knowledge of the partner’s character
- resolve periodic nonsexual disagreements
- re-attain psychological intimacy
- understand how important sex is as a means to erase anger, reduce extramarital temptation, reaffirm the couple’s bond, and have fun.
Stage 4: The physiologic downturn in midlife for women begins during perimenopause and is characterized by diminished drive, vaginal dryness, and reduced vulvar and breast erotic sensitivity.12 Men’s physiologic decline—usually apparent to them by their mid-50s—is characterized by reduced drive and less-firm penile tumescence.13
Stage 5: Aging effects emerge gradually as individuals move into their 60s. Both sexes usually find orgasm more difficult to attain. Women may say they have sex primarily to please their partners, and men may notice less consistent potency.
Both sexes rely on motivational aspects of desire to have sex, not on sex drive per se. A man may say he wants to have sex, for example, because “it is normal to want to have sex as long as the body is willing; it makes me feel manly.” Women who maintained natural vaginal lubrication during their 50s often now use lubricants.14
Stage 6: The era of serious illness—whether psychiatric or physical—can occur any time in the life cycle. Illnesses ranging from congestive heart failure to complicated grief can limit a person’s sexual activities. Some changes can increase the frequency of sex—such as hypomania or mania, the new appreciation of a now-impaired spouse, or substance abuse that decreases sexual restraints—but most serious illnesses diminish the patient’s or partner’s sexual desire and arousal.
When death, divorce, or other separations disrupt relationships and individuals find themselves unattached, they return to stage 1: unfolding. With new partners, they will have different desire, arousal, and orgasmic characteristics than they did when last unattached. Their next sexual equilibrium will be different from the one before.
Related resources
- Levine SB. Sexual life: a clinician’s guide. New York: Plenum; 1992.
- Risen CB. Listening to sexual stories. In: Levine SB, Risen CB, Althof SE (eds). Handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003:1-20.
1. Levine SB. Sexuality in mid-life. New York: Plenum; 1998.
2. Maurice WL. Sexual medicine in primary care. Philadelphia: Mosby; 1999.
3. Risen CB. Listening to sexual stories. In: Levine SB, Risen CB, Althof SE (eds). Handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003:1-20.
4. American Psychiatric Association. Principles of medical ethics with annotations especially applicable to psychiatry (pamphlet). Washington, DC: American Psychiatric Association; 1993.
5. Levine SB. A reintroduction to clinical sexuality. Focus 2005;III(4):526-31.
6. Diamond M, Watson LA. Androgen insensitivity syndrome and Klinefelter’s syndrome: sex and gender considerations. Child Adolesc Psychiatr Clin North Am 2004;13(3):623-40.
7. Schlechte JA. Prolactinoma. N Engl J Med 2003;349(21):2035-41.
8. Gabbard GO. Mind, brain and personality disorders. Am J Psychiatry 2005;162(4):648-55.
9. Kafka MP. The paraphilia-related disorders: nonparaphillic hyper-sexuality and sexual compulsivity/addiction. In: Leiblum SR, Rosen RC (eds). Principles and practices of sex therapy. New York: Guilford Press; 2000:471-503.
10. Basson R. Sexual desire and arousal disorders in women. N Engl J Med 2006;354(14):1497-1506.
11. Basson R. Human sex response cycles. J Sex Marital Ther 2001;27(1):33-43.
12. Dennerstein L. The sexual impact of menopause. In: Levine SB, Risen CB, Althof SE (eds). The handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003.
13. Schiavi RC, Schreiner-Engel P, Mandeli J. Healthy aging and male sexual function. Am J Psychiatry 1990;147(6):766-71.
14. Kellett JM. Older adult sexuality. In: Szuchman LT, Muscarella F (eds). Psychological perspectives on human sexuality. New York: John Wiley & Sons; 2000:355-82.
1. Levine SB. Sexuality in mid-life. New York: Plenum; 1998.
2. Maurice WL. Sexual medicine in primary care. Philadelphia: Mosby; 1999.
3. Risen CB. Listening to sexual stories. In: Levine SB, Risen CB, Althof SE (eds). Handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003:1-20.
4. American Psychiatric Association. Principles of medical ethics with annotations especially applicable to psychiatry (pamphlet). Washington, DC: American Psychiatric Association; 1993.
5. Levine SB. A reintroduction to clinical sexuality. Focus 2005;III(4):526-31.
6. Diamond M, Watson LA. Androgen insensitivity syndrome and Klinefelter’s syndrome: sex and gender considerations. Child Adolesc Psychiatr Clin North Am 2004;13(3):623-40.
