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Ruth Cohn
The Natural History of Sexuality:
Staying Abreast of the Changes

Over the last decade my special, and perhaps narrow focus has been the sexual problems and impasses of couples coping with histories of childhood trauma and neglect. The compelling complexity of these issues has kept my thinking plenty occupied. Many of these couples coming through my door have had little or even no sexual relationship for many years. In 2003 Michele Weiner Davis published The Sex Starved Marriage, a quick best seller. Increasingly the mainstream press has featured research, about large numbers of all sorts of couples whose sexual life is dramatically altered or diminished, even dormant or dead. In the last decade, the appearance on the cultural scene of erection enhancing drugs, swept the once hidden magnitude of male sexual performance problems out into the light. Before that, nobody realized that so many other people were struggling one way or another with sex. The baby boomer/free love generation is advancing in age. (That includes many of us!)  While our world keeps us bombarded with constant sexual stimulation, a sad reality of the Bush era of “Abstinence Only Sex Education,” is minimal sexual information. Reasons abound why long term partners, or single people (dating or not,) may be experiencing changes in their sexuality; or why many couples’ intimate life may be dropping off. I am realizing that it behooves us as clinicians to be increasingly savvy about the range of possible factors contributing to this, so we can help to fill that information void, and effectively both educate and treat.

First Blush – The Phenylethelamine Effect

It is no surprise that the first stage of an intimate relationship is different. Anyone who has ever been newly in love remembers its highly energized, semi-psychotic euphoria state. Sleep may seem unnecessary, libido boundless, and sex spontaneous and frequent. Even my couples with trauma histories are generally able to look back on a time, early in the relationship, that was free of traumatic triggering and pain. There is a whole biology of this. Because we are evolutionarily designed to stay sexually interested in a partner long enough to procreate, in the early stages of a new coupling, a potent biochemical cocktail of elevated hormones and neurotransmitters and the peptide, Phenylethalamine (PEA), spikes in the bodies of both partners. This is true across sexual orientations even when procreation is not an issue. We are in effect chemically enhanced, intoxicated from the inside, for a while. It is this potent biochemistry that accounts for the extreme of feeling “I have finally found my sexual match.”

Because it is nature’s design to insure preservation of the species but not necessarily lasting relationship, after requisite time to procreate, endogenous chemistry returns to baseline. Then naturally lower libido individuals find themselves back at their usual desire levels, the action may slow down, sex may be less frequent or less hot, and uninformed couples will wonder “Where did it go?” Partners may wonder if they have “fallen out of love.” Now symptoms such as the sequelae of trauma and neglect, or more garden variety sexual anxieties may begin to appear. And now the calm and informative words of a knowledgeable therapist can be a source of comfort and normalization. A good resource for both therapists and clients on this issue is Hot Monogamy by Pat Love. Knowing that the potential for diminishing quality, quantity and ease of sexual activity is predictable and normal may not ease the loss, but may certainly help with the distress fear and doubt of attributing other sorts of meanings to it.


This brief article does not pretend to be a course in some major and complex fields of science. My intention is rather to raise awareness of important areas where our clients may need our help; and to cite at least a few reliable references for more detailed information. The world of hormones is vast and complex. The potency of these substances is humbling as anyone who has ever had PMS (for example,) or known someone who did, can attest. Most of us know that testosterone is responsible for libido in both men and women. In women, where estrogen is responsible for a sense of well-being, ease and lubrication, it has little directly to do with sexual desire. Times of the month or lifespan where estrogen levels fluctuate or drop, may affect different women in widely varying ways. Research show that some women experience heightened libido and some diminished libido around menstruation.

Pregnancy and birth present massive challenge to couples, and of course the sexual relationship is a part of that. Apart from post partum healing, fatigue; busyness; new roles and multiple relationships in the household, there are hormonal changes too.  One obvious symptom which can affect sexual response is post partum depression.  Less obvious, however, is the fact that breast feeding produces increased levels of prolactin which sustain lower estrogen production. The result of this can be dryness or thinning of the vaginal walls similar to that experienced in menopause. So where technically libido may not be diminished per se, sex may be uncomfortable and even if desired, more difficult for nursing women to accomplish.

