It’s a familiar move for Kathy Cross:* her husband reaches over in bed and begins to give her a massage. Cross, a mother of two, knows exactly what this signals—and she dreads it. “Last time, I let out a big sigh, and said, ‘Oh God,’ out loud. Usually, I just think it to myself. But he knew what that meant and rolled over.”
Since she had her second child seven years ago, Cross says she just isn’t as interested in sex. She and her husband hit the sheets about once or twice a month, she guesses, but it’s always at his initiation. “He wants to have sex more often, but I think sleep is more important. Sex becomes just another thing on my to-do list,” she says.
She knows her low sex drive is putting a strain on their 15-year relationship. “I know he wishes I would make the first move once in a while.”
Message boards and mothers’ groups are filled with women talking about their lacklustre sex lives. It’s not unheard of for girlfriends in mommy groups to trade tips like avoiding eye contact and feigning sleep. For some women the dry spell is short—ending when they emerge from the fog of new motherhood. But for others, low sexual desire haunts their relationships.
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A 2005 study in the Canadian Medical Association Journal found that 35 to 40 percent of Canadian women suffer from low libido, but only 10 to 12 percent of them are worried enough to do something about it, says Lori Brotto, an associate professor at the University of British Columbia and a Vancouver psychologist who specializes in female sexual arousal and dysfunction. While there are already at least five sexual dysfunction medications available to men, including Pfizer’s 1.8-billion-dollar blockbuster drug Viagra (approved in Canada 15 years ago), pharmaceutical treatments for women are lagging behind. (This has garnered cries of sexism from doctors like Brotto.) However, the landscape is changing, and a female version of Viagra could reach consumers within the next two years.
The race to market
Several different companies are vying to bring their own female-sexual-desire drug to market first. Canadian company Trimel Pharmaceuticals is seeking regulatory approval in the US, Canada and Australia for Tefina, a testosterone-containing nose spray that could hit shelves by 2018.There’s also Sprout Pharmaceutical’s Flibanserin, a daily pill undergoing additional clinical trials after it was denied approval in the US by the Food and Drug Administration in December 2013. But Lybrido, a pill women would take three to six hours before having sex, is the current front-runner. Its manufacturer, Emotional Brain, a Dutch research company that specializes in female sexual health, is hoping that Lybrido will be just the thing for women like Cross who don’t feel interested in sex anymore. The drug has been green-lit for phase-three trials in the US and Europe (the last round of regulatory testing before a drug can be sold), and is projected to hit the American market in 2016, pending FDA approval. (Though there is no set timeline for a Canadian release, Health Canada usually trails FDA decisions by three months, on average.)
Like Viagra, Lybrido contains sildenafil, the same active ingredient that increases blood flow to the genitals. Increased blood flow gives men an erection, and will increase sensation and vaginal lubrication for women. Lybrido has a two-in-one formulation, however, combining sildenafil with testosterone, which turns on the brain’s awareness of sexual cues, whether you’re a man or a woman. The drug is designed to work on both the body and the brain to arouse dormant desire.
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Jim Pfaus, a neurobiologist at Concordia University in Montreal, is working with Emotional Brain on the development and chemistry of Lybrido. He explains that there’s a very basic and obvious anatomical signal that men are ready for sex—an erection. But with women, well, it’s complicated. Women may not interpret or notice their own physical signs of readiness as a reason to get busy. While simply increasing blood flow may work for men, it may not be enough for women, because feeling turned on isn’t only about the physical changes. Good lighting, the right music and a glass of wine aren’t always the magic formula for getting it on, either (though they can help). Your body and mind have to work together to get the process started, and some doctors, including Pfaus, say that a dose of extra testosterone may be the nudge some women need. (Women naturally produce small quantities of testosterone, released by the adrenal glands and ovaries.) In other words, the pill may push the brain toward a state of arousal by priming a woman’s brain for intimacy.
Emotional Brain is also developing a sister pill to Lybrido called Lybridos, which contains buspirone, an anti-anxiety drug. The buspirone is intended to lower inhibition—the feeling that puts the brakes on sex or distracts from desire—by causing the short-term suppression of seratonin levels.
