A Case of Disappearing Desire

How do you help a client who wants a relationship but can’t seem to sustain sexual interest, even for partners they deem desirable? Sex and relationship therapist Tammy Nelson, author of The New Monogamy and Integrative Sex and Couples Therapy, and trauma expert Frank Anderson, author of To Be Loved and coauthor of Internal Family Systems Skills Training Manual, share their unique approaches to working with a client who “couldn’t be happier with life” … except when it comes to longstanding sex and commitment issues.

Meet Simon

Simon is a 29-year-old medical student who struggles in committed relationships. He says he loses sexual interest in the women he dates soon after things get serious. “I always thought I got bored because I hadn’t met the right person, but my last girlfriend was hot, funny, smart—I was crazy about her. When I stopped wanting sex, it confused her, but she stayed. When she caught me watching porn, though, it wrecked her.”

Simon jokes about his physical appearance a lot in your first session. “I used to be chopped,” he says. You ask about this, and he clarifies that he was overweight, had bad acne, and broke his nose in a fight in high school. “I mostly avoided mirrors till I was in my 20s. Surgery turned my life around. That’s why I’m becoming a plastic surgeon.”

Simon says he has no memory of his mom, who died when he was a toddler, but his dad was a great parent. “We’re still super close. There’s nothing my dad wants more than for me to find a partner and start a family. Honestly, other than this issue with sex and commitment,” he tells you, “I couldn’t be happier with the way my life is going.”

A New Narrative Around Intimacy

By Tammy Nelson

Simon’s story is not uncommon, but it’s touching how much he wants a relationship and doesn’t understand what might be wrong with his level of desire for his partners. He is a high-functioning, high-achieving young man with issues around eroticism. His confusion around desire—and its disappearance in the context of closeness—is a clue. When clients say, Everything in my life is great, except for this one thing, I listen carefully. That “one thing” is usually the thread that connects everything underneath.

Simon’s disinterest in sex after emotional intimacy may not be because he grows bored with the sex or the relationship, it may be that his attachment bond desexualizes the relationship. The early loss of the first attachment figure—a mother who disappeared from his life before he could make sense of absence—may have created a rupture in how he bonds and stays connected. In early developmental trauma like this, the body often “remembers” through behavioral and relational patterns.

But let’s not blame his mother. I’d be more curious about the narrative of losing his mom. How does his dad talk about her? What were his earliest relationships like after the loss of his mother? Did he remarry after his first marriage? Is there a story here that no one could replace his mother, and that no one should?

His sexual shutdown is not a rejection of his partners, it’s self-protection. He’s reenacting an old wound: connection equals loss. If he lets himself get too close, his body may preemptively shut down the very thing that makes him vulnerable: desire. If he wants someone, they could leave him.

While we don’t know that he has early abandonment wounds, it’s quite possible he had plenty of positive connections with his father and other adults, which may have been more than enough, but there’s a story of loss underneath his story of surviving a tough adolescence.

Porn and masturbation may be not just a coping mechanism but a safe container. Masturbation offers controlled arousal, there’s no risk, no rejection, no relationship, and no need to stay emotionally present. That’s not pathological; that’s emotional and relational survival. I see Simon’s porn use as a behavior he developed to soothe himself, so with compassionate curiosity I’d ask more about his fantasies and masturbation behavior without shaming him. What he turns to as his arousal scenario can tell us a lot about what his internal life contains. Emotionally, is he looking for attention, a soothing figure to tell him he’s wanted? This can come out in a sexual fantasy of being desired, of a woman telling him he’s sexy and that she wants him in an erotic way. If he feels out of control in his life, he may have sexual fantasies of being in charge, telling a woman what to do, or holding her down while he makes love to her. These scenarios are narratives that are not necessarily stories he’d need to act out in real life, but may provide a soothing internal mechanism that allows him to manage his emotions.

Simon also lives in a body he once hated. His comment, “I used to be chopped,” followed by descriptions of bullying, reveals body dysmorphia and a sense of humiliation. His transformation into a “desirable” man through surgery and his career choice to become a plastic surgeon show that he’s trying to fix on the outside what may still hurt on the inside. His desire to transform other people’s bodies may be a longing to rescue his own wounded self.

It feels like Simon is masculinizing himself, and still in search of the missing feminine, the one who could make him feel safe, loved, whole. Therapeutically, I’d explore what sex, closeness and eroticism mean to him beyond just performance. Can he feel desire without fear? Can he stay present in intimacy without feeling like he wants to run away?