7. Schlechte JA. Prolactinoma. N Engl J Med 2003;349(21):2035-41.
8. Gabbard GO. Mind, brain and personality disorders. Am J Psychiatry 2005;162(4):648-55.
9. Kafka MP. The paraphilia-related disorders: nonparaphillic hyper-sexuality and sexual compulsivity/addiction. In: Leiblum SR, Rosen RC (eds). Principles and practices of sex therapy. New York: Guilford Press; 2000:471-503.
10. Basson R. Sexual desire and arousal disorders in women. N Engl J Med 2006;354(14):1497-1506.
11. Basson R. Human sex response cycles. J Sex Marital Ther 2001;27(1):33-43.
12. Dennerstein L. The sexual impact of menopause. In: Levine SB, Risen CB, Althof SE (eds). The handbook of clinical sexuality for mental health professionals. New York: Brunner/Routledge; 2003.
13. Schiavi RC, Schreiner-Engel P, Mandeli J. Healthy aging and male sexual function. Am J Psychiatry 1990;147(6):766-71.
14. Kellett JM. Older adult sexuality. In: Szuchman LT, Muscarella F (eds). Psychological perspectives on human sexuality. New York: John Wiley & Sons; 2000:355-82.
Sexual dysfunction: What’s love got to do with it?
Concepts of love and sexual desire lurk around clinical discussions of sexual dysfunction. Love is frequently dismissed as hopelessly unscientific, whereas desire is simplified as if it were a thing called libido. Decreased libido per se tells us little about a patient’s sexual complaints; the key is to differentiate between:
- those with sexual drive but no motivation for their partners
- those with no driveFemale sexual dysfunction”).
Psychiatrists avoid talking about love; it has too many meanings and nuances, too many avenues of defeat, and is too abstract. All you have to say to a patient is, “Tell me about your marriage,” and listen closely as he or she comes to grip with love’s complexity.
This article’s aim is to help you counsel patients more effectively about relationship and sexual problems by exploring two questions: “What is love?” and “What is sexual desire?”
What is love?
Mrs. C, age 41, is being treated for depression and wonders why she has lost desire for her husband. The antidepressant she is taking improves her mood and diminishes her considerable anxiety but makes her feel sexually dead. “My husband doesn’t mind how I feel, as long as he can have sex,” she says.
After adjusting her medication, you explore other problems that might be contributing to her sexual dysfunction. She expresses uncertainty about what love is. Though faithful and committed to her husband, she has stopped enjoying the way he interacts with her, their two grade-school children, her family, and friends.
Love is the usual context within which sexual activities are viewed. Among adults, unhappiness in love predisposes to sexual concerns, and sexual concerns interfere with loving and being loved.
Our patients’ expectations for feeling and receiving love and experiencing satisfying sex are disappointed through a myriad of avenues. Clinicians may overlook it, but demoralization about love can precede the onset of anxiety, panic attacks, and lingering depression.2 Sexual love is expected to begin with connecting with a partner and to evolve for 65 or more years. Most individuals harbor the secret that they are not certain what love is (Table 1) or are surprised by their lack of words to explain it.
1. Love as transient emotion. The assumption that love is a feeling leads too many people waiting to experience the pure feeling. But unlike sadness, fear, anger, or shame, love does not indicate a discrete feeling. Saying, “I love you,” connotes at least two feelings: pleasure and interest.
- Pleasure begins with pleasantness and moves up through delight to exhilaration.
- Interest ranges from mild curiosity to preoccupying fascination.
Most events simultaneously provoke more than one feeling. Discovering that your beloved wants to marry you usually brings about at least happiness, pride, gratitude, and awe. Even if only one feeling is produced, our attitude towards that feeling complicates the experience. When a child is taught that feeling envy is wrong, for example, his experience of it evokes anxiety (from the guilt) and shame (if someone is watching).
After the family, culture, and the person have worked on a simple feeling, it becomes a layered complexity called an emotion. Love, the emotion, is quickly layered with attitudes (which are the product of feelings and defenses against them) based on the person’s sense of safety stemming from earlier attachments.3 When someone says “I love you,” he or she knows the motive for saying it and hopes for a particular response from the listener.
Sexual desire is an ingredient of love’s emotional complexity. Because “I love you” can create sexual arousal in the listener, the speaker can use the phrase when his or her primary pleasure and interest in the person is the anticipation of sex.
Meanings and motives for expressing love change all the time. When someone tells us “I love you,” we have to discern both meaning and motive. Love’s emotions and their expression to another person are always complicated by past, present, and future considerations.
2. Love as an ambition. Love is so intensely celebrated in every culture that few people grow up without longing to realize it. Table 2 shows one version of the ambition to love and be loved.4 Many clinical declarations of love for a partner signify that the person has not yet given up on this ambition.
3. Love as an arrangement. All adult sexual relationships are quid pro quo exchanges of hopes, expectations, and assets. During courtship, both people are preoccupied with answering the question: “What will this person bring to my life?”
