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. Author manuscript; available in PMC: 2023 Sep 1.
Published in final edited form as: J Women Aging. 2021 Sep 20;34(5):649–657. doi: 10.1080/08952841.2021.1977070

“How much desire should I have?”: A qualitative study of low libido in postmenopausal women

Holly Thomas 1,2, Megan Hamm 1, Tamar Krishnamurti 1,2, Rachel Hess 3, Sonya Borrero 1,2,4, Rebecca C Thurston 2,5
PMCID: PMC8934312  NIHMSID: NIHMS1740113  PMID: 34543166

Abstract

We conducted 15 interviews and 3 focus groups (total N=36) among women 60 and older with low libido to better understand the role that it plays in their lives. Interviews and focus groups were led by facilitators using open-ended questions. A codebook was developed, then codes were assigned to all data. We identified three themes. First, women reported that sex was an important aspect of their lives. Second, women desired to know what was “normal” with regards to sexuality and aging. Third, women were distressed by low libido, concerned that it could have negative effects on romantic relationships and self-image.

Keywords: postmenopause, sexual function, low libido, qualitative

Introduction

Despite popular assumptions, many older women are still sexually active. Fifty-nine percent of women over 60 who are romantically partnered are sexually active (Thomas, Hess, & Thurston, 2015). However, reports of low libido are common among women, and become more common as women age (Laumann, Paik, & Rosen, 1999; Shifren, Monz, Russo, Segreti, & Johannes, 2008). Among women 65 years and older, up to 75% will report low libido (Shifren et al., 2008). In quantitative studies, low libido has been associated with worse quality of life, lower relationship satisfaction, guilt, and shame (Biddle et al., 2009; Conde, Pinto-Neto, Santos-Sa, Costa-Paiva, & Martinez, 2006; Leiblum, Koochaki, Rodenberg, Barton, & Rosen, 2006; Ventegodt, 1998). Only about a third of women across all age groups who have distressing sexual problems actually seek treatment (Shifren et al., 2009). Some have proposed that women do not seek treatment because they view changes in sexual function as part of normal aging, or may just feel that it is not severe enough to seek out care (Gott & Hinchliff, 2003; Hinchliff & Gott, 2011; Moreira et al., 2005; Utian & Maamari, 2014). What resources women rely on when constructing their views of “normal” sexuality with aging is not well understood. Further, the ways in which low libido impacts the lives of women is likewise not well understood, particularly among older women.

Prior academics have reminded us that the experience of aging and menopause is a biocultural phenomenon; any symptoms or changes that women experience are filtered through culture, and this often means a culture of ageism and sexism (Beyene, 1986; Lock, 1995; Morganroth Gullette, 2011). Within the Western world, the dominant narrative regarding menopause and aging is one of decline (Beyene, 1986; Morganroth Gullette, 2011); that menopause is a state of estrogen deficiency, and therefore, negative symptoms are to be expected. How these cultural influences impact women’s experiences with changing libido during aging is not well understood.

Anthropologists have emphasized the power of qualitative and narrative research to better understand women’s experiences of menopause through a biocultural lens (Lock, 1995). Menopause is a biocultural phenomenon, meaning that women’s experiences of these changes are influenced by culture, and that culture can influence biology, which in turn can influence the experience of menopause as well (Beyene, 1986; Lock, 1995). It is well-documented that women from different ethnic backgrounds experience the symptoms of menopause differently, including sexuality, even if they are from the same geographic location (Avis et al., 2009). Survey research may fail to capture these nuances and variations in women’s personal experiences. In contrast, qualitative approaches allow women to speak at length, using their own words, to describe their experiences, thereby potentially revealing nuances or aspects of the phenomenon not captured by quantitative methods. In this qualitative study, we sought to understand the ways in which low libido affects the lives of older women.