Perimenopause, the long period of transition to menopause includes a significant reduction in testosterone production in women. By age 40 women on the average, secrete half as much testosterone as they did at age 20. For many  women this does not appreciably affect libido. About one third of women do experience diminished libido during perimenopause and about 40% do in completed menopause.

The difficulties caused by reduced estrogen are by now well known: vaginal dryness, loss of elasticity and thinning of the vaginal walls which can make some sexual activities uncomfortable at best. What is less known is that the vaginal surface is now more vulnerable to injury; and women who are not sexually active can develop scar tissue between surfaces that touch each other. It is important to know that although hormone replacement therapy is controvercial and research findings about it are ambiguous and confusing, some women who do not attend to the reduced estrogen levelsin some way may be at risk for developing dyspareunia (painful intercourse) or some form of sexual aversion.

Again, although estrogen does not directly affect desire levels, the reduced blood flow to the vagina can result in less engorgement of the tissues during arousal with a possible impact on stimulation and orgasm. And estrogen does contribute to muscle tone, so muscles contract less easily which may also affect pleasure levels. Finally, as estrogen levels decline, some women develop a type of “nerve apathy” which might make touch that is otherwise pleasant, irritating or painful.      

Men in midlife, similarly experience lower testosterone levels. Where some men are relieved to have a less relentless sexual urge and find that it makes both their lives and their partnerships easier and more comfortable; often too (and even within the same man) there is a significant identity adjustment. Having always known himself to be “high desire” it may be a mainstay in a man’s sense of manhood or self. Less frequent sexual desire may bring with it feelings and anxieties about aging and mortality.

Men getting older may find that they need more stimulation to get and stay aroused.  Where when they were younger little or no encouragement was needed, (or quite the opposite,) now a man might need visual or even tactile stimulation. This too may be an adjustment for both individual and couple. A man may be asking for more from his partner now, and a widened paradigm of sexual activies and/or modes of sustaining arousal. This may be a significant piece or relationship work. Again, information and compassion can both normalize and guide a process that could be alienating, toward one that is both intimate and successful.

Finally as men age, erections and orgasms may become less reliable. Preparing couples and helping them to work together with that normal fact of life, can minimize shame and fear, or the potential for an over-reliance on pharmaceuticals.

My intention with this information is not to be pessimistic or bleak! Many women and couples will sail through the sexual life cycle without missing a sexual beat. Rather, my intention is to advance awareness that will help partners understand changes in their own and each others’ bodies. With information and compassion, treatments and adaptations become much more possible and likely.

Summing Up

The sexuality field is attempting to move in a new direction. The sex crazed mass media emphasize performance, intercourse and orgasm at the expense of all else.  Rock hard erections, shrieking orgasms, instant lubrication and swinging from the chandeliers are our models. Of course everyone feels inadequate, and more so as we age. We can help our clients by shedding light on this, by emphasizing connection, intimacy, pleasure; and feeling good about oneself and one’s partner. This attitude, coupled with sound information, makes the natural course of sexual life less daunting and a lot more fun!


Love, Pat  Hot Monogamy
1995. Penguin books NY

Reichman, Judith  I’m Not in the Mood
1998 New York. William Morrow and Co. Inc.

Weiner Davis, Michele  The Sex Starved Marriage

The New Male Sexuality, Revised Edition
by Bernie Zilbergeld

Ruth Cohn, MFT is in private practice in Rockridge. AASECT Certified Sex Therapist, also certified in EMDR and Sensorimotor Psychotherapy. She specializes in relationship work with adults overcoming histories of childhood trauma and neglect, their intimate partners and families. She can be reached at cohnruth@aol.com or www.cominghometopassion.com.

© 2006