The question has many dimensions: social, economic, aesthetic, recreational, sexual, medical, time-to-death, and more. In their first romantic relationships, people generally prefer not to think in these terms. Their embarrassment dissipates with experience.
This ordinary process can be more clearly perceived after a relationship ends by breakup, divorce, or death and the person begins anew with someone. The person then can deliberately weigh the factors that will determine his or her involvement. When an arrangement is worked out, each person perceives what has been offered by the partner. Of course, perceptions vary in accuracy.
Anticipating making a deal can be very exciting, and once the deal is formally accepted, people often feel a celebratory degree of pleasure, interest, and sexual desire. They think that life is good. In cultures where parents make the deal, the couple courts in the hope that they will fall in love by early marriage.
4. Love is an attachment. Love also means the presence of a bond or attachment. People weave their psyches together and begin to feel a hunger to be with the other person. They think of themselves as belonging with and to the other.
Sexual activities—particularly those that lead to orgasm—facilitate attachment, but the bonds within each partner’s mind do not necessarily develop at the same time or solidify at the same rate. Thus, some people are unable to answer, “I love you, too,” when the partner reveals feelings that are summarized as love.
5. Love as a moral commitment. The rituals that sanctify marriage emphasize clearly that love is a commitment for couples to try to realize the grand idealized ambition (see “Love as an ambition”). The rituals are public promises to honor and cherish each other through all of life’s vicissitudes.
This love as moral commitment instantly restructures life by generating a new set of obligations. Many hostile, disappointed, and seemingly asexual spouses who have not felt pleasure and interest in a partner for a long time will tell their doctors they love the partner. They mean they remain bound by their moral commitment.
6. Love as a mental struggle. Love’s original emotions are stimulated by an idealized version of the partner. This image is internalized early in the relationship. As time passes, discovering our partner’s limitations gradually attenuates our idealization. We think of our earlier appraisals as naïve. Even so, disappointment does not quickly cancel our commitment because of our:
- ambition to love
- obligation to live through bad moments
- ability to love the idealized version of the partner
- moral commitments to raising our children.
The moral commitment to love can sustain people for a lifetime, despite grave disappointments. It also explains the persistent guilt many feel as they contemplate extramarital affairs, divorce, and the agonizing dilemma between their commitment to live with their children and their wish to be free of unhappiness with their partner.
“I love my partner, but I am not in love with him/her,” means, “although I’m still committed, I have lost my ability to idealize my partner.”
7. Love as a force of nature. Love is a force in nature that creates a unity from two individuals. It casts our fates together, organizes reproduction, and remains vital to adult growth and development and to the maturation of children. This love is a backbone that supports the sexual and non-sexual processes of our lives.5
Among older couples, “I love my partner but I am no longer in love with her/him” may mean, “We have shared so much of our lives that my partner is an inextricable part of me. I could never be free of my partner, even though most of the pleasure is gone.”
8. Love as an illusion. We create love for our partner by internal private processes, maintain it by prudent diplomatic dishonesties, and can lose it without the partner’s knowing. To remain in an intimate relationship, the processes of love require defensive distortions of a person’s feelings, thoughts, and perceptions.
As individuals gain experience, many look back and see that their assumptions about love were self-serving illusions. When entire relationships are dismissed with “what was I thinking?” the person usually means that now I can perceive that I created illusions so as not to admit to the depth of my disappointment with my partner.
9. Love as a stop sign. When a person says, “I love you,” the listener is challenged to discern its meaning. The emotions and motives behind the sentence can be very difficult to accurately perceive. Some love relationships, after all, are deceptions.
At any particular moment, we may know what we mean by “I love you” and why we are saying it. We may not be willing, however, to have our motives, meanings, and emotions fully known by the listener. In fact, the motive for saying “I love you” is often to obscure the view:
- Lover A: I love you.
- Lover B: Why do you love me?
- Lover A: I don’t know, I just do.
- Doctor: Why do you put up with this behavior from your spouse?
- Patient: Because I love him.
- Doctor: What does that mean?
- Patient: I don’t know.
What is the meaning of ‘I love you’? Love is…
| A transient emotion |
| An ambition |
| An arrangement |
| An attachment |
| A moral commitment |
| A mental struggle |
| A force of nature |
| An illusion |
| A stop sign |
Love as ambition: 7 ideals for loving relationships
| Mutual respect |
| Behavioral reliability |
| Enjoyment of one another |
| Sexual fidelity |
| Psychological intimacy |
| Sexual pleasure |
| A comfortable balance of individuality and couplehood |
| Source: Reference 4 |
What is sexual desire?