Methods

We conducted 15 individual interviews and 3 focus groups (total N=36). Women were recruited from the general public of Pittsburgh, Pennsylvania, in the United States, using social media, flyers placed in senior centers and doctors’ offices, the University of Pittsburgh Clinical and Translational Research Institute research registry, and the University of Pittsburgh Claude D. Pepper Older Americans Independence Center research registry. Women were screened over the telephone; eligible women were aged 60 and older, reported participating in some type of sexual activity at least once in the prior year with a partner (male or female), and screened positive for bothersome low libido using the Decreased Sexual Desire Screener (Clayton et al., 2013; Clayton et al., 2009). Included women had to be English-speaking. Women were given the choice to participate in an individual interview or focus group. We used both approaches because some women may feel uncomfortable discussing sexuality in a group, while focus groups may foster connectivity and peer support that allows themes to emerge that would not in an individual interview. As is standard in qualitative research, sample size was estimated to ensure thematic saturation – meaning no new information or themes are uncovered in the course of ongoing interviews and focus groups – which was achieved in this study.

Interviews and focus groups were conducted face-to-face in private offices or small conference rooms located on the University campus. Sessions began by reading an informed consent script explaining the purpose of the study, risks to participating, and that participation was voluntary. This informed consent process was recommended and approved by the University of Pittsburgh Institutional Review Board.

Interviews and focus groups used a semi-structured guide. Women were asked about changes in their sex lives with aging, factors that contributed to these changes, and the importance of sex in their lives. Interviews and focus groups were led by one of two facilitators with extensive training and expertise in qualitative research (one with a PhD in anthropology, the other with a master’s degree in community and behavioral science; both with at least 3 years’ experience in facilitating interviews and focus groups). Interviews and focus groups lasted approximately 60–90 minutes and were audio recorded and transcribed verbatim. At the conclusion of the sessions, participants completed a brief pen-and-paper demographic questionnaire.

Consistent with accepted methods (MacQueen, McClellan-Lemal, Bartholow, & Milstein, 2008), the primary investigator and both facilitators met to discuss broad themes and develop an initial codebook. The primary investigator and one facilitator then iteratively refined the codebook using sets of 2 transcriptions at a time until a final codebook was agreed upon. These two then proceeded to code 5 interviews to ensure inter-coder reliability. The primary investigator then coded all data. Coding used a fine-grained, phenomenological approach. Codes were examined using a thematic analysis approach to draw out key themes.

Results

Demographic data are summarized in Table 1. Ninety-four percent of women were White, 83% were married or co-habitating, and 97% were heterosexual. We did not collect detailed information on participant’s ethnic or religious background. Similar themes emerged in both interviews and focus groups. We found that the impact of low libido on women’s lives was varied and complex. We identified several key themes. First, women reported that sex was an important aspect of their lives. Second, women wanted to know what was “normal” with regards to desire and aging. Third, many women were distressed by low libido, concerned about effects it may have on their romantic relationships and self-image. These themes, and representative quotations, are detailed below.

Table 1.

Demographic information regarding participants

Interviews, N(%) Focus group 1, N(%) Focus group 2, N(%) Focus group 3, N(%)
Total N 15 10 5 6
Mean age (range) 63 (60-68) 66 (62-71) 66 (61-71) 64 (61-67)
Race
 White 13 (87) 10 (100) 5 (100) 6 (100)
 Black 2 (13) 0 (0) 0 (0) 0 (0)
Relationship status
 Married 10 (67) 8 (80) 4 (80) 5 (100)*
 Co-habitating / civil partnership 2 (13) 1 (10) 0 (0) 0 (0)
 Divorced 2 (13) 1 (10) 0 (0) 0 (0)
 Never married 2 (13) 0 (0) 0 (0) 0 (0)
 Widowed 0 (0) 0 (0) 1 (20) 0 (0)
Sexual orientation
 Heterosexual 15 (100) 10 (100) 4 (80) 6 (100)
 Bisexual 0 (0) 0 (0) 1 (20) 0 (0)
 Homosexual 0 (0) 0 (0) 0 (0) 0 (0)
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*

One woman in focus group 3 marked more than one response regarding relationship status

Sex is important

Women in this study reported that sex was an important aspect of their lives. One woman said, “[Sex] is important, and I hope it always will be… If I decided to kick my guy to the curb, there will be another guy.” Another woman explained, “At this stage of my life, [sex] is pretty important… My mother is 83… and she has not been sexually active for a pretty long time… and it’s hard to imagine me in that same boat… almost no matter what age you are, I think it’s important.” Women in this study expressed a desire to push back against a society that they feel pressures them to de-prioritize sex. One woman said, “It’s OK for older people to have sexual desires and have sexual fun. Because I don’t think that’s been stressed enough… I do think that if we can change society’s perception of sex and older people, I think it’ll benefit everybody, because everybody’s going to get old at some point, if they’re lucky enough [laughter]. So hopefully the next generation will learn from us.”

