Natalie Rosen. Photo: Dalhousie University

When women first walk into Natalie Rosen’s private psychology practice in Halifax seeking counseling for their low sexual interest or arousal, they often come alone.

“I think a lot of that comes from just our society’s belief that someone has the diagnosis, so they’re the problem,” Rosen said.

“But I don’t think that makes a lot of sense.”

She’ll ask women whether their partner will join them.

“It’s really difficult to talk about sex and sexual relationships when you’re just guessing what the other person is doing or feeling,” Rosen said.

“We can do some guesswork, but we’re not mind readers. And it also puts a lot of the onus on her to go home and try and explain things to her partner and involve her partner, when my approach is very much to include the partner if he or she also wants to come and be engaged and to approach it from a couple’s perspective.”

That’s why Rosen, a clinical psychologist who also teaches at Dalhousie University, decided it was time to delve deeper into both sides of the equation with a new research project.

“The key thing that really got us going with this study, and the very novel piece to it, is that it’s about couples,” Rosen said.

“As far as we know, and I’ve been in this literature researching sexual dysfunction for about 10 years now, there are no studies … of women with low desires that also include their partner. So we always only focus on the person with the problem.”

Rosen is trying to delve into the perspectives of both the women and their partners, and how they’re reacting to and communicating about the problem.

“The particular types of things we’re interested in are what might be some protective factors and what might be some risk factors,” Rosen said.

Some couples might be doing quite well, she said.

“Some of them might have figured out ways to talk about it. They might still be having sex. They might be quite satisfied with the relationship and they’ve sort of figured out a way to navigate this problem so that it’s not having as much of an impact,” Rosen said.

“Then we’re expecting there might be also a number of couples that are not doing so great. We know that women struggle with depression in this population, that they feel sort of low self-esteem related to this problem, and it does really negatively impact both the sense of self and the relationship.”

While the focus of her study is on women with low desire, one of Rosen’s students has also just started looking at men who have the same problem.

“All the couples we’ve recruited so far have been with women with the low desire,” she said.

“It’s definitely more prevalent in women; probably about double.”

Large population-based surveys show up to 40 per cent of women report a lack of interest in sex, Rosen said.

“We know that about 34 per cent of women and 15 per cent of men report a lack of interest in sex. But then when we take into account whether they’re bothered by it, whether they’re distressed, it drops to about 7-10 per cent of women. And we actually don’t really have a good estimate for men because there aren’t great studies. But it’s probably less than five per cent of men.”

She’s taken something of a shotgun approach to finding just over 100 willing couples to participate in the study.

“We are using a huge range of strategies,” Rosen said.

“The most successful stuff we’re doing is online. So we post ads on Kijiji, Craigslist in the States because that’s still big there, and we use Reddit quite a bit. We get a lot of participants through Reddit. We contact various Facebook pages that might be relevant, like women’s health pages or sexuality pages, and ask for a posting there. That goes pretty well. And then, locally, in both Halifax and Toronto, because my main collaborator on this project is in Toronto, we go around and poster in the universities and in hospitals and (other) locations that are relevant.”

Rosen and her colleague Amy Muise, an assistant professor of psychology at York University, launched their joint recruitment effort in September. So far, they have enrolled 34 couples.

“So the rate of recruitment is about two a week, and that’s the ones who end up meeting our eligibility criteria and actually get enrolled. We get inquiries that are probably about triple that of people who contact us for the study, but then for a variety of reasons don’t end up being enrolled.”

Couples need to be in a relationship that’s at least six months old in order to qualify. “And not only that, it can’t be a long-distance relationship. So they have to see each other, in person, at least four times a week. And that’s because there needs to be opportunities for sexual attraction.”

Both people in the couple have to be older than 18, though there is no ceiling on the age restriction.

“The woman can’t be pregnant, breast feeding, or within one year post partum,” Rosen said, noting there are a number of hormonal changes that go on across that whole period that can effect women’s desire and arousal.

To participate in the study, women also can’t be on any kind of hormonal therapy, though contraceptives such as birth control pills are allowed.

“And the really key one that’s challenging is that their low desire or arousal difficulties are not attributed to some kind of medication that they’re on. Like, ‘I noticed this problem started at the same time I started anti-depressants,’ or some other medication that’s known to have sexual side effects.”

Participants also can’t be dealing with a medical condition known to dampen their interest in sex. “If they’re undergoing treatment for cancer, for example, would be another exclusion criteria, or they just had a hysterectomy.”

To get in on this academic action, people need to have been diagnosed with sexual interest arousal disorder.

That means they have to meet or endorse at least three of the following six criteria:

  1. lack of interest in sex
  2. few or no sexual thoughts
  3. lack of receptivity to a partner’s sexual initiations and no initiations of their own
  4. lack of pleasure during sexual activity
  5. lack of responsive desires to erotic cues (which means erotic thoughts or activities don’t turn them on)
  6. difficulties with physical signs of sexual arousal (such as a lack of genital arousal sensations during sex)

On top of checking the box next to at least half of those, participants must be distressed about the situation.

“Some people call and are like, ‘Yeah, I think I meet this criteria, but it doesn’t really bother me. It doesn’t really bother my partner. So we haven’t had sex in the last year, but we’re not really that concerned about it,’” Rosen said.

“They wouldn’t meet the criteria. In order to be diagnosed with a dysfunction, you have to care. It has to be causing some kind of interference in your life, or distress.”

Third base, if you will, is that these problems have to be persistent for at least six months.

