Sexual dysfunction: What’s love got to do with it?
In clinical discussions, we simplify desire as if it were libido.
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.
The emotion of love implies an occasional intense degree of pleasure and interest, sometimes to the point of joy.
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.
All people buffer their disappointment. The private mental struggle to maintain cooperative, kind behaviors is a dynamic process with fluctuations in all people.
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.
Clinically, a patient saying, “I love my partner” can mean, “I don’t want to examine this further now:”
- 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
A moral commitment
A mental struggle
A force of nature
A stop sign
Love as ambition: 7 ideals for loving relationships
Enjoyment of one another
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.
Drive. Science shows with certainty that desire’s biological component has a basis in anatomy and neuroendocrine physiology. Factors that account for different endowments in the strength of desire over time for any person have not been clarified, however, and neither have the immediate precursors to feeling spontaneously “horny.”
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. A person’s sexual desire and behaviors are shaped by families, schools, religions, politics, regional influences, history, and economic forces. These cultural influences begin in childhood and can be remodeled as individuals are exposed to new ideas as they mature.
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?
Values are forces beyond the biological or psychological details of the person’s life. When orthodox religious injunctions against sex envelop a culture, for instance, its followers are likely to suffer in their sexual function without knowing why. Old-fashioned ideas—such as, “Nice women do not enjoy sex”—can inhibit desire long after they are cognitively outgrown.