Even women who reported sex was not as important to them as it had been in the past felt it ought to be more important. Said one woman, “You have other demands and other things going on… [sex] drops down in your priority list. Really shouldn’t, but it does.” These women had feelings of regret or guilt if sex was less important to them than in the past.

What is “normal”?

Women expressed a desire to understand what was “normal” with regards to sex and aging. Multiple women asked other women in their focus group or the interviewer if decreasing desire was part of normal aging. Women reported that there was not enough high-quality information to help them understand what to expect with regards to sex as they get older. They expressed that sex and aging are not discussed enough among women, between doctors and their female patients, or in society in general. One woman in focus group 3 said:

So, how much desire should I have?… How pain-free should you be?… What’s healthy aging? What’s unhealthy? And we actually don’t know, because we haven’t been there yet. And there’s not… a book about aging in general and about sexual function and aging. There’s probably not enough discussion about that period, necessarily.

They expressed that having more open discussions about these issues would be beneficial. In fact, women in the focus groups saw it as an excellent opportunity to share experiences with one another.

Women were interested in knowing whether decreasing desire was “normal” because it would help them decide whether to pursue treatment. If libido loss is part of normal aging, they would be more able to accept it, but if it is not, they would be more willing to seek out treatments.

We’re in this weird area where we don’t really know that much about it… maybe it’s like, okay, this is life. Picasso had sex until he was 95, but guess what? After menopause, women don’t. So don’t beat yourself up; just accept this. And I just don’t know enough about it, to know if this is normal or abnormal, and.. I don’t really talk about it with anybody… I don’t know whether I should be getting the testosterone and talking to a sex therapist… is there something I should be doing to have a better sex life, or is this how life is? And that’s okay too; as I said, it’s not ruining my life. I just…it’s a very grey and unknown territory for me… But if there are things that can be done, I’d love to know.

Low libido is distressing

Most of the women were distressed by their low libido. They worried that a decrease in sexual activity could have negative effects on their romantic relationships or their self-image. Women discussed how sexual activity was a key aspect of romantic relationships – that it is an important part of maintaining emotional closeness and intimacy, particularly in a long-term relationship. Women in one focus group had this discussion:

A: [Sex is] like the ultimate connection. Because you let yourself experience this other person, and you just feel the ultimate closeness.

B: Yeah. It brings you together.

C: I think there’s an emotional connection that you don’t want to miss.

D: It just makes things easier, I think. You know, if there’s a period where we haven’t had sex, you can start to feel isolated, that we’re not in sync as much. And then if we have a sexual encounter, it just seems like the air is clearer, and that closeness comes back, and life becomes easier.

C: Smooth.

D: Yeah. Like you’re not as isolated; you all of a sudden are talking a little bit more; there’s more interest in each other, what you’re doing. And I don’t know, it’s just easier.

E: It’s almost like it greases the relationship, so things go a little smoother after sex.

They also discussed how without sexual activity, partners could become irritable, or she may feel guilty for not meeting his needs. One woman described it this way: “I feel I’m disappointing him if I am not pleasing him. And our relationship is so wonderful, I don’t want to displease him or make him unhappy… there will be tension that we’re not [having sex]. He is the type of person who, he’s very loving, but he needs reassurance…” Some women discussed participating in sex, even if it was not satisfying or outright painful, in order to meet their partner’s needs.

When addressing the topic of self-image, women worried that decreasing or stopping sexual activity would make them feel less attractive, less feminine, or old. One woman said, “I would say [sex is] important just because that’s one of the things that makes you feel like a woman. You feel like you are desired by men or whoever your partner is.” Another woman described it this way:

I mean, it’s sort of sad. Like, you get older, and you really don’t turn heads anymore. I don’t care if I turn heads anymore, but I still—we have a group of girls who are all real close. And so…I don’t want them to view me as not sexual, or as like, old… I still want to feel somewhat youthful. I don’t want to feel like I’m old. You know, I mean, I’m still curious, and working, and healthy, and so I want to be viewed like that.