Diagnosing low libido
Many women will experience bouts of low desire, whether it’s because of hormone changes, switching birth-control methods, stress or major life changes. But when does a sustained period of “Not tonight, honey,” become sexual interest arousal disorder (SIAD)? Brotto helped develop the new criteria for defining SIAD (formerly called HSDD, or hypoactive sexual desire disorder) in the DSM-5, the latest edition of the medical reference book, and says that clinicians will first ask women whether their lack of lust is affecting their lives negatively. There are six other criteria (see sidebar below), and three are required for diagnosis. While Cross agrees that she definitely meets at least three of the criteria, she still isn’t sure she’d ever try a medication promising to improve her sex life. “Take a pill and solve all your problems—this is such a modern-day approach.”
Sexless? For a clinical diagnosis of sexual interest arousal disorder (SIAD), women must meet three of the following criteria for at least six months:
- Reduced interest in sex
- Infrequent or lack of intensity in sexual thoughts or fantasies
- Absent or reduced interest in initiating sex and lack of reception to partner’s advances
- Reduced pleasure in approximately 75 percent of sexual encounters
- Infrequent sexual interest elicited by verbal, visual or written sexual cues
- Reduced intensity or frequency of genital or non-genital sensations in approximately 75 percent of sexual encounters
For most parents, it’s no surprise to learn that passion can decrease over time due to situational and relationship factors, and not just biological ones. The after-work rush of daycare, dance, soccer, dinner, homework and bedtime can be downright draining for those of us who barely have time to take off our coats, let alone pull out the lacy lingerie. There’s also the mental shift—it can be difficult to transition between all the demanding roles that women play (mother, wife, worker, daughter, carpooler, chief bottle washer). Often, says Brotto, the role of lover falls to the bottom of the list.
When Cross gets home from her job running a media company, she just wants to be left alone. “It started with the babies and the breastfeeding. Once the kids were in bed I just wanted my own space without little hands all over me. Now that the kids are older, they’re still demanding, sometimes more so. By the time I get home from work, and after dinner and homework, I just want some time when no one is asking anything of me,” she says.
Sometimes talking or arguing about not having sex takes up the same amount of time as actually doing it, she says. “I know it’s silly, but in the moment, it makes sense. And it adds to the feeling of never having time. I don’t know why I don’t say ‘yes,’ because the truth is, I’m usually happy about it afterward, and I wonder why I’d been putting it off.”
Pfaus argues that Lybrido could help put sex on the top of the to-do list, just like, he explains, a hungry person instinctively makes his or her next meal a priority. “The hornier you are, the more likely you are to make time for it, just like the hungrier you are, the more likely it is that you will eat,” he says. “And for some women, the pill will make that change.”
But if combining Viagra and testosterone were the secret combination, says gynaecologist Jen Gunter, there would be more literature to support its success. Gunter, a Winnipeg-born and Canadian-trained OB/GYN, now runs a San Francisco–based practice that specializes in treating women for whom sex has become physically painful. She has significant concerns about the long-term safety of taking any amount of testosterone, and says she would be hesitant to prescribe Lybrido until more extended studies have been conducted. She waits to prescribe any medication until large-scale randomized trials have proved that it works, without side effects. “The data is lacking at this point,” she says.
For many of her patients, Gunter says it’s often impossible to pinpoint one single issue. “Sexual function is very complex. There are so many factors involved: physical, emotional and situational.” With all these competing factors in each woman’s life, she says it’s difficult to conclude that a single drug could be the answer. Hormonal birth control (including traditional oral contraceptives) can hamper desire for some women, as can antidepressants. (Some studies have linked oral contraceptives to decreased levels of androgens, the group of hormones that includes testosterone.) For women who are breastfeeding, sex can become uncomfortable due to lowered estrogen levels, which can cause vaginal dryness. And for some of her patients, Gunter says that “birth trauma”—including injuries like physical tears—can also cause women to associate sex with pain. “If sex is painful, then obviously you’re going to avoid it.”
While vaginal dryness can be treated with an over-the-counter lubricant or topical estrogen creams, other new-mom side effects that impact lust levels—like fatigue, mood changes or postpartum depression—aren’t as easily solved.
