What is This Thing Called Love?
The Answers Are Being Discovered in the Laboratory
by Pat Love
Late on a chilly spring night several years ago, my husband inquired when I would be coming to bed. "Mmm, a little later," I replied. Translation: "Do you want to make love?" Answer: "Not a chance." The dialogue was familiar, but this time it was edged with a quality of brooding tension that distinguished it from the hundreds of similar invitation-and-refusal scenes we'd enacted before. When I finally came to bed that night, my husband was still awake, bristling with outrage and hurt. "Every night, it's the same routine," he stormed. "Aren't we ever going to have sex?"
I began to marshal my usual arguments about being exhausted after a day of chasing two small kids when, suddenly, I felt myself go limp with dejection. I felt bone-weary of the years of conflict, guilt and crushing sense of inadequacy that pervaded my lack of interest in lovemaking. Turning my face to the wall, I said softly but entirely audibly: "I don't care if I ever do it again."
From the other side of the bed, there was silence.
How had it come to this? When I first began dating my husband, a rangy, dark-haired college athlete with a chiseled physique and a talent for making me feel like the only woman on the planet, I was plenty attracted. Saving sex for our wedding night only heightened my desire. But even after our marriage, we made love frequently, passionately and often for hours at a time. If, during those early years, he wanted sex slightly more than I did, the difference in our sexual setpoints seemed negligible. On the erotic front, we seemed about as perfectly matched as any couple could hope to be.
Until it all ended. Two years into our marriage, my libido began to wilt; after giving birth to our first child, it went permanently AWOL. Truth to tell, I didn't much care about the demise of our sexual synchrony. Furiously busy with the demands of an infant son, homemaking and church work, I rarely even thought about sex, much less craved it. My husband's desire for me, however, had dimmed not one iota. One evening he arrived home, full of hope, bearing a book on sensual massage for couples. When I glanced through the photos of smiling, nude women pleasuring their partners, I felt my inadequacy like a physical attack and threw the book into the trash.
Silently, I blamed my husband for being inconsiderate enough to desire me when the feeling wasn't mutual, and while he never explicitly said so, he must have felt profoundly unwanted. For years, we coped by simply repressing all of our anger and sorrow--each of us fearful to say out loud how desperately unhappy we had become in our marriage.Â Then, on the night I finally spoke the unspeakable--"I don't care if I ever do it again"--our mutual disenchantment bottomed out into despair. Like many people, my husband and I equated sexual passion with love, so we concluded that if I had lost all interest in sex, I must no longer love him. At the very least, it seemed that each of us was trapped in an unbearably incompatible marriage, a union that doomed one partner to everlasting sexual frustration and rejection, and the other to feeling perpetually invaded and, at the same time, somehow defective. These convictions led to an action that remains the deepest regret of my life--an unnecessary divorce from a thoroughly decent, loving man and the father of my two children.
I say "unnecessary" not because we didn't try to work things out. We sought therapy and got the best that was available. But the intensity of shame and hopelessness that permeated our mutual sense of sexual failure was beyond the usual therapeutic jump-starts. Rather, I believe our divorce was unnecessary because we did not understand then that our desire gap was rooted, to a large degree, in powerful, automatic, biochemical processes that had little to do with how attractive I found my husband or how much I actually cared for him. In fact, I did love him; the problem was that my body didn't know it.
If the idea that desire is orchestrated by our body chemistry hasn't yet found its way into the clinical conversation, it may be because the evidence is still largely buried in scientific journals, primarily from the emerging fields of behavioral endocrinology and psychophysiology. The provocative core of the new research is this: Each of us approaches our erotic encounters already primed by a premixed neurochemical and hormonal "cocktail" that influences both the strength and staying power of sexual passion. Having delved into this new biological evidence and observed its impact in my own couples therapy practice, I am convinced that as long as our clients remain unaware of these bodily processes, they are at high risk for making disastrous decisions about their intimate commitments. Some clients will misread their clashing desire levels as the death of love and lose faith in basically sound marriages, as my husband and I did. Others will choose badly to begin with, making lifelong commitments while under the influence of short-lived, highly irrational brain states.
But I believe that both catastrophes are largely preventable. The emergent data on the biology of desire offers therapists a potent new tool for helping troubled couples--a genuinely new kind of sex psychoeducation. This form of "desire ed," which I now use routinely in my work with couples, doesn't dwell on the usual sex therapy instruction about performance anxiety or the search for the elusive G spot. Instead, its objective is to help clients understand how their hidden neurobiological agendas may operate in the bedroom, so that they can make conscious, thoughtful decisions about their intimate relationships rather than ones that misinterpret the critical messages of the body.
But let me be clear: I am not proposing that the complexities of sexual desire can be reduced to Chemistry l0l. There is no question that problems of passion also can be influenced by relationship conflicts and a long list of other factors, from depression, stress and past sexual trauma to certain medications and a host of medical disorders. Likewise, it goes without saying that chronic sexual problems can contribute hugely to relationship difficulties. Nonetheless, the biochemical action of the human brain--the organ that nature writer Diane Ackerman calls our "three pounds of blood, dream and electricity"--may influence how often and how badly each of us wants sex more than we ever imagined.