I might also discuss his own dreams, versus his father’s dreams. (“He wants me to start a family.”) If he’s still in medical school, it might be too soon to settle down in a serious relationship, maybe he wants or needs more freedom, or perhaps he doesn’t know what he wants at all.

I’d want to help Simon understand that losing desire isn’t the problem. Losing himself and what he really desires in the relationship is what’s shutting him down.

Healing won’t happen when he finds the “right person” but from integrating the lost parts of himself. Inside Simon is the boy who was mocked, the teen who avoided mirrors, the man who doesn’t remember his mother but has been shaped by her absence. And there’s also the successful adult man inside of him who helps to shape other people’s lives. All of these parts are important to recognize and acknowledge. This way he can understand which part of him is running the show when he feels a certain way or reacts in a relationship. He doesn’t have to negate or avoid these parts. Once he understands that they’re all parts of him, he can become the parent to them that he always needed. The adult that can soothe him, the grown-up that can tell the frightened parts of him that he’ll be ok, and the father inside him that can tell him he’ll survive and that whether he’s in a relationship or not, he’s loveable. Only then can Simon create a new narrative around intimacy, one that includes trust, arousal, connection, and sexual companionship.

An Integrative Approach to Relational Trauma

By Frank Anderson

As my first session with Simon unfolds, several hypotheses begin to form. My notes are anything but linear, but I jot down things he says and does, along with quick questions and possible connections I’m noticing in the process of mapping out the salient information he offers up. As I listen to him, I take in every word, watch every gesture, pay attention to the slight shifts and body movements, track his eyes as they dart around the room, and listen to every sigh. These are all clues to the root cause of his symptoms.

Having trained as a medical doctor first and a psychotherapist second, I understand that symptoms are what bring people into treatment, be it medical or psychological. Because I’ve been trained in Eye Movement Desensitization Reprocessing (EMDR), Sensorimotor Psychotherapy, and Internal Family Systems (IFS), I use an integrative approach to trauma treatment—one that’s based in my knowledge of neuroscience. I know there’s something deeper going on for clients who come to talk about problems, which I see as the root cause of their symptoms. Unresolved trauma—whether it’s considered big T or little t, relational trauma or complex PTSD—can rarely be addressed by just one method or model of therapy, and it usually takes time to unravel for sustainable transformation to occur.

At the same time, having done this work for many years, I’ve learned it’s not idealistic to hold the hope that clients’ symptoms can be eliminated, or that underlying trauma can be healed as they deepen self-awareness, strengthen their connection to themselves, and release the weight of suffering over issues that don’t truly belong to them. Therapy, done skillfully and sensitively, allows people to move forward in life in a different way: from a place of calm power.

Simon’s main symptom or chief complaint is a lack of interest in sex and difficulty committing in intimate relationships. He’s a medical student, which means he’s smart, driven, focused, and works hard to achieve his goals. (I write “smart” at the top left corner of my note pad.) Is he a wounded healer like so many of the other physicians I’ve worked with? Does he have a strong caretaking part because he didn’t get his needs met when he was a child? (I put a question mark next to the word “smart” because we don’t yet know what need or longing is driving his success.)

Simon tells me he has commitment issues and loses interest and erections when things get serious. (I instantly write “commitment/sex” in the center of the paper.) My first thought is attachment trauma, but I wouldn’t bring a clinical term like that up with a client this early, so as not to depersonalize the work or scare him away with psychobabble. Instead, I ask him to tell me more about what “commitment issues” means. It’s important to hear how clients define their own problems, but I also want to assess his level of insight and capacity for self-reflection.

I listen carefully and notice that Simon’s body tenses up as he describes his “super high sex drive” and how confusing it is when he’s not into it after a few months of “great sex.” He diverts his gaze down and away from me. (I can see there’s activation and shame held in his body around sex and intimacy. I write “tense/shame” next to the word sex.) I wonder what his relationship with his parents is like. What did he witness unfold between them when it came to affection or loving touch? I also wonder if something medical is going on around sexual functioning and hold the thought that he might be gay. (I write “physical” and “gay” with a question mark beside them.) So many questions have arisen in the first few moments of our meeting. I’m feeling deeply engaged and a bit overwhelmed as well.