Sexual desire—at any given moment—is the sum of biological, psychological, interpersonal, and cultural forces that incline us toward and away from sexual behavior.6 Understanding desire can help you:
- ask patients insightful questions about their relationship concerns
- formulate a hypothesis to explain how drive, motivation, and values contribute to a patient’s sexual dysfunction.
Motivation is the degree of willingness an individual has to enter into sexual behavior with a particular partner at a moment in time. Sexual motivation is a psychological force that is influenced by:
- affective states, such as joy or sorrow
- interpersonal states, such as mutual affection, disagreement, or disrespect
- relationship stage, such as short or long duration
- cognitive states, such as moral disapproval.7
Values serve an evaluative function as our minds screen personal sexual behaviors with two questions:
- Is the behavior normal or abnormal?
- Is it morally acceptable or unacceptable?
In talking with Mrs. C, for example, you learn that her family reinforced the religious prohibition against extramarital sexual expression. “When I was a teenager, my father told me not to come home if I got pregnant before I was married,” she relates.
Values augment or diminish desire by affecting our willingness to engage in sexual behaviors. Values are camouflaged as motivation; Mrs. C may not realize that values she acquired at home early in life continue to influence her and may contribute to her lack of desire for nonreproductive sex.
Related resources
- Regan PC: Love relationships. In: Muscarella F (ed). Psychological perspectives on human sexuality. New York: John Wiley & Sons; 2000:232-82.
- Aron A, Fisher H, Mashek DJ. Reward, motivation, and emotion systems associated with early stage intense romantic love. J Neurophysiology 2005;94:327-37.
Singer Tina Turner recorded “What’s Love Got To Do With It?” in 1984.
1. Basson R. Sexual desire and arousal disorders in women. N Engl J Med 2006;354(14):1497-1506.
2. Levine SB. What is love anyway? J Sex Marital Ther 2005;31(2):143-51.
3. Bowlby J. The making and breaking of affectional bonds. London: Routledge; 1989.
4. Levine SB. Sexuality in mid-life. New York: Plenum; 1998.
5. Lear J. Love and its place in nature: a philosophical interpretation of Freudian psychoanalysis. New York: Farrar, Straus & Giroux; 1990.
6. Levine SB. The nature of sexual desire: a clinician’s perspective. Arch Sex Behav 2003;32(3):279-85.
7. Clement U. Sex in long-term relationships: a systemic approach to sexual desire problems. Arch Sex Behav 2002;31(3):241-6.
Concepts of love and sexual desire lurk around clinical discussions of sexual dysfunction. Love is frequently dismissed as hopelessly unscientific, whereas desire is simplified as if it were a thing called libido. Decreased libido per se tells us little about a patient’s sexual complaints; the key is to differentiate between:
- those with sexual drive but no motivation for their partners
- those with no driveFemale sexual dysfunction”).
Psychiatrists avoid talking about love; it has too many meanings and nuances, too many avenues of defeat, and is too abstract. All you have to say to a patient is, “Tell me about your marriage,” and listen closely as he or she comes to grip with love’s complexity.
This article’s aim is to help you counsel patients more effectively about relationship and sexual problems by exploring two questions: “What is love?” and “What is sexual desire?”
What is love?
Mrs. C, age 41, is being treated for depression and wonders why she has lost desire for her husband. The antidepressant she is taking improves her mood and diminishes her considerable anxiety but makes her feel sexually dead. “My husband doesn’t mind how I feel, as long as he can have sex,” she says.
After adjusting her medication, you explore other problems that might be contributing to her sexual dysfunction. She expresses uncertainty about what love is. Though faithful and committed to her husband, she has stopped enjoying the way he interacts with her, their two grade-school children, her family, and friends.
Love is the usual context within which sexual activities are viewed. Among adults, unhappiness in love predisposes to sexual concerns, and sexual concerns interfere with loving and being loved.
Our patients’ expectations for feeling and receiving love and experiencing satisfying sex are disappointed through a myriad of avenues. Clinicians may overlook it, but demoralization about love can precede the onset of anxiety, panic attacks, and lingering depression.2 Sexual love is expected to begin with connecting with a partner and to evolve for 65 or more years. Most individuals harbor the secret that they are not certain what love is (Table 1) or are surprised by their lack of words to explain it.
1. Love as transient emotion. The assumption that love is a feeling leads too many people waiting to experience the pure feeling. But unlike sadness, fear, anger, or shame, love does not indicate a discrete feeling. Saying, “I love you,” connotes at least two feelings: pleasure and interest.
- Pleasure begins with pleasantness and moves up through delight to exhilaration.
- Interest ranges from mild curiosity to preoccupying fascination.
Most events simultaneously provoke more than one feeling. Discovering that your beloved wants to marry you usually brings about at least happiness, pride, gratitude, and awe. Even if only one feeling is produced, our attitude towards that feeling complicates the experience. When a child is taught that feeling envy is wrong, for example, his experience of it evokes anxiety (from the guilt) and shame (if someone is watching).
