Let's talk about Sex and Psychiatry

As a psychiatrist, I have the privilege of hearing a lot about people's lives—including their sex lives. When the topic of sex comes up, the question I hear most often is: "What is normal?"

My answer is always the same: "Normal" is a spectrum. Whatever makes you and your partner(s) happy, whatever feels good, and whatever helps you connect is what is most important. While everyone has their own unique idea of how often or what kind of sex is "right," the common thread I see is that for most folks, sexual activity is a vital way to feel closer to others and experience pleasure. This sense of pleasure and connection is a deeply important part of the human experience, and regular sexual activity is often associated with improved psychological well-being.

However, a healthy and satisfying sex life is not always easy to maintain. Several factors can affect your libido (sex drive) and function.

When Libido Takes a Dip: Understanding the Causes

A decrease in sex drive or changes in sexual function can be a signal that something else is going on in your body or mind.

Mental Health and Stress:

Mental health issues are often a major culprit. Conditions like depression, anxiety, PTSD, insomnia, and substance abuse can significantly dampen desire. Additionally, life stressors such as burnout, grief, relationship strife, and poor body image can be powerful inhibitors of sexual interest.

Medical Conditions:

Physical health also plays a huge role. Medical diseases like cardiovascular disease, diabetes, high blood pressure, and cancer can affect sexual function. Similarly, hormonal changes, especially as we age, naturally impact our sexual appetites and response.

When Function is the Concern: Sexual Dysfunction

Beyond low libido, I also encounter patients who experience specific forms of sexual dysfunction, even without the psychological or medical factors listed above. These concerns can profoundly impact a person’s happiness and ability to connect with their partner. These issues include:

• Erectile disorder

• Delayed ejaculation

• Inability to orgasm

• Sexual Interest/Arousal Disorder (previously called Hypoactive Sexual Desire Disorder)

• Genito-Pelvic Pain/Penetration disorder

The good news is that there are effective treatments. Psychological treatments, often involving a specialized sex therapist, are very effective. We also have several medications available:

• For Men and Women: Medications like sildenafil (Viagra), tadalafil (Cialis), and other PDE5 inhibitors, originally used for men, are being studied for use in women as well.

• For Women: Addyi (flibanserin) and Vyleesi (bremelanotide) are approved for treating certain types of low desire. Hormone Replacement Therapy (HRT) can also be helpful for perimenopausal or menopausal women experiencing these issues.

The Medication-Libido Link: Navigating Antidepressants

A very common concern I hear is about whether medications can affect libido—and the answer is a resounding yes, they can.

Antidepressants, particularly SSRIs and SNRIs, are notorious for causing side effects like reduced desire or difficulty achieving orgasm. While some people can manage their depression and anxiety with talk therapy (like CBT or ACT), for many others, medication is essential for their overall function and well-being.

So, what can be done if your antidepressant is affecting your sex life?

1. Switching Medications: Some antidepressants are less likely to cause sexual side effects, including mirtazapine, bupropion, and buspirone. A doctor may recommend switching to one of these.

2. Add-on Strategies: Sometimes, these less-impactful medications can be added to your existing regimen to counteract the side effects.

3. Medications for Function: Medications like sildenafil or tadalafil can sometimes be added to help with function issues caused by antidepressants.

4. Hormonal/Topical Aids: Adding testosterone (under medical supervision) or using over-the-counter creams to aid with lubrication and stimulation can also be helpful.

Making Sex a Priority

Beyond treating specific disorders, one of the biggest concerns I find is a simple lack of time and focus. Life is busy, but sexual health is vital, and it often requires intentional effort.

• Make Time: Schedule time for sex, just as you would for a workout or a dinner date.

• Self-Care: Prioritize exercise and healthy eating so that you feel good about your body, no matter its size.

• Connect Outside the Bedroom: Make time to talk and connect with your partner about non-sexual things. Emotional connection often leads to physical desire.

• Experiment: Introduce toys, props, or different positions to enhance stimulation and pleasure.

The Most Important Step: Talk About It

Because sexual function is so important to well-being and because it can be a marker of a variety of physical and mental health issues, it should be part of the health conversation.

I encourage everyone to talk to their medical providers about their sex life. If they don't ask, you should bring it up. Get informed by reading books and listening to experts. Talk to your partner openly and honestly about your needs and desires. And, if you feel stuck, consider talking to a sex therapist.

Your happiness and ability to connect with others matter, and your sexual health is a critical component of both.

Resources

If you're looking to deepen your understanding of sex, desire, and partnership, these two books by leading experts are essential additions to your reading list. They offer groundbreaking perspectives on what makes sexual connections thrive over the long term.

1. Come As You Are: The Science (and Art!) of Creating Lasting Sexual Connections - Emily Nagoski, Ph.D.

This book is an excellent resource for women and their partners. Psychologist Emily Nagoski delivers knowledge and tools that blend science with practical advice.

• Key Insight: Nagoski was one of the first experts to widely discuss the difference between spontaneous desire(the "just happens" kind) and responsive desire (the kind that's sparked by arousal or context). She explains that responsive desire is actually much more common for women, particularly in long-term relationships, which helps reduce pressure and self-blame.

• Why You Need It: It reframes the conversation around female desire, offering a compassionate, evidence-based approach to understanding your own body and sexuality.

Find out more about Emily Nagoski's work at https://www.emilynagoski.com/

2. Mating in Captivity: Unlocking Erotic Intelligence - Esther Perel

Relationship expert and psychotherapist Esther Perel is one of the most compelling voices in the space of modern partnerships and sex. This book tackles the compelling paradox of how to maintain desire and mystery within the safety and familiarity of a committed relationship.

• Key Insight: Perel explores the complex dynamic of wanting both security and passion, arguing that erotic intelligence involves cultivating a sense of space and separateness to allow desire to flourish. She's brilliant at discussing how the elements that make a relationship safe (like intimacy and dependability) can sometimes work against the elements that spark desire (like novelty and risk).

• Why You Need It: Her work provides incredibly valuable insights into the psychology of partnership, helping couples navigate the tension between domesticity and desire. Perel also hosts a popular podcast and offers various online courses.

Explore Esther Perel's books and other resources at https://www.estherperel.com/books