Like Gunter, Lori Brotto, the Vancouver psychologist, has her doubts. “Everyone wants a pill for everything. But women need to address their different issues and have discussions about their expectations and their needs. Medications are not a panacea,” she says. Brotto warns that the poor track record of women’s sexual dysfunction drugs seeking FDA approval isn’t promising—Lybrido will have to show very compelling evidence of its efficacy—and she believes that researchers may be oversimplifying the female sex drive. Lybrido and Lybridos may only help the small subset of women who cannot become physically aroused, she says. “There are so many other reasons why women have diminished desire—the lack of time, fatigue, not prioritizing sex, physical pain during sex, relationship issues.” A medication to increase libido doesn’t create more time in the day for overcommitted moms. “People only have one gas tank,” says Brotto. “If that gas tank is expended during the day’s activities, there is no gas left in the tank for sex.”
It’s not me, it’s us
For many women, the biggest question hovering over their sex life—or lack thereof—is the quality of their relationship. What if it isn’t a physical issue, and isn’t linked to stress, but is actually an indication of an ailing marriage or partnership? If you don’t find the thought of sex with your partner exciting, Gunter suggests this test: “Can you imagine yourself having sex with someone other than your partner? If the answer is ‘yes,’ it’s less likely the problem is physical.” Another comparison point Gunter uses is the vacation test: If your vacation sex is amazing and you can’t keep your hands off each other, then it may just be a timing issue, related to work-life balance and everyday demands.
Melissa Richards,* a mother of two kids, ages nine and 11, in a small town in BC, says she’s “honestly not interested” in sex anymore. Her marriage would fail Gunter’s vacation test, she admits. While she loves her husband, she describes their sex life, after 12 years together, as dismal. “I tell him I’m ‘just not in that place.’ Then he’s hurt, and sometimes angry, and it manifests itself as other arguments in our relationship. The resentment toward me for not meeting his needs is a gigantic problem in our marriage.” She wonders if she’s still as attracted to him as she used to be, and would definitely take a pill to improve the situation if she could.
All relationships—especially long-term ones—go through highs and lows when it comes to passion. Many women are more aroused for the few days during ovulation, and may feel less frisky during other times of the month, something that men don’t always realize, adds Pfaus. Sometimes partners just need to communicate during a dry spell and be clear with each other about the reasons why sex isn’t a priority. Speaking honestly about hesitations in the bedroom—whether they’re due to pain, fatigue or just a feeling of being overwhelmed—can lead to healthy compromises.
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It’s also important to remain in close contact (emotionally and in terms of touch), during the low periods, says Gunter. Remember that intimacy can come in all forms, and simple or even sappy displays of affection, such as holding hands or stealing a quick kiss, can help partners who are having sexual issues. “I tell couples to try and just be intimate with each other. Hold hands and cuddle on the couch watching TV. There are lots of ways to be physical together,” says Gunter. It’s very hard to go from no touching at all to intercourse, she adds. If even this kind of affection feels like work, then it may be time to seek professional help.
Aside from pharmaceuticals like Lybrido and Viagra, treatment options for couples with sex-drive discrepancies include mindful meditation, cognitive-behavioural therapy and traditional sex therapy. All forms of counselling should help couples open up, says Brotto. Partners may not understand each other’s expectations at first, but a knowledgeable couples therapist can help mediate.
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Pfaus, the advocate for Lybrido, doesn’t want consumers to think of the pill as a quick fix, either. He’s more interested in the possibility of a permanent solution for couples. A vacation or a love-potion-in-a-pill might jump-start or revive a love life that has dwindled, but that’s not enough, he says. “You want to have good sex more often than one week a year. You don’t want to be on your deathbed and think, ‘the best sex of my life was that week in the Dominican,’” he says. That’s why, in the best-case scenario, he’d like to see Lybrido prescribed along with sex therapy, for longer-lasting and more significant results. In fact, once the medication starts to work, he says, and women find that sex can be an exciting and satisfying part of their lives again—they may no longer need a medication to get them in the mood.
Gunter agrees that breaking the pattern is key. “Typically, good sex begets good sex,” she says. “The more pleasurable sex you have, the more you will want. But is it OK to pop a pill to trump a situational problem? I don’t know. Just because we can doesn’t always mean we should.”
* Name has been changed.
A version of this article appeared in our May 2014 issue with the headline “Love potion in a pill,” pp. 70-73.