After the family, culture, and the person have worked on a simple feeling, it becomes a layered complexity called an emotion. Love, the emotion, is quickly layered with attitudes (which are the product of feelings and defenses against them) based on the person’s sense of safety stemming from earlier attachments.3 When someone says “I love you,” he or she knows the motive for saying it and hopes for a particular response from the listener.
Sexual desire is an ingredient of love’s emotional complexity. Because “I love you” can create sexual arousal in the listener, the speaker can use the phrase when his or her primary pleasure and interest in the person is the anticipation of sex.
Meanings and motives for expressing love change all the time. When someone tells us “I love you,” we have to discern both meaning and motive. Love’s emotions and their expression to another person are always complicated by past, present, and future considerations.
2. Love as an ambition. Love is so intensely celebrated in every culture that few people grow up without longing to realize it. Table 2 shows one version of the ambition to love and be loved.4 Many clinical declarations of love for a partner signify that the person has not yet given up on this ambition.
3. Love as an arrangement. All adult sexual relationships are quid pro quo exchanges of hopes, expectations, and assets. During courtship, both people are preoccupied with answering the question: “What will this person bring to my life?”
The question has many dimensions: social, economic, aesthetic, recreational, sexual, medical, time-to-death, and more. In their first romantic relationships, people generally prefer not to think in these terms. Their embarrassment dissipates with experience.
This ordinary process can be more clearly perceived after a relationship ends by breakup, divorce, or death and the person begins anew with someone. The person then can deliberately weigh the factors that will determine his or her involvement. When an arrangement is worked out, each person perceives what has been offered by the partner. Of course, perceptions vary in accuracy.
Anticipating making a deal can be very exciting, and once the deal is formally accepted, people often feel a celebratory degree of pleasure, interest, and sexual desire. They think that life is good. In cultures where parents make the deal, the couple courts in the hope that they will fall in love by early marriage.
4. Love is an attachment. Love also means the presence of a bond or attachment. People weave their psyches together and begin to feel a hunger to be with the other person. They think of themselves as belonging with and to the other.
Sexual activities—particularly those that lead to orgasm—facilitate attachment, but the bonds within each partner’s mind do not necessarily develop at the same time or solidify at the same rate. Thus, some people are unable to answer, “I love you, too,” when the partner reveals feelings that are summarized as love.
5. Love as a moral commitment. The rituals that sanctify marriage emphasize clearly that love is a commitment for couples to try to realize the grand idealized ambition (see “Love as an ambition”). The rituals are public promises to honor and cherish each other through all of life’s vicissitudes.
This love as moral commitment instantly restructures life by generating a new set of obligations. Many hostile, disappointed, and seemingly asexual spouses who have not felt pleasure and interest in a partner for a long time will tell their doctors they love the partner. They mean they remain bound by their moral commitment.
6. Love as a mental struggle. Love’s original emotions are stimulated by an idealized version of the partner. This image is internalized early in the relationship. As time passes, discovering our partner’s limitations gradually attenuates our idealization. We think of our earlier appraisals as naïve. Even so, disappointment does not quickly cancel our commitment because of our:
- ambition to love
- obligation to live through bad moments
- ability to love the idealized version of the partner
- moral commitments to raising our children.
The moral commitment to love can sustain people for a lifetime, despite grave disappointments. It also explains the persistent guilt many feel as they contemplate extramarital affairs, divorce, and the agonizing dilemma between their commitment to live with their children and their wish to be free of unhappiness with their partner.
“I love my partner, but I am not in love with him/her,” means, “although I’m still committed, I have lost my ability to idealize my partner.”
7. Love as a force of nature. Love is a force in nature that creates a unity from two individuals. It casts our fates together, organizes reproduction, and remains vital to adult growth and development and to the maturation of children. This love is a backbone that supports the sexual and non-sexual processes of our lives.5
Among older couples, “I love my partner but I am no longer in love with her/him” may mean, “We have shared so much of our lives that my partner is an inextricable part of me. I could never be free of my partner, even though most of the pleasure is gone.”
8. Love as an illusion. We create love for our partner by internal private processes, maintain it by prudent diplomatic dishonesties, and can lose it without the partner’s knowing. To remain in an intimate relationship, the processes of love require defensive distortions of a person’s feelings, thoughts, and perceptions.
As individuals gain experience, many look back and see that their assumptions about love were self-serving illusions. When entire relationships are dismissed with “what was I thinking?” the person usually means that now I can perceive that I created illusions so as not to admit to the depth of my disappointment with my partner.
9. Love as a stop sign. When a person says, “I love you,” the listener is challenged to discern its meaning. The emotions and motives behind the sentence can be very difficult to accurately perceive. Some love relationships, after all, are deceptions.
