Some have stated that sex is a basic human need. Of course, none of us would exist without it! As stated by one writer, “How boring life would be without sex to stir our passions.” Nonetheless, Hypoactive sexual desire disorder (HSDD), the medical term for lack of libido, is a common but frequently undiagnosed condition. It is the most common form of sexual dysfunction in women. 

HSDD may include bothersome and distressing symptoms of reduced motivation for participation in sexual activity due to decreased spontaneous desire (sexual thoughts/cognitions or fantasies), decreased sexual desire in response to erotic cues and stimulation, or inability to maintain desire or interest through sexual activity. HSDD can cause emotional and relational conflicts leading to further feelings of loneliness and isolation. 

Although there are a variety of potential causes of HSDD (including antidepressant medications, antianxiety medications, birth control, diabetes, high blood pressure, and poor partner social relations), one of the most “fixable” is stress. 

Stress raises levels of the hormone cortisol, which can lower sex drive.

The Culprit Cortisol

With the COVID pandemic, social distancing, and sociopolitical conflicts…Americans are stressed! According to a recent survey done on behalf of the American Psychological Association in January 2021, the average reported stress level during the prior month was 5.6, on a scale from 1 to 10 where 1 means “little to no stress” and 10 means “a great deal of stress.” This was higher than the stress levels reported in the same survey conducted in April 2020. 84% of adults reported feeling at least one emotion associated with prolonged stress in the prior two weeks, namely anxiety (47%), sadness (44%), and anger (39%).

The effects of emotional and mental stress, from any source, are real. Stressful states lead to a rise in one crucial player responsible for these negative effects: cortisol. Cortisol (along with its partner adrenaline) is normally released in the morning or during exercise. Cortisol is best known for its involvement in the “fight-or-flight” response. This natural hormone is released by the adrenal glands, which sit comfortably on top of each kidney. When we encounter a physical threat, our cortisol levels rise in an attempt to keep us safe. 

However, cortisol is not only released at times of threats of physical harm. Chemical studies have now shown that self-inflicted mental stressful states lead to rising levels of cortisol in the brain and body. Published medical evidence confirms the fundamental link between the thoughts we have and the stress levels we experience. Cortisol in the brain leads to addictive-type negative thinking and seems to foster negative, fear-based processes. There is in effect a positive feedback loop for negative thinking where one negative thought leads to another in this perpetual cycle of altered neurochemistry. Have you ever noticed that negative people tend to stay negative and that their thought processes always seem to follow a predictable pattern? It may be hardwired into their thinking!

In the body, high persistent cortisol wreaks havoc as well. This hormone triggers a domino effect leading to system wide inflammation. System wide inflammation leads to free radical formation in the body, and together with cortisol, is a contributor and marker of chronic diseases including heart disease, stroke, metabolic syndrome, obesity, some cancers, and even dementia

So, what does this have to do with SEX? Well, EVERYTHING!

Remember we stated that cortisol leads to more negative thinking? That process of replaying negative fears, negative thoughts, and negative emotions is a process called mental rumination.  Rumination can deplete dopamine. Dopamine is the reward neurochemical related to positive thinking and pleasurable activity. So, lower dopamine levels raise depression and anxiety risk. Low dopamine in the brain has been associated with decreased libido. This also occurs with serotonin. Lower dopamine and serotonin levels can lead to depression, and as we all know…depressed people typically suffer from decreased libido. This domino effect all starts with the persistent secretion of cortisol. 

Unfortunately, as they say in TV Infomercials, “But wait- there’s more!”: This same rise in cortisol seems to shut down the hormonal signals (FSH and LH) from the brain (pituitary) that stimulate the testes and ovaries to release testosterone and estrogen. This may also contribute to the lack of sexual desire and even arousal in both men and women who are exposed to long term stressful states. Don’t forget, the underlying power behind all these reactions is the mind.

Coping with stress and anxiety using mindfulness, meditation and yoga. Vector background in pastel vintage colors with a woman sitting cross-legged and meditating.. Vector illustration
Mindfulness can increase arousal, desire, and sexual satisfaction, and may even help with erectile dysfunction.

 Mindfulness: The Mind and Sex

This brings us to MINDFULNESS. Yes, mindfulness can improve sex drive and sexual satisfaction in both men and women. It is well accepted by medical professionals and counselors alike that sexual desire and arousal start not in the groin, but in the mind! So, taking proactive steps to “retrain our brains” not only leads to lower stress but is a sex booster as well. The goal of mindfulness-based therapy is to encourage individuals and/or couples to connect and engage with their sexuality by learning and practicing a variety of mindfulness exercises that focus on awareness of the moment. 

One of the largest supporting pieces of medical evidence for mindfulness and sexual benefit was published in 2019 in the Journal of Sexual Medicine. This was a “systematic review” where several studies are grouped together and analyzed to see if a common conclusion can be agreed upon. Fifteen original research articles were included in the review. The results stated that mindfulness techniques led to improvement in arousal and desire, sexual satisfaction, and a reduction of fear linked with sexual activity. Mindfulness was also found to be helpful in the treatment of male erectile dysfunction in one study.

Part of mindfulness sexual therapy is sensate focus. Sensate focus is not a new concept and the published data show that it can boost libido, orgasm ability, and overall sexual satisfaction. Sensate focus is about touching and being touched without the expectation of sexual penetration or orgasm. While typically encouraged to be practiced as a couple, it may be learned and performed alone. This initially, in the first stages, includes non-genital touch…think sensuality vs sexuality. Later phases of sensate focus may include breast and genital touch or other errogeous zone stimulations but orgasm should not be the only expected result. These techniques work by primarily lowering the body’s stress induced by cortisol levels. They also help with blood flow, and help relax the body and mind. 

Now, as a physician, I must mention that there is indeed an FDA approved medication for female hypoactive sexual desire, Flibanserin. However, this medication is not without its own controversy. Unclear efficacy (unsure if it really works to a large or significant degree) and some concerning side-effects (like abnormally low blood pressure) have some physicians hesitant to prescribe it. Additionally, medications like sildenafil and bupropion have been used for this condition (neither are approved by the FDA) with varying results. By all means, if medications are needed, or some other health condition requires attention, seek medical consultation. This review is simply intended to encourage individuals who may be concerned about decreased sexual drive that a solution is not found only in a prescription bottle. 

And lastly, while it is true that stress can reduce the desire and satisfaction of sexual activity, the reverse is also true: SEX IS A GREAT, AND NATURAL, Stress RELIEVER! Science confirms sex is beneficial on a physiological and emotional level. Sexual activity and orgasm can improve mood, lower blood pressure, and even boost immunity. Orgasm floods the brain with dopamine (remember, that’s our pleasure hormone), serotonin (the other “happy” hormone), and oxytocin (our emotional “binding” hormone). Oh…the prices we are willing to pay for better health