To begin to understand the biology of desire, think back to the last time you fell fiercely, feverishly in love. He, or she, merely walked into the room and your body was zapped by a thousand-watt current, transforming you from a reasonably rational, functional adult into a trembling, mushy puddle of pure yearning. When the two of you were together, the most mundane activity--say, going to Wal-Mart for poultry scissors--became an exhilarating, deeply rewarding event. Not to mention the sex. Remember? The sex was amazing .
Most of us who have spent any time in infatuation's clutches also remember the sense of pure, utter helplessness that permeates this state. In the throes of new romance, there is something strangely involuntary about one's behavior--the workaholic misses deadlines; the penny-pincher blows his paycheck on plane tickets for two to Paris; the solidly married woman finds herself whispering on the phone, making furtive, high-risk plans with her paramour. Our culture speaks of "falling" in love. Other societies have compared infatuation to divine revelation, and to psychosis. We often say, in jest, that this experience of hurricane-force passion is "like a drug."
But that oft-quipped analogy may turn out to be no joke. Some scientists now believe that the frenzied euphoria of romantic love may well be a bona fide, altered state of consciousness, primarily brought on by the action of phenylethylamine (PEA), a naturally occurring, amphetamine-like neurotransmitter. Michael Liebowitz, a research psychiatrist at the New York State Psychiatric Institute, believes that when we come into contact with a person who highly attracts us, our brains become saturated with a "love cocktail" comprised of PEA and several other excitatory neurotransmitters, including dopamine. This chemical brain-bath theory explains why new lovers can talk till dawn, make love for hours on end, lose weight without trying and feel so outrageously, unquenchably optimistic. Their neurons are soaking in natural speed.
Thus far, much of what we know about PEA's action comes from animal studies. When mice are injected with PEA, they cavort and squeal in displays of rodent rapture, while rhesus monkeys dosed with PEA-like chemicals make pleasure calls and smack their lips, a courting gesture. While the brains of romance-besotted humans have yet to be directly studied, Theresa Crenshaw, a sexual medicine researcher and author of Sexual Pharmacology , reports that elevated levels of PEA have been found in the bloodstreams of lovers. Crenshaw also has found that women's PEA levels tend to rise at ovulation, which suggests a role for this potent molecule in the survival of the species.
Still, speed-spiked blood and the antics of small animals hardly prove a pivotal role for PEA in firing human passion. To date, the most compelling evidence comes from studies on a group of people suffering from a disorder known as hysteroid dysphoria, characterized by a desperate, boundless craving for attention and admiration, coupled with an acute hypersensitivity to rejection. Unlike most adults, who succumb to infatuation upon occasion, the hysteroid dysphoric is a kind of "romance junkie," falling in love constantly, violently and often with unsuitable partners. This person's usual pattern is to enjoy a brief, thrilling infatuation, followed by a traumatic breakup, often precipitated by his or her anxious, seemingly bottomless need for displays of love and affection. Upon rejection, the romance-hooked person predictably plunges into deep depression, which he or she tries to cure by falling in love all over again.
Research psychiatrist Liebowitz and his colleague Donald Klein suspected that such "infatuation junkies" might suffer from some kind of biochemical imbalance--perhaps abnormally low PEA levels. They wondered: Was it possible that these individuals jumped compulsively from lover to lover in order to keep their PEA sufficiently revved up to feel normal? To find out, Liebowitz and Klein treated a group of hysteroid dysphorics with the class of antidepressants known as monoamine oxidase (MAO) inhibitors, which block the action of brain enzymes that break down PEA. MAO inhibitors, therefore, act to boost PEA levels. Within weeks of starting their medication regimen, some of the lovesick subjects began to choose partners more judiciously, while others reported feeling reasonably comfortable without any love interest in their lives at all. Apparently, these individuals no longer craved the PEA jolt they once got from their euphoric, disastrous romances.
But one doesn't have to have a diagnosable love disorder to be influenced by PEA. Researchers propose that in the presence of a sufficiently intense sexual and emotional attraction, virtually everyone's neural lattices become marinated in natural speed. Given some of the dangerously delusionary thinking that accompanies new romance, the concept of an overstimulated brain makes compelling sense. If the frenzied action of lovers' neurons tends to render them maniacally optimistic, it is no wonder that they tend to discount patently alarming qualities in their sweethearts. You may gently remind a love-struck client: "Have you really considered the fact that she is a practicing alcoholic, has lost three jobs in a row and has been divorced only two months?" Your client sweetly responds: "We can work it out." Indeed, in a study of 400 men and women involved in a new romance, psychologist Dorothy Tennov found that while infatuated individuals had no trouble identifying shortcomings in their lovers, they tended to recast even the most serious liabilities as trivial, tractable and even charming.