At any particular moment, we may know what we mean by “I love you” and why we are saying it. We may not be willing, however, to have our motives, meanings, and emotions fully known by the listener. In fact, the motive for saying “I love you” is often to obscure the view:
- Lover A: I love you.
- Lover B: Why do you love me?
- Lover A: I don’t know, I just do.
- Doctor: Why do you put up with this behavior from your spouse?
- Patient: Because I love him.
- Doctor: What does that mean?
- Patient: I don’t know.
What is the meaning of ‘I love you’? Love is…
| A transient emotion |
| An ambition |
| An arrangement |
| An attachment |
| A moral commitment |
| A mental struggle |
| A force of nature |
| An illusion |
| A stop sign |
Love as ambition: 7 ideals for loving relationships
| Mutual respect |
| Behavioral reliability |
| Enjoyment of one another |
| Sexual fidelity |
| Psychological intimacy |
| Sexual pleasure |
| A comfortable balance of individuality and couplehood |
| Source: Reference 4 |
What is sexual desire?
Sexual desire—at any given moment—is the sum of biological, psychological, interpersonal, and cultural forces that incline us toward and away from sexual behavior.6 Understanding desire can help you:
- ask patients insightful questions about their relationship concerns
- formulate a hypothesis to explain how drive, motivation, and values contribute to a patient’s sexual dysfunction.
Motivation is the degree of willingness an individual has to enter into sexual behavior with a particular partner at a moment in time. Sexual motivation is a psychological force that is influenced by:
- affective states, such as joy or sorrow
- interpersonal states, such as mutual affection, disagreement, or disrespect
- relationship stage, such as short or long duration
- cognitive states, such as moral disapproval.7
Values serve an evaluative function as our minds screen personal sexual behaviors with two questions:
- Is the behavior normal or abnormal?
- Is it morally acceptable or unacceptable?
In talking with Mrs. C, for example, you learn that her family reinforced the religious prohibition against extramarital sexual expression. “When I was a teenager, my father told me not to come home if I got pregnant before I was married,” she relates.
Values augment or diminish desire by affecting our willingness to engage in sexual behaviors. Values are camouflaged as motivation; Mrs. C may not realize that values she acquired at home early in life continue to influence her and may contribute to her lack of desire for nonreproductive sex.
Related resources
- Regan PC: Love relationships. In: Muscarella F (ed). Psychological perspectives on human sexuality. New York: John Wiley & Sons; 2000:232-82.
- Aron A, Fisher H, Mashek DJ. Reward, motivation, and emotion systems associated with early stage intense romantic love. J Neurophysiology 2005;94:327-37.
Singer Tina Turner recorded “What’s Love Got To Do With It?” in 1984.
Concepts of love and sexual desire lurk around clinical discussions of sexual dysfunction. Love is frequently dismissed as hopelessly unscientific, whereas desire is simplified as if it were a thing called libido. Decreased libido per se tells us little about a patient’s sexual complaints; the key is to differentiate between:
- those with sexual drive but no motivation for their partners
- those with no driveFemale sexual dysfunction”).
Psychiatrists avoid talking about love; it has too many meanings and nuances, too many avenues of defeat, and is too abstract. All you have to say to a patient is, “Tell me about your marriage,” and listen closely as he or she comes to grip with love’s complexity.
This article’s aim is to help you counsel patients more effectively about relationship and sexual problems by exploring two questions: “What is love?” and “What is sexual desire?”
What is love?
Mrs. C, age 41, is being treated for depression and wonders why she has lost desire for her husband. The antidepressant she is taking improves her mood and diminishes her considerable anxiety but makes her feel sexually dead. “My husband doesn’t mind how I feel, as long as he can have sex,” she says.
After adjusting her medication, you explore other problems that might be contributing to her sexual dysfunction. She expresses uncertainty about what love is. Though faithful and committed to her husband, she has stopped enjoying the way he interacts with her, their two grade-school children, her family, and friends.
Love is the usual context within which sexual activities are viewed. Among adults, unhappiness in love predisposes to sexual concerns, and sexual concerns interfere with loving and being loved.
Our patients’ expectations for feeling and receiving love and experiencing satisfying sex are disappointed through a myriad of avenues. Clinicians may overlook it, but demoralization about love can precede the onset of anxiety, panic attacks, and lingering depression.2 Sexual love is expected to begin with connecting with a partner and to evolve for 65 or more years. Most individuals harbor the secret that they are not certain what love is (Table 1) or are surprised by their lack of words to explain it.
1. Love as transient emotion. The assumption that love is a feeling leads too many people waiting to experience the pure feeling. But unlike sadness, fear, anger, or shame, love does not indicate a discrete feeling. Saying, “I love you,” connotes at least two feelings: pleasure and interest.