In contrast, there were a few women who were not distressed by decreases in libido, or felt ambivalent about it. One woman said, “I wanted to address my diminished libido and increased pain during intercourse, but it’s not… how I define myself… I would prefer a better sex life, let’s put it that way, but it isn’t something that gives me great psychological pain, or even minor psychological pain. It’s like, ‘Gee, I wish this were better’ kind of a thing more than a ‘this is terrible.’”

A few women even saw decreasing libido with aging as a positive change; it was freeing to devote less “mental energy” to sex or noted that their libido was now closer to their partner’s. One woman explained,

When I married my husband, he didn’t like to have sex as often as I did. And it was an adjustment for me, for a while, to get used to that… Now that my libido has gone down some, we match really well… I feel like when you’re young, your attention is on sex a lot. And it’s kind of freeing a little bit to have your attention not on sex so much. I mean, I still like having sex as part of my life, but it’s kind of freeing to have your focus in different places.”

Discussion

In this qualitative study of sexually active women aged 60 and older with low libido, we found that women’s responses to low libido were complex and varied. We identified three major themes: first, women reported that sex was an important aspect of their lives; second, women wanted to know what was “normal” with regards to desire and aging; third, many women were distressed by low libido, concerned about effects it may have on their romantic relationships and self-image.

Women in our study reported a strong desire to understand what was “normal” with regards to sex and aging. They expressed that there is not enough high-quality information available to help them know what was normal. Prior literature also suggests that women are interested in whether their sexuality is “normal” or “abnormal” (Hinchliff, Gott, & Wylie, 2009; Maserejian et al., 2010). Women in our study felt that knowing whether the changes they experienced were “normal” would help them decide whether to “accept” or “fight” changes in libido. Perception of sexual changes as “normal aging” is a top reason for not seeking treatment (Gott & Hinchliff, 2003; Hinchliff & Gott, 2011; Maserejian et al., 2010; Moreira et al., 2005; Utian & Maamari, 2014), and women in other studies have struggled with this decision about whether to take action or simply accept declines in libido with aging (Hinchliff et al., 2009; Utian & Maamari, 2014).

A desire to know whether changes are normal is common and understandable; labels such as “sexual dysfunction” can help a person contextualize and understand changes that they are experiencing, and may help de-stigmatize changes and empower women to seek treatment. However, labels can also be used to “medicalize” and pathologize common life experiences. As explained by Richard Grinker, the value in medical labels lies in “what is has to offer the sufferer,” and the “border between health and sickness is the judgement call we make about whether a person’s symptoms are impairing their lives and warrant treatment.” (Grinker, 2021)

Unfortunately, women may get their ideas of “normal” desire from inaccurate sources (Hinchliff et al., 2009; Nicholson & Burr, 2003). Collins reminds us that our ideas about what is “normal” sexually are “carefully manufactured and promoted by schools, organized religion, the news media, and government policies” (Hill Collins, 2000). Therefore, what we perceive to be normal may be based on misinformation. Additionally, an undue focus on what is normal versus abnormal, especially with regards to sexuality and aging, may hinder us by situating sexuality within a false binary (Hill Collins, 2000; Morganroth Gullette, 2011). In reality, unwanted sexual symptoms exist on a spectrum of severity; some symptoms may be barely bothersome to some, or highly distressing to others. Additionally, experiences regarding sexuality and aging vary widely; when it comes to sexuality, variation is the norm (Hinchliff, Gott, & Ingleton, 2010). These experiences may be influenced by a range of interweaving biological, sociocultural, interpersonal, and psychological factors. For example, more positive attitudes about aging and menopause have been associated with improved experiences of sexuality and aging in women. (Avis et al., 2009; Lock, 1995).