What about sex? We don't need a slew of studies to convince us that with a new lover, sex is the Mount Everest of romantic peak experiences. Some neuropsychologists now think that the sexual euphoria that accompanies infatuation issues from brain secretions of both PEA and dopamine, a neurotransmitter that both stimulates libido and mobilizes people to actively pursue the pleasure of lovemaking. With two potent brain molecules working overtime, it's as though our erotic thermostat gets overwhelmed--we want scads of sex with our beloved, we get our fill, then in short order we're ready for more. It must be love.
Until it's not. For the universal and much-denied truth is this: Romance has no legs. Numerous studies that have measured the duration of infatuation--from the first moment of stuttering euphoria to the first feeling of neutrality for one's love object--have found that the state of romantic rapture predictably burns out after 18 to 36 months. And while the demise of infatuation certainly encompasses emotional components, such as the resentment that attends the inevitable discovery that our lover has other priorities besides keeping us happy, our wilting desire is also likely to be grounded in brain physiology. Liebowitz and others theorize that the brain cannot eternally maintain its revved-up, lust-crazed state of romantic bliss, either because the nerve endings become habituated to the brain's natural stimulants or because levels of PEA and related substances begin to drop. It certainly makes sense that if infatuation is a "high" that is chemically analogous to an amphetamine jolt, lovers would develop a tolerance for each other over a period of time. Whatever the precise mechanism involved, all of us have experienced this downshift in desire--slowly but predictably, euphoria sneaks out the back door while reality, that perpetually unwelcome houseguest, makes its sullen entrance.
If the sexual reality facing postinfatuation couples were limited to plummeting desire, it would be tough enough to cope with. But the dilemma of many disillusioned lovers is made far more difficult by a substantial desire gap between partners. To fully understand this element of a couple's sexual struggle, we need to introduce a second biological factor--testosterone. When most of us think of this steroid hormone, we reflexively think "male," and a pumped-up, perpetually horny one at that. We almost never think about the ways in which testosterone influences women--and consequently, we may be missing one of the biggest clues to the desire difficulties of many couples.
Scientists have known for decades that both sexes produce testosterone: men manufacture gobs of the stuff in their testes and adrenals, while women pump out smaller quantities from their ovaries and adrenals. But while testosterone has been conclusively shown to highly correlate with male libido, it was long dismissed as a nonfactor in the sex drive of women. Then, in 1987, Barbara Sherwin, a psychologist and psychoendocrinology researcher at McGill University in Montreal, published her now-classic study on the impact of hormone replacement therapy on women's sex lives. Sherwin divided her 43 subjects, all of whom had undergone surgical removal of their ovaries, into three groups, giving one group estrogen medication, a second group a regimen of estrogen and testosterone and a third group a placebo.
The results were swift and dramatic. The women who received the testosterone-estrogen cocktail reported a greater upsurge in sexual arousal, more lustful fantasies, a stronger desire for sex, more frequent intercourse and higher rates of orgasm than the women in either of the two other groups. Sherwin replicated these findings in several other carefully conducted, double-blind studies.
Subsequent research on women's naturally produced testosterone has yielded similar results. In the absence of infatuation, women with high baseline levels of testosterone--so-called "high-T" women-- tend to be significantly more sexually interested and responsive than "low-T" women. This now-substantial body of psychoendocrinological research has exploded decades of mythology about female sexuality by establishing that libido requires a goodly supply of testosterone in women as well as in men. But herein lies a key source of the postinfatuation desire gap. Both genders rely on testosterone for a robust sex drive, yet on average, men have 10 times more of the stuff circulating in their systems as women do. This doesn't mean that women are typically only one-tenth as lusty as men; many endocrinologists suspect that because women are exposed to lower levels of testosterone, they are more sensitive than men to a given amount. Nor does it mean that all men are the sexual equivalents of the Energizer Bunny. Testosterone levels drop gradually with age, and at any stage of life, the genetically determined sensitivity of androgen receptors in the genitals and brain influences how strongly testosterone pumps up male libido.
Nonetheless, the biological reality remains that, on average, men tend to be hornier than women--by quite a bit. Surveys show that, among both heterosexuals and homosexuals, men think about sex more frequently, masturbate more often and rank sex as more important in their lives than women do. Of course, there are millions of exceptions to this gender-typed scenario. I worked with one young couple in which the woman wanted daily lovemaking, while her husband felt the urge maybe once a week. Sharing a bed with him aroused her to such a pitch that she had taken to sleeping alone in a back bedroom. I also have worked with many lesbian and gay couples on problems of mismatched desire, indicating that passion quotients vary within as well as across gender lines.
Whatever the gender positions of this lust gap, it is a commonplace phenomenon: A survey of 289 sex therapists found "desire discrepancy" to be the single most common presenting problem of clients. Yet couples might be able to cope more sanely with their divergent desire levels were it not for the biochemical blinders they wear in the early stages of their relationship. It is during the infatuation stage that the two major components of the biology of desire--the time-limited PEA factor and T-level mismatches--collide to create sexual catastrophe for many couples. If the brains and bloodstreams of new lovers are awash in the aphrodisiac properties of PEA and other brain molecules, any disparity in libido is, at first, likely to go blissfully unnoticed.