- Pleasure begins with pleasantness and moves up through delight to exhilaration.
- Interest ranges from mild curiosity to preoccupying fascination.
Most events simultaneously provoke more than one feeling. Discovering that your beloved wants to marry you usually brings about at least happiness, pride, gratitude, and awe. Even if only one feeling is produced, our attitude towards that feeling complicates the experience. When a child is taught that feeling envy is wrong, for example, his experience of it evokes anxiety (from the guilt) and shame (if someone is watching).
After the family, culture, and the person have worked on a simple feeling, it becomes a layered complexity called an emotion. Love, the emotion, is quickly layered with attitudes (which are the product of feelings and defenses against them) based on the person’s sense of safety stemming from earlier attachments.3 When someone says “I love you,” he or she knows the motive for saying it and hopes for a particular response from the listener.
Sexual desire is an ingredient of love’s emotional complexity. Because “I love you” can create sexual arousal in the listener, the speaker can use the phrase when his or her primary pleasure and interest in the person is the anticipation of sex.
Meanings and motives for expressing love change all the time. When someone tells us “I love you,” we have to discern both meaning and motive. Love’s emotions and their expression to another person are always complicated by past, present, and future considerations.
2. Love as an ambition. Love is so intensely celebrated in every culture that few people grow up without longing to realize it. Table 2 shows one version of the ambition to love and be loved.4 Many clinical declarations of love for a partner signify that the person has not yet given up on this ambition.
3. Love as an arrangement. All adult sexual relationships are quid pro quo exchanges of hopes, expectations, and assets. During courtship, both people are preoccupied with answering the question: “What will this person bring to my life?”
The question has many dimensions: social, economic, aesthetic, recreational, sexual, medical, time-to-death, and more. In their first romantic relationships, people generally prefer not to think in these terms. Their embarrassment dissipates with experience.
This ordinary process can be more clearly perceived after a relationship ends by breakup, divorce, or death and the person begins anew with someone. The person then can deliberately weigh the factors that will determine his or her involvement. When an arrangement is worked out, each person perceives what has been offered by the partner. Of course, perceptions vary in accuracy.
Anticipating making a deal can be very exciting, and once the deal is formally accepted, people often feel a celebratory degree of pleasure, interest, and sexual desire. They think that life is good. In cultures where parents make the deal, the couple courts in the hope that they will fall in love by early marriage.
4. Love is an attachment. Love also means the presence of a bond or attachment. People weave their psyches together and begin to feel a hunger to be with the other person. They think of themselves as belonging with and to the other.
Sexual activities—particularly those that lead to orgasm—facilitate attachment, but the bonds within each partner’s mind do not necessarily develop at the same time or solidify at the same rate. Thus, some people are unable to answer, “I love you, too,” when the partner reveals feelings that are summarized as love.
5. Love as a moral commitment. The rituals that sanctify marriage emphasize clearly that love is a commitment for couples to try to realize the grand idealized ambition (see “Love as an ambition”). The rituals are public promises to honor and cherish each other through all of life’s vicissitudes.
This love as moral commitment instantly restructures life by generating a new set of obligations. Many hostile, disappointed, and seemingly asexual spouses who have not felt pleasure and interest in a partner for a long time will tell their doctors they love the partner. They mean they remain bound by their moral commitment.
6. Love as a mental struggle. Love’s original emotions are stimulated by an idealized version of the partner. This image is internalized early in the relationship. As time passes, discovering our partner’s limitations gradually attenuates our idealization. We think of our earlier appraisals as naïve. Even so, disappointment does not quickly cancel our commitment because of our:
- ambition to love
- obligation to live through bad moments
- ability to love the idealized version of the partner
- moral commitments to raising our children.
The moral commitment to love can sustain people for a lifetime, despite grave disappointments. It also explains the persistent guilt many feel as they contemplate extramarital affairs, divorce, and the agonizing dilemma between their commitment to live with their children and their wish to be free of unhappiness with their partner.
“I love my partner, but I am not in love with him/her,” means, “although I’m still committed, I have lost my ability to idealize my partner.”
7. Love as a force of nature. Love is a force in nature that creates a unity from two individuals. It casts our fates together, organizes reproduction, and remains vital to adult growth and development and to the maturation of children. This love is a backbone that supports the sexual and non-sexual processes of our lives.5
Among older couples, “I love my partner but I am no longer in love with her/him” may mean, “We have shared so much of our lives that my partner is an inextricable part of me. I could never be free of my partner, even though most of the pleasure is gone.”
8. Love as an illusion. We create love for our partner by internal private processes, maintain it by prudent diplomatic dishonesties, and can lose it without the partner’s knowing. To remain in an intimate relationship, the processes of love require defensive distortions of a person’s feelings, thoughts, and perceptions.