Then, Simon takes me off guard: he mentions looking “chopped,” shifting the focus and lightening the mood with a joke about his appearance. I don’t know what chopped means, so I ask, wondering if the age gap will have a negative effect on our connection. I notice a part of me show up that feels insecure: What if he thinks I’m too old to help him or relate to him? I acknowledge the feeling and ask it to soften. It does, and my body relaxes.

Simon proceeds to talk about being overweight, having acne, being made fun of, a fight leading to a broken nose. There’s so much to unpack from experiences he had outside of his home growing up. How did he learn to self-soothe? Does he frame what happened as bullying? Are there anger issues here? Social struggles? Shame? How has he learned to deal with conflict? (I write “school/social/shame” with a big circle around it.)

Then, I hear “no mirrors, surgery, and becoming a plastic surgeon.” This is a big deal, I think—not your typical adaptation to a schoolyard fight. (I write “nose/plastic surgeon” on the top right of the paper.) Maybe this has less to do with his parents than I assumed. Maybe we’re dealing with peer trauma, and this is the source of his commitment/sexual/intimacy issues. I notice a deeply curious part of me emerging. I haven’t worked much with social trauma, so I can learn a lot from Simon. Another part of me shows up, too, remembering how much my brother and I fought as kids. I know that working with Simon could activate my own trauma history. Am I prepared for that?

Before our session ends, Simon tells me about his mom dying when he was a toddler. “I have no memory of her,” he says. But he reassures me, and perhaps himself, that he has a great relationship with his dad.

The pieces of the puzzle are starting to become clearer. Simon has experienced preverbal trauma, early implicit memories of a traumatic loss in addition to his school trauma. He likely carries emotional and physical memories that are unconscious and stored in his body. He probably holds some level of neglect—growing up with one parent, even a good parent, is usually accompanied by experiences of unmet needs. The preverbal trauma could have set the stage for being targeted at school. Maybe these experiences are linked, or maybe they’re separate traumas. Simon could truly have a great relationship with his father, or he could be idealizing their connection. He might have had to view his father as “all good” as a survival strategy. (I add, “mom died” and “great relationship with dad” with a question mark next to it. I’ve written these notes close to “commitment/sex” at the center of the page.)

At this point, I’m careful not to jump to any conclusions. I’m mostly here to ask and listen, create a connection with Simon, and build a relationship with him that allows us to explore painful, hidden aspects of his life in a safe and effective way. I’m truly awed by his complexity, and I’m looking forward to seeing him again so we can start unraveling the thoughts, feelings, and behaviors that have been confusing him, and perhaps begin to heal the trauma drivers that shaped his life in ways he hasn’t been consciously aware of.

As the session ends, I ask Simon if there’s anything else he wants to share before we close. He shakes his head no, but with a look of despair on his face. I can see that the work we’ve done hasn’t been easy for him. For us to continue, I know I need to give him an authentic message of hope and healing.

Slowly, I summarize what I’ve heard him share, and his expression softens. Over the years, I’ve learned that my great wisdom and brilliant interpretations are not the true change agents in psychotherapy. Instead, hope, healing, and a genuine connection are what give clients the confidence they need to move forward into uncharted waters. I tell Simon I’m confident we’ll get to the root cause of his issues. And I let him know that losing a mom at an early age, and being “chopped” in school, can have a big impact on a person’s life. “But the suffering that can come with these events isn’t permanent,” I say. “I believe you have the capacity to release the pain you’re carrying, and that you can live a more fulfilling life that includes satisfying intimate relationships.”

“Then I’m open to giving it a try,” he says.

Our work will entail building a strong therapeutic alliance, one that helps him connect to his own wounded parts, including ones carrying feelings of abandonment that come with a parent’s death, and shame related to being bullied. Our goal will be to give these parts corrective experiences. He and I will get to know and appreciate his problematic behaviors. We’ll strive to understand the intention behind unwanted patterns he’s tried so hard to change.

While we’re doing this deeper healing work, I’ll check in with him to see how his present-day life is going. I’ll encourage him to move forward and try new things. I’ll help him learn to connect to his internal wisdom, trust his intuition, and communicate more effectively. He’ll begin to develop a different relationship with his body as he repairs the internal chasm created in the aftermath of his traumas.

I’ve come to believe that therapy is about revisiting the past, repairing the internal relationships severed by trauma, helping our clients release energy that doesn’t belong to them, and helping them take risks and change old habitual patterns that get in the way of the life they’re creating now. I’m hopeful that the journey we’re on together will change Simon’s disruptive relational patterns while helping me to grow alongside him.