Let us say, for argument's sake, that you are a "low-T" woman who has fallen fervently in love with a "high-T" man. You, a person whose needle on the sex meter usually points close to zero, suddenly find yourself fantasizing about sex in graphic, Omnivision detail, and approaching lovemaking with a level of gusto bordering on zeal. You think to yourself: "I am a sexual person--I just needed the right partner." Your naturally highly sexed new lover, meanwhile, finds himself in a state of erotic nirvana: "Finally, I've found someone as hot as me!" Over and over again, I have heard clients recall their mingled sense of exhilaration and relief at having finally found their "perfect" lover. Even if they had experienced a similar sense of sexual harmony in the early months of a past romance, infatuated people tend to discount history: It is this lover, at this moment, who satisfies me more deeply than any other. That is, until the tide of PEA begins to recede and preexisting T-levels emerge, unveiling for each person his or her "real" sexual partner.
At this juncture, the "high-T" person is apt to feel bitterly disappointed, even betrayed. For even though his or her brain may no longer be drenched in a PEA-dopamine cocktail, he or she typically has sufficiently high T-levels to still want plenty of action in the bedroom. The "low-T" partner, meanwhile, is likely to feel bewildered by the loss of his or her temporarily turbocharged libido, as well as sexually pressured by what now seems like an insensitive, even predatory, partner. A downward spiral of mutual anger, bad sex, more anger and still worse sex--or none at all--finally leads many couples into therapists' consulting rooms, raging with sorrow, shame and profound doubts about the future of their disappointing marriages.
At first glance, the proposal that something as fluffy-sounding as "desire education" could make any difference to dispirited couples sounds inflated, if not preposterous. As University of Washington psychologist John Gottman's research indicates, on average, couples straggle into therapy a full six years after their troubles first erupt. If anything is going to help at this late date, it seems as though it would have to be an intervention that does something fairly dramatic--something that packs a real emotional wallop or teaches potent relationship skills or both. Faced with the typical couple's end-of-their-rope discouragement, how is dispensing a bunch of facts on body chemistry going to make any difference?
In my experience, the difference is as profound as hope. For beneath the "dry" facts on neuronal and hormonal processes lies a radically normalizing, shame-reducing message: Sexual passion is rooted in our natural body rhythms. That means that if the thrill is gone or if the thrill is different for you than it is for me, I have not failed and you have not failed. Nor has our relationship failed. There may be plenty of emotional junk that is also mucking up our sexual connection, but that's not all that's going on. If our desire problems are at least partly innate--mirroring neither messed-up psyches nor a bankrupt relationship, but rather the pulse and flow of ordinary bodily processes--then maybe we don't need to feel quite so ashamed and despairing about the muddle we're in. Maybe each of us, and the embattled, fragile relationship we're trying to sustain, are even fundamentally okay. Maybe we've got a chance.
Of course, every therapeutic approach tries to engender hope. The particular potency of desire education is its capacity to plant seeds of optimism so early in therapy--sometimes as soon as the first session. Every clinician who works with discouraged couples understands that there is no time to waste: You need a way to show them, quickly and compellingly, that what they view as a sorry excuse for a relationship is even worth expending further energy on. The problem here is that the palpable rewards of most couples work--the profound emotional breakthroughs, the fruits of well-learned relationship skills, the mastery of new sexual techniques--take time to emerge. By contrast, the matter-of-fact, calming information of "desire ed" can be dispensed almost immediately to interrupt the furious, toxic, blame-shame cycle that sabotages so many sexually polarized couples at the very outset of therapy. As a potent, front-end couples intervention, desire education can make the difference between a willingness to plunge into relationship work with a measure of motivation and the decision to prematurely quit in despair.
When Eddie and Joyce, a couple in their mid-thirties, arrived for their first session with me, it quickly became clear that their sexual standoff was already calcifying into a kind of listless bitterness. Slumped in his chair, Eddie complained that Joyce was his "wife in name only"--that is, she had avoided sex with him as much as possible duringÂ the past five years. "Your basic ice queen," he quipped grimly. Joyce countered that Eddie made her feel ugly and invisible by openly flirting with other women, to which she often responded by collapsing into tears, panic stricken that she was losing her husband. Eddie made clear that this was a real possibility. "Do you know what it feels like to get down on your knees and beg for sex?" he asked me. Joyce snapped, "It's more like being cornered by a dog in heat." Twice before, they had tried therapy, which had focused on improving communication and injecting more novelty into their erotic repertoire, to little effect. In a last-ditch attempt to stave off separation, Joyce had dragged Eddie to see me.
In the past, I would have begun therapy with a couple like Joyce and Eddie by focusing immediately on communication about relationship issues, such as Joyce's anger and "withholding" of sex and Eddie's motives for his blatant attentions to other women. But my experience has been that sexually struggling couples can rarely focus on such efforts at relationship repair at the outset, because they feel too deeply flawed and full of shame to believe that genuine change is even possible.
