We have had a great response to the series of Sexy Saturday Conversations we inaugurated last year. Many women have written to say that they enjoy the frank talk between Dr. Pat and Dr. Hilda, two friends who just happen to know a lot about sex and relationships.  

However, we’ve heard from more than a few women who want to know why we keep talking about “keeping that spark alive.” There is a theme these women would like us to address: Why assume that all women want to have a sex life, partnered or not? 

This seems like a good conversation for Dr. Pat and Dr. Hilda to have—especially in light of the findings of a recent peer-reviewed study, “Sexual Activity and Satisfaction in Healthy Community-dwelling Older Women.” Among the results of their survey of 806 women (median age 67), the researchers found, “Forty percent (39.87%) of all women [surveyed] stated that they never or almost never felt sexual desire.” Why might that be?—Ed.  

Dr. Pat: Women, even in their early 40s, do tell me that they have no interest in any sexual activity with their partner. Other women tell me that they are unattached, and happily so, with no interest now or in the future in developing a relationship with someone that has a sexual component. What do you hear from women over 40, Hilda?

Dr. Hilda: I hear this too, and not just in the office. We all know people who have no interest in sex. Zero. And they often feel as if there is something wrong with them . . . that the world is judging them.

Dr. Pat: It is true that each man and woman has a unique appetite for sex, just as they may have varying appetites for food, rock climbing or other extreme sports, wine, travel, or other sources of pleasure that may not be shared by everyone. However, as gynecologists, Hilda, we do have an opportunity to use this information about “no sexual interest” from a patient to take a sexual history. Hilda, what are some of the questions that you would ask a patient who reports that she has no sexual interest at all?

Dr. Hilda: I would like to know, first of all, if she ever had pleasure from a sexual experience. That determines the rest of the questions.

Dr. Pat: I agree. If she had pleasant sexual encounters over the years, was she ever really interested and orgasmic, or did she just go through the motions because the partner was a nice enough person and the relationship had reached a stage where sex was the next expected thing?

Dr. Hilda: Or were these women capable of having orgasmic sex with a partner who knew what to do, but then, over time, developed a long-term relationship with someone who had no talent in this area, so they just decided to opt out of sex? And there are other women who may not be in a relationship, and have just found that the effort expended in developing an intimate relationship was just not worth it, or was no longer important to them.

Dr. Pat: Then there are medications that totally lower the libido. Many antidepressant medications, for example.

Dr. Hilda: And, of course, illness that causes fatigue, pain, or constant worry and anxiety about the impact of this illness of the course of the person’s life.

Dr. Pat: Then there are women who have unexpectedly aged into a new stage where opportunities for many things seem to have decreased—women who are forced into early retirement, who may have limited social contact as a result of this, along with the inability to afford to do the things they did when they were employed, had fewer financial worries, and had a broader social network. I find that this takes a real toll on a woman’s libido.

Dr. Hilda: When we have a conversation with a patient who tells us that she never had any interest in sexual activity, it is important to gently ask if we can take a brief sexual history. Pat, I always tell the patient in this part of a consultation that she should not answer any question that makes her uncomfortable. This gives her permission to end this line of questioning at any time. What do you do?

Dr. Pat: I agree that WHEN a woman reports no interest in sex for all of her life, there may be issues that she could find too uncomfortable to discuss with anyone other than a therapist. It is important to reassure her that she is in control of this brief conversation.

Dr. Hilda: I ask the standard questions, don’t you? I usually start with “How old were you when you had your first sexual experience? Did you want to have that sexual experience, or was it something that you were somehow forced to have?”

Dr. Pat: I always find that it is important to give the patient some uninterrupted time in a safe place to ask if the first sexual experience was a pleasant one. Or were there unexpected results from this experience that caused her to be afraid of sex, or wary of sex, for the rest of her life?

Dr. Hilda: We know that incest, rape, date rape, pregnancy, or family or friends’ finding out about the sexual experience and reacting in a judgmental way, can have a lifelong impact on the ability to enjoy sexual intimacy. These women often feel judged and guilty even if they are in a loving partnered relationship.

Dr. Pat: For women who report that they have no interest in sex, I generally ask about masturbation. Some women may not identify self-pleasure as sex. I ask, “How old were you when you began to masturbate? How often did you masturbate until you decided that you had no interest in sex?”

Dr. Hilda: Sometimes you can get lots of information from this question. If a woman has never masturbated, there may be a layer of guilt and shame about sex. Negative messages that she may have received during childhood can have a lasting negative effect on her desire for sex and her ability to experience sexual pleasure.

Dr. Pat: I find that an important question to ask in these consultations is, “Were you ever orgasmic?” Women who may have suffered from sexual abuse as children and young adolescents may never have had an orgasm. We call this “primary anorgasmia.” Fear, shame, and the capacity to feel safe with a sexual partner are a few of the barriers to this condition.

Dr. Hilda: I do hear from women who are not in a partnered relationship that they are happy without a sexual relationship. They don’t have sexual fantasies. They don’t masturbate. They like other things, like going on trips, going to the movies, being involved in church and community activities, and they may be passionate about work or social causes. After all, we  have only so much energy. And some people choose to spend part of that energy on sex, and others just don’t see the point.

Dr. Pat: The point is, not everyone is alike. Women come to this site to read about sex because they want information. And maybe because they like the idea of two friends who are gynecologists—who share a professional interest in sexual issues—having a drink and discussing sex from a professional and personal point of view. We certainly hope so!

Dr. Hilda: We do understand that sex is not important to every person. And there is no judgment here. If someone is in a relationship that is celibate, and that is fine with both partners, then there is no problem. If a woman is unattached and has no interest in sexual activity, then that is not a problem either.

Dr. Pat: We celebrate the differences here, not impose a standard that is “right.”