As individuals gain experience, many look back and see that their assumptions about love were self-serving illusions. When entire relationships are dismissed with “what was I thinking?” the person usually means that now I can perceive that I created illusions so as not to admit to the depth of my disappointment with my partner.
9. Love as a stop sign. When a person says, “I love you,” the listener is challenged to discern its meaning. The emotions and motives behind the sentence can be very difficult to accurately perceive. Some love relationships, after all, are deceptions.
At any particular moment, we may know what we mean by “I love you” and why we are saying it. We may not be willing, however, to have our motives, meanings, and emotions fully known by the listener. In fact, the motive for saying “I love you” is often to obscure the view:
- Lover A: I love you.
- Lover B: Why do you love me?
- Lover A: I don’t know, I just do.
- Doctor: Why do you put up with this behavior from your spouse?
- Patient: Because I love him.
- Doctor: What does that mean?
- Patient: I don’t know.
What is the meaning of ‘I love you’? Love is…
| A transient emotion |
| An ambition |
| An arrangement |
| An attachment |
| A moral commitment |
| A mental struggle |
| A force of nature |
| An illusion |
| A stop sign |
Love as ambition: 7 ideals for loving relationships
| Mutual respect |
| Behavioral reliability |
| Enjoyment of one another |
| Sexual fidelity |
| Psychological intimacy |
| Sexual pleasure |
| A comfortable balance of individuality and couplehood |
| Source: Reference 4 |
What is sexual desire?
Sexual desire—at any given moment—is the sum of biological, psychological, interpersonal, and cultural forces that incline us toward and away from sexual behavior.6 Understanding desire can help you:
- ask patients insightful questions about their relationship concerns
- formulate a hypothesis to explain how drive, motivation, and values contribute to a patient’s sexual dysfunction.
Motivation is the degree of willingness an individual has to enter into sexual behavior with a particular partner at a moment in time. Sexual motivation is a psychological force that is influenced by:
- affective states, such as joy or sorrow
- interpersonal states, such as mutual affection, disagreement, or disrespect
- relationship stage, such as short or long duration
- cognitive states, such as moral disapproval.7
Values serve an evaluative function as our minds screen personal sexual behaviors with two questions:
- Is the behavior normal or abnormal?
- Is it morally acceptable or unacceptable?
In talking with Mrs. C, for example, you learn that her family reinforced the religious prohibition against extramarital sexual expression. “When I was a teenager, my father told me not to come home if I got pregnant before I was married,” she relates.
Values augment or diminish desire by affecting our willingness to engage in sexual behaviors. Values are camouflaged as motivation; Mrs. C may not realize that values she acquired at home early in life continue to influence her and may contribute to her lack of desire for nonreproductive sex.
Related resources
- Regan PC: Love relationships. In: Muscarella F (ed). Psychological perspectives on human sexuality. New York: John Wiley & Sons; 2000:232-82.
- Aron A, Fisher H, Mashek DJ. Reward, motivation, and emotion systems associated with early stage intense romantic love. J Neurophysiology 2005;94:327-37.
Singer Tina Turner recorded “What’s Love Got To Do With It?” in 1984.
1. Basson R. Sexual desire and arousal disorders in women. N Engl J Med 2006;354(14):1497-1506.
2. Levine SB. What is love anyway? J Sex Marital Ther 2005;31(2):143-51.
3. Bowlby J. The making and breaking of affectional bonds. London: Routledge; 1989.
4. Levine SB. Sexuality in mid-life. New York: Plenum; 1998.
5. Lear J. Love and its place in nature: a philosophical interpretation of Freudian psychoanalysis. New York: Farrar, Straus & Giroux; 1990.
6. Levine SB. The nature of sexual desire: a clinician’s perspective. Arch Sex Behav 2003;32(3):279-85.
7. Clement U. Sex in long-term relationships: a systemic approach to sexual desire problems. Arch Sex Behav 2002;31(3):241-6.
1. Basson R. Sexual desire and arousal disorders in women. N Engl J Med 2006;354(14):1497-1506.
2. Levine SB. What is love anyway? J Sex Marital Ther 2005;31(2):143-51.
3. Bowlby J. The making and breaking of affectional bonds. London: Routledge; 1989.
4. Levine SB. Sexuality in mid-life. New York: Plenum; 1998.
5. Lear J. Love and its place in nature: a philosophical interpretation of Freudian psychoanalysis. New York: Farrar, Straus & Giroux; 1990.
6. Levine SB. The nature of sexual desire: a clinician’s perspective. Arch Sex Behav 2003;32(3):279-85.
7. Clement U. Sex in long-term relationships: a systemic approach to sexual desire problems. Arch Sex Behav 2002;31(3):241-6.