Instead, I began by empathizing with each of them about how painful it must be to live in a relationship in which one partner wants sex more than the other. Then, gently probing about their desire history, I learned that both partners had experienced their particular passion level over time, with several different partners. This suggested to me that Eddie and Joyce's sexual problem wasn't purely relationship-driven, but probably also had a hormonal component. So I introduced some information about T-levels and the consequent normality, even near inevitability, of their desire gap.Â As I spoke, Eddie and Joyce became quiet and attentive. Neither of them had had the slightest idea that testosterone--or the relative lack of it--was such a major player in female desire. I concluded with my core message: "What all of this means is that it's entirely possible to love someone a lot, but still not be very sexually turned on by him or her." Joyce and Eddie remained silent for a moment. Finally, Joyce spoke up. "So what you're saying," she said slowly, "is that I'm not just trying to punish my husband."
She glanced quickly at Eddie, who seemed lost in thought. "Well," he finally said, "I guess the good news is that maybe I don't have to feel like such a jerk when I get turned down." I sat quietly with them for a few minutes, letting the deeper message of my mini-primer soak in. I wasn't expecting any big epiphanies or tearful embraces, nor did they materialize. All I wanted was to give this couple sufficient relief from their mutual sense of sexual failure to commit to the work ahead. I wanted time. Eddie gave me my opening. "I like the idea that the trouble we're having maybe isn't all personal," he began. "But, not to be rude, so what? If I'm some kind of hormone factory and she's not, what the hell are we supposed to do now?" I responded that even if their hormonal makeup contributed to a natural difference in libido, it was entirely possible, with sufficient time and effort on their part, to develop a satisfying sexual connection. When, in the last few minutes of the session, they agreed to try, I felt a small jolt of elation.
Having now worked with scores of couples who suffer a substantial desire gap, I understand more about the private hell that couples like Joyce and Eddie inhabit. In our sex-saturated culture, the woman or man who is "low-T" is already, by definition, defective. But if you are that person, imagine then the experience of living with a "high-T" partner, who comes to you for sex again and again and again, when you truly feel you have little to give. The screws of inadequacy get turned still tighter as you experience your many varieties of unworthiness--unworthiness for not matching the "normal" sex drive of your partner, unworthiness for failing to live up to a fundamental expectation of a committed relationship, unworthiness for repeatedly turning your back on your partner's helpless, fervent desire for you.
And the inescapable truth is that your partner is hurting. How could it be otherwise, when he or she inhabits a reality of constantly slamming doors? Because of the raw exposure of self that attends sexual intimacy, this more ardent partner may experience chronic sexual rejection as an existential wound. Again and again, I have heard the more sexually desirous partner say to the other: "I've shown you myself--the real me. And you don't want it."
As I worked with Joyce and Eddie in the succeeding months, my goal was never to transform them into the hot couple of the month; nor was it theirs. Using other strands of "desire ed" that I wove into our therapy sessions, they understood that they had long since spent their allowance of PEA-spiked passion; from now on, whatever sexual intimacy they might experience would have to be consciously created.
To begin this process, I asked each partner to share with each other what kind of sexual-emotional activity would feel most loving and satisfying to them. For Eddie, it was what this couple jokingly came to call a "marital"--a periodic, 15-minute session of sex that gave him both a measure of physical release and, more important, the feeling that Joyce cared for him. For Joyce, it was receivingÂ regular, leisurely massages from her husband, which might or might not culminate in intercourse, depending on her wishes. Haltingly at first, each tried to respond to the other's requests for behavior that seemed, initially, alien to his or her own impulses. But as they gradually deepened their understanding that their partner's experience of passion was both different from their own and entirely valid, they became more generous in their capacity to stretch to respond to it. The result wasn't blood-boiling sexual fireworks, but rather a budding sense of mutual intimacy and trust that began to energize both their erotic and emotional connection. Slowly but perseveringly, they began to feel their way toward a state of marital grace that I call mature love.
I am not arguing here for any particular therapeutic approach to sexual desire problems. My observation is that a number of useful ones already exist, from the skill-building orientation of traditional sex therapy to the more emotion-centered approaches of numerous schools of couples therapy. Many therapists, no doubt, pick and choose from several models. My point is that whatever overall approach you favor will almost certainly be rendered more potent and effective by integrating some basic education on the biology of passion. By the same token, if you omit desire education, you risk giving your clients a hazardously incomplete understanding of their situation.
For example, if Eddie and Joyce had taken their dilemma to a mainstream sex therapy clinic, their problem would likely have been diagnosed as "hypoactive sexual desire" on Joyce's part, with a program of sensate focus exercises prescribed. There is much to be said for sensate focus, in which partners are taught to hold and stroke each other while attending to the sensations that emerge, to help each discover what kind of touch is pleasurable. The limitation of traditional sex therapy antidotes is that they are typically taught in the absence of context: They rarely give unhappy couples a way to feel less flawed and freakish about the sexual afflictions they have laid bare. In fact, a couple's shame may even be deepened by sex therapy's habitual use of such pathology-laden labels as "hypoactive sexual desire" or "retarded ejaculation." Desire education, by contrast, avoidsÂ the medicalization of sex in favor of a gentle, humanizing context. It conveys the idea that nobody here is inherently damaged or inherently unlovable. Desire differences are natural and normal. Relax.