“In the general population, desire really can ebb and flow,” she said. “If you’re feeling stressed about school, feeling really stressed about work, a parent is sick or a kid’s been home sick for two weeks — there’s lots of normal fluctuations that happen in desire and relationships. Even things that could last a month — a new stressor at work, a new boss or whatever.”

People can go for a month or two experiencing low sexual interest, then bounce back, said Rosen, an assistant professor at Dal’s Departments of Psychology and Neuroscience, Obstetrics & Gynaecology.

“A dysfunction has to persist beyond that natural ebb and flow.”

The concept of this research at Dal’s Couples and Sexual Health Lab is that it’s a pilot study.

“We want to get a sense of how many people we can recruit,” Rosen said.

The idea is to get some preliminary evidence that proves the theory that there are a number of reasons that people have sex, despite low desire.

“Things like choosing to still have sex because she wants to please her partner or build intimacy in the relationship, or because she’s focusing on the positives of potentially still having sex,” Rosen said.

“Whereas some women might be still having sex with their partner because they don’t want to have a fight with their partner about it. Or they don’t want to feel guilty. Or they don’t want to feel badly about themselves in some ways. So one of our hypotheses is around this idea that people have different motivations to have sex. Some motivations might help promote positive outcomes and satisfaction. And some motivations might actually exacerbate some of the things like couple conflict and feeling bad about yourself that you’re kind of trying to avoid in the first place.”


Another driving force behind the research is the lack of any Health Canada approved medication for low desire in women, Rosen said.

“Given this huge prevalence, you can’t go to your doctor and say, ‘Treat me. What can you give me?’ There’s no medication for it,” she said.

“However, there is some promising evidence around psychological interventions … There was a new study just in 2016 looking at mindfulness-based therapy for improving women’s desire and arousal. There’s some evidence for cognitive behavioral therapy.

“But again,” continues Rosen, “none of these studies have included the partner. So that’s where I’m going with this. We know that sex happens with another person, generally, and the women who present with low desire and arousal are distressed and upset about it tend to be partnered. They are like five times more likely to be in a relationship. We don’t really hear from women who are single and have low desire. So we know that this is happening in a couple context and we are not treating it that way. We’re treating it just as if it’s the woman who has the problem. And one can imagine that they way the partner responds to the problem and how they interact together and talk about it is also going to effect how they do over the long term. So that’s the end that I have in mind.”

Rosen wants to develop an intervention that’s couple-based to help alleviate their suffering.

She’s hoping this current study leads to an even larger one with more complex methodology.

“We’ll take this data – this project that we’re running over a six- to eight-month period – and go to the Canadian Institutes of Health Research to pitch a much bigger project once we are able to tell them, yes we can gather these couples.”

But for the research going on now, couples start with a brief telephone conversation with one of Rosen’s research assistants to screen people who don’t fit the bill.

“If they meet that criteria they then get scheduled for a clinical interview with a PhD student who has the skills, because they’re in the clinical psychology PhD program, to actually assess (whether) they meet the diagnostic criteria for this problem.”

Once they make it past that level of screening, both members of the couples are sent emails with independent links to an online survey and they complete the measures for the study.

Along with questions about motivations for having sex, the survey will probe how partners respond to the problem.

“There might be questions like, when your partner initiates sex, what do you do? How do you decline the request? Or do you decline the request? And how do you? And how does your partner respond to that decline? With the idea that there might be certain ways of telling your partner, ‘No, not today,’ that can be helpful and certain ways that might make them feel worse.”

The survey will also look at how members of couples deal with their emotions around sex.

During sex with a partner, do they try to suppress negative emotions? Or are they trying to focus on or promote positive emotions?

They’ll be asked about their level of sexual desire, frequency of sexual activities, sexual and overall relationship satisfaction, depressive symptoms – “because we know that women with low desire and arousal are also more likely to be depressed” – and feelings of distress about sexual problems.

While it can be difficult for people to talk about sex, the fact that the questionnaires are anonymous seems to help, she said.

“Even though they have to give us their name and we talk to them on the phone to get them into the study, their name is not actually ever connected to their data,” Rosen said.

“So once they do the questionnaires, it’s completely anonymous.”

Rosen’s current research, meant to provide a glimpse of what’s going on with these couples, ends with the survey.

A larger future study would “follow these couples a little bit more intimately,” she said.

That would involve couples filling out daily diaries about their experiences over two months.

For that research, people could be asked to complete a brief online questionnaire on the days they have sex. “Which is just going to be a lot more accurate than trying to remember how did I feel in the last month? Or what did I do last time my partner asked me to have sex, which might have been a month ago. So we want to do a study that actually will … allow us to hear from the couples, right when they’re having these interactions, which we expect will be much more accurate and meaningful.”

She’s also contemplating longitudinal models that would follow couples over a longer term. That could involve touching base with them again six months later, a year later, and potentially even two years later, to look at the temporal order of things.

“So what comes first? And then what comes next?” she said. “When we have single occasion snapshot design, we can say that things are related. But we can’t draw any kind of causal conclusions about what leads to what in these variables. When I have sex because I want to feel close to my partner versus when I have sex to avoid a fight with my partner, it might be related to more or less sexual satisfaction. That’s what you could say in a snapshot. But when you follow couples longer term, and take multiple assessments, we could say at time one, those people who said that they were having sex to feel closer to their partner, six months later, that lead to them feeling more satisfied.”

There’s more information here for people who want to participate in the current research.

“At the rate we’re going, we should have a full sample of 100 towards the end of the summer,” Rosen said.

“But we’re hoping to start looking at some of the preliminary data when we get about halfway through at 50 couples, because then we’ll use that data for the larger grant application.”

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