Desire education also has a key role to play in couples therapies that focus explicitly on the emotional aspects of sexual desire dilemmas. The hazard of purely relationship-centered sex therapies is that by focusing solely on the interpersonal factors that fuel passion problems, a therapist may convey the message that once partners resolve these emotional conflicts, they will become, once again, the effortlessly synchronized sexual match of their courting days. But by judicious melding of information on the psychology and the biology of desire--especially about the experience of red-hot sex as a short-lived, PEA phenomenon--a therapist can convey reasonable optimism about a couple's sexual future without raising erotic expectations to untenable levels. For the reality is that when a substantial, hormonally mediated desire gap exists between partners, their ultimate erotic satisfaction will depend on a steady, vigilant effort to sustain their sexual connection. Even when two people love each other deeply, postinfatuation passion is rarely a free ride.
Even as I write this, I am confronting this challenge in my own life. I am still a classic "low-T" woman who, just three months ago, married an unmistakably "high-T" man. Fortunately, this time I knew--and so did he--that the exquisite tango of brand-new love would downshift, inevitably, into the reality of differing sexual setpoints. We know, now, that our work together for the long term will encompass much stretching beyond our respective sexual comfort zones--stretching to understand, to empathize with and to accommodate the other's unique experience of passion. Neither of us expects this process to be easy; at times, it may well be excruciating. Our hope is that during the toughest moments, when even our best efforts cannot bridge our differences, we can hold fast to the conviction that our desire dissonances are rooted in nature, not in an insufficiency of love.
For clinicians, perhaps the most invigorating potential of the emerging science of passion is the challenge it poses to radically reenvision our concept of human sexual relationships. Up to now, therapists have been offered two divergent, even diametrically opposed, ways of looking at clients' sexual problems: Either they are a direct reflection of the troubled state of the relationship, requiring deep emotional work, or they are a set of physiological problems, requiring primarily technical intervention--usually through referral to a sex therapist. The biology of desire offers a more encompassing vision: Our sexual selves are mind-body creations in the deepest, most inclusive sense. To consider the influence of our neural and hormonal processes is neither to diminish the power of emotional factors nor to deny the usefulness of sexual skill-building; instead, therapists can use the lens of human biochemistry to enlarge clients' understanding of the entire spectrum of influences on human erotic connection.
All of us need to become active, knowledgeable sex educators in this new, more inclusive sense. While we may think of this realm as belonging to clinicians who somehow "specialize" in sexual difficulties, the reality is that virtually all therapists work with people who are struggling with problems of passion--the woman who wonders whether she should leave her boring husband for the new, more enthralling man she has met at the office; the love-struck, single man who is rushing to the altar far too precipitously; the couple on the verge of splitting up because she wants it and he doesn't. These are deeply emotional concerns, but they are also matters of raw, palpitating bodily desire, and our clients can ill afford to have us uninformed about them. The emerging science of passion, which has relevance for nearly every sexual-emotional event that transpires between two individuals, can help us explicate these dilemmas for clients with a new level of depth and authority.
Still, it can be tricky, demanding work. As we teach clients more about the biology of desire, the age-old, inexorably human tug-of-war between biological imperative and moral responsibility is likely to emerge with renewed force in the consulting room. If desire is tied to biological processes, how responsible are clients for their sexually motivated behavior? Under the influence of PEA, can a long-married man "help" having an affair with his sexy new law partner? Or, if a woman now comfortably accepts herself as a "low-T" person, is that a legitimate reason to abandon all efforts to revitalize a sexually stagnant, otherwise committed relationship?
These are the moments when therapy becomes a high-wire act, as we try to maintain a fragile balance between a generous acceptance of biological reality and a fierce, nonnegotiable allegiance to consciousness, the quality that makes us human and saves us from being utterly at the mercy of our molecules. If we are serious about trying to stem the tide of marital and family misery in this culture, our clients' most torturous questions about their intimate relationships--Do I stay? Do I bail? DoÂ I officially stay but just go through the motions?--will require arduous discussions about choice and responsibility, as well as about the proclivities of neurons and hormones. Our body chemistry counts--much more than we ever imagined. But in the end, biology is only backdrop.
Pat Love, Ed.D., a family life educator, trainer and lecturer, is the coauthor of Â Hot Monogamy. Â Address: 6705 Highway 290 West, Suite 502-291, Austin, TX 78735; e-mail address: Pat@patlove.com
Rx for Passion
Antidepressants needn't depress the libido
by Valerie Davis-Raskin
As a psychiatrist and couples therapist, some days it seems as if I never talk about anything but sex. And increasingly, I find myself educating my patients about the impact of the new selective serotonin reuptake inhibitors (SSRIs) on sexual interest and pleasure. Sure, I've had patients blush or change the topic, but most welcome the invitation to discuss problems in their sex lives, some related to medication, others not.
I didn't used to talk so much about sex and the sexual side effects of antidepressant medications. When I started practicing psychiatry a dozen years ago, we weren't yet in the better-sex-through-modern-chemistry era. Then the landscape changed. We began to live and practice in a culture that has come to consider pharmacology an acceptable (if not ideal) means of reducing depression. But until we had some ideas about how to counteract the sexual side effects of antidepressants, it still didn't much matter whether we talked about them or not.
Things are different now. We know that sexual side effects are among the most common and most troublesome difficulties experienced by antidepressant consumers. And more important, I know that I usually can help my patients recover from debilitating depression or anxiety without paying a sexual price.
When Prozac first came on the market, the medical profession didn't have a clue about how vital serotonin was to sexual pleasure and responsiveness. We didn't realize that Prozac and its two bestselling counterparts, Paxil and Zoloft, can and often do greatly reduce human suffering, but they also frequently kill sex drive, cause delayed ejaculation or completely eradicate orgasms. To this day, the Physician's Desk Reference (PDR) grossly underestimates the rate of sexual dysfunction caused by SSRIs. The PDR lists an incidence rate of medication-induced sexual dysfunction in the range of two percent or less. Would that this were true! In reality, between one third and one half of all individuals taking the most commonly prescribed antidepressants experience sexual side effects. And these three drugs--Prozac, Paxil and Zoloft--are among the top 10 most common prescriptions written in the United States for any condition--affecting, literally, millions of Americans.
The target of antidepressants are the neurotransmitters, our brains' chemical messengers. But neurotransmitters like serotonin are also found outside the brain wherever there are small blood vessels, a fact that accounts for many of the common side effects of SSRIs, such as nausea or jitteriness. Because serotonin is a sexually inhibitory neurotransmitter, increased serotonin in the brain may curtail the urge to have sex. Outside of the brain, serotonin may reduce genital sensation, somewhat like a mild anesthetic: what used to feel great feels good, what used to feel good feels okay, and what used to feel okay doesn't even register now. This means that arousal, both the psychological interest and physiological blood vessel reaction (blood flow to the clitoris, while less obvious, is as important for pleasure for females as blood flow to the penis is for males), may be suppressed by antidepressants that increase serotonin. Clinically, this translates into any combination of possibilities: lack of interest in sex, difficulty reaching an orgasm or outright absence of orgasm, inability to maintain an erection or prolonged erection. Some individuals experience a variety of side effects, while others experience only one, in an unpredictable fashion. And of course, it's just common sense that if you can't have an orgasm, eventually the libido falters as a consequence.
The chart below summarizes the degree of sexual side effects likely to be caused by the most frequently prescribed antidepressants.
Prevalence of Sexual Side Effects Caused by Antidepressants
Monoamine oxidase inhibitors (Nardil, Parnate)
One common intervention for any SSRI-induced sexual side effect is simply to lower the dose, as long as effective treatment for the psychiatric condition can be maintained. Since arousal, erection and orgasm changes are all dose-related phenomena, a substantial number of people will continue to benefit emotionally from smaller amounts of the offending SSRI. However, lowering the dose always carries the risk of a symptomatic relapse, and should symptoms exacerbate following dose reduction, other strategies are necessary.
Some people will benefit from a so-called "drug holiday" (an intervention that does not work for Prozac, due to the much longer time that Prozac remains in the bloodstream, compared with the shorter-acting SSRIs). A physician might recommend a regular drug holiday, in which the medication is taken on Thursday morning, skipped on Friday and Saturday, and resumed on Sunday morning. Ideally, a couple would opt to make love first thing Sunday morning, but many couples would find that a Saturday-night schedule is preferred.
Should these more conservative measures fail (or be clinically inappropriate in the prescribing physician's or patient's view) there are other options. Three of the new antidepressants--Wellbutrin, Serzone and Remeron--have no sexual side effects at all. Wellbutrin is generally well tolerated, but may cause insomnia, headache, tremor or increased anxiety. Its major drawback is that it is only effective for depression and may exacerbate conditions such as panic disorder. Wellbutrin is pharmacologically distinct from the SSRIs in that it enhances the neurotransmitter dopamine rather than serotonin. As a result, while it has comparable efficacy for depressive disorders in general, any particular individual may respond preferentially to an SSRI (or vice versa).
Both Serzone and Remeron are very sedating, although this effect often wears off over time, especially for Remeron, which is taken at bedtime. However, Serzone must be taken in the morning as well, and sedation is a troublesome side effect for many. Remeron's major drawback is the high incidence of weight gain, a side effect far less tolerable in many cases than low libido.
The tricyclic antidepressants, such as Elavil, Norpramin, Pamelor and Tofranil, may cause sexual side effects, including erectile or arousal problems and anorgasmia. Nevertheless, the incidence is far lower than with the SSRIs. The major drawback to tricyclic antidepressants is their potentially negative cardiac effect, elevating the risk of suicide and overdose. Higher doses may cause sedation, constipation, dry mouth and weight gain. Tricyclics have a particular utility for panic disorder, since lower doses than those needed for depression may be effective, allowing a mid-range dose that causes neither sexual dysfunction nor other significant side effects. Antianxiety medications, such as Klonopin and Xanax, do not affect serotonin and do not have sexual side effects as a rule.
Finally, some physicians may recommend St. John's wort, which is not believed to cause sexual side effects, although this has not been systemically studied. Unfortunately, because St. John's wort is not regulated as a pharmaceutical substance, efficacy may vary widely among preparations, and even from one bottle of the same brand to the next. This, along with the fact that it has not been rigorously tested in head-to-head comparisons with traditional antidepressants (for efficacy and also for side effects), limits its use to mild cases of depression or anxiety. St. John's wort should be taken three times per day and many people have a problem remembering the midday dose.
If switching to an alternative medication is not clinically appropriate or effective, a physician might recommend adding another medication on a daily or as-needed basis. Taking a second medication may be problematic on several counts. Women often feel awkward about actively seeking sexual pleasure. Many people also are extremely hesitant to take anything for depression, let alone two drugs. For others, a second medication offers a wonderful antidote to the side effects of an otherwise helpful medication.
Most commonly, psychiatrists prefer a single low dose of Wellbutrin for patients complaining of sexual side effects from other antidepressants. It is prescribed initially only as needed, but daily if required. This comedication strategy employs lower doses of Wellbutrin than would be necessary to treat depression. Pharmacologically, Wellbutrin enhances dopamine, which has the opposite effect on libido and orgasm of serotonin. Small doses may restore the serotonin-dopamine balance, alleviating sexual side effects.
The list of agents used to comedicate for sexual side effects include stimulants such as Ritalin (methylphenidate), Urecholine (bethanechol), Yocan (yohimbine), Symmetrel (amantadine) and Periactin (cyproheptadine). Anecdotal evidence suggests that the botanical preparation ginkgo biloba may reverse libido, arousal and/or orgasm problems. Anecdotal reports also suggest that Viagra (sildenafil) is effective for SSRI-induced absence of orgasm--even in women--but its use may be limited by cost ($9 per pill).
At times, it's easy to distinguish whether sexual problems are a relationship issue or are caused by side effects. SSRI-induced sexual dysfunction follows a typical pattern: it begins within days or weeks of starting the new medication. For example, soon after she began takingÂ Prozac for obsessive-compulsive disorder, Maria found she could no longer reach climax with her husband, Steve. She did not volunteer this information, which is one reason I routinely ask women about inability to orgasm. My male patients can tell me that "things aren't working right sexually," without having to look me in the eye and complain that sex is no longer pleasurable. Many women, however, experience an ambivalence about whether nice girls are allowed to like sex or should just go along with it. And some women are terribly embarrassed to talk about orgasms. "He could stand on his head and nothing happens" is Maria's euphemistic description of her sexual difficulty. "It's like a switch turned off down there." Maria hasn't talked about this with Steve, and I suggest that she let him know that medication is the problem, since he may be wondering if it's his "fault." Maria looks horrified at the thought, so I give her some written information to hand him.
I invite Maria to bring her husband to a session so that we can talk this over together. In our joint session, I explain that she is on a high dose of an SSRI for Obsessive-Compulsive Disorder, an illness that only responds to serotonin enhancing antidepressants. Because an SSRI is the only reasonable medication, switching to something like Wellbutrin isn't an option. Further, I explain to her that since effective doses of SSRIs are typically higher for OCD than for depression or panic disorder, lowering the dose isn't a good idea. Likewise, the drug-holiday approach isn't appropriate for Maria. This leaves co-medication, an idea that Steve likes a lot more than does Maria.
Steve reveals that he feels so selfish since Maria stopped having orgasms, and he would like things to be the way they were before. He feels that he is imposing on Maria, because these days, he's the only one reaching a climax when they make love. Somewhat reluctantly, Maria agrees to try comedication and I review the alternatives. Does trying something just when needed prior to intercourse seem best, or would a regular daily comedication be better? I explain that the only-when-needed medication is like a diaphragm--you lose spontaneity, but you don't have to ingest it all the time. When I mention that the only "natural" remedy I know of that may alleviate inability to orgasm requires daily use, however, Maria jumps at this, stating that she'd rather take something natural even if it means taking it every day. I tell her about ginkgo bilboa, which she purchases at her health food store. Six weeks later, she reports that "it's not like fireworks or anything, but it's lots better. Steve says thank you."
Maria remains reluctant to "own" sexual pleasure, continuing to describe her medication-induced sexual side effects-- and return of orgasms--as Steve's issue. Until Prozac came into her bedroom, Maria's unexamined belief was that Steve mostly cared about his own pleasure, and that she was just there fulfilling her wifely duties. Now she's heard from Steve loud and clear that her sexual pleasure is an integral part of his pleasure. A seed has been planted. For the first time, she and her husband have discussed their sexual relationship openly, and she has an opportunity to reframe her sexual self-image.
Valerie Davis-Raskin, M.D., is the director of academic psychiatry at MacNeal Hospital in Berwyn, Illinois, and a clinical associate professor of psychiatry at the University of Chicago. She is the author of When Words Are Not Enough: The Women's Prescription for Depression and Anxiety Â and coauthor with Karen Kleiman, M.S.W., of Â This Isn't What I Expected: Overcoming Postpartum Depression.