In contrast to a “normal versus abnormal” mindset, women could be encouraged to assess whether and to what degree changes in libido are impacting their overall quality of life through resisting outside forces telling them what they ought to do or be, and instead listen to their inner voice (Lorde, 1984; Morganroth Gullette, 2011). What is normal for you sexually? What do you want sexually? This may be particularly challenging for women, because often societal norms discourage women from understanding their own sexual desires, and instead encourage women to do what is expected of them by society and by partners (Gavey & McPhillips, 1999; Hinchliff & Gott, 2008; Hinchliff et al., 2009; Nicholson & Burr, 2003; Nicolson, 1993). Women are often taught to suppress inner desires, to “fear the yes within ourselves, our deepest cravings” (Lorde, 1984).

We noted that reasons for distress often relate to concerns women have about romantic relationships and how they are viewed by society. Women worried that, if they decrease or stop having sex, they will lose emotional intimacy with their partner or fail to meet the partner’s sexual needs. These feelings were echoed in prior studies of women with low libido: a top reason for sexual distress is concern about not meeting a male partner’s needs (Gavey & McPhillips, 1999; Hinchliff et al., 2009; Nicolson, 1993). It should be noted that these concerns focus more on the needs of the romantic partners than the women themselves. In our culture, male sexuality is often seen as the most important aspect of a sexual encounter, with men as the sexual subject and women as the sexual object (De Beauvoir, 1949; Lorde, 1984; Morganroth Gullette, 2011). Within this study, likewise the distress that many women felt over low libido was more centered around the effect it might have on their male partner and their relationship with him than on themselves. But authors have argued that, to optimize women’s sexual satisfaction and well-being, women must become sexual subjects instead of merely sexual objects (Morganroth Gullette, 2011; Potts, 2002).

Women in our study also expressed concern that decreasing sex will make them feel less attractive, less feminine, less healthy, or less young. Within the culture of the United States, youth is highly valued, especially with regards to women, and especially with regards to women’s sexuality (Morganroth Gullette, 2011). The dominant narrative is that young women have higher sexual well-being compared to older women, despite the fact that research does not bear this out. In other cultures, where women may gain certain advantages after menopause and the importance of youth is not as highly emphasized, symptoms can differ significantly (Lock, 1995). Other studies done within the United States have noted this linking of sexual activity to femininity and youth. Low desire is associated with feelings of androgyny and decreased femininity, particularly in post-menopausal women (Hinchliff et al., 2009; Leiblum et al., 2006; Maserejian et al., 2010; Utian & Maamari, 2014). Women in our study and prior studies held a belief that sexual activity can make you feel, or even actually keep you, younger and healthier (Hinchliff et al., 2009; Katz & Marshall, 2003). While it is important to validate concerns about decreased feelings of femininity or youth, we should recognize that these concerns are rooted in traditional ideas about gender and aging (Hinchliff et al., 2009; Morganroth Gullette, 2011; Nicholson & Burr, 2003; Nicolson, 1993).

We also found that there are women with low libido that feel ambivalent, are not particularly bothered, or even see it as positive. In other studies, distress about sexual changes varies widely from person to person (Goberna, Frances, Pauli, Barluenga, & Gascon, 2009; Hinchliff et al., 2010; Hinchliff et al., 2009; Winterich, 2003). Not all women who note changes with aging have sexual dysfunction, and an evaluation of sexual function always requires an assessment of distress.

This study has limitations. Women who volunteer for a study regarding sexuality may differ from those who do not; they may have less guilt or shame than women with low libido who do not volunteer for a study, and therefore the negative impacts of low libido may be under-emphasized in this study. Despite attempts to recruit a diverse sample, our sample was majority White, and most of the women were heterosexual. By design, all women were English speaking. We did not collect detailed information on participant’s ethnic or religious background. Future research on low libido with diverse groups of women is warranted.

This study also has strengths. There are few qualitative studies of sexuality among women 60 and older; thus, we are addressing a relatively under-studied topic and population. We used a stakeholder-vetted interview guide and highly trained facilitators. We used a validated screening tool to ensure only women with low libido were included.

Conclusions

Older women feel that sex is an important aspect of their lives. When decreases in libido occur, many feel distressed and seek to know what is “normal”, in order to decide whether to accept or fight these changes. Women are concerned that low libido will lead to decreased emotional intimacy with their romantic partners or that they will fail to meet their partners’ sexual needs. They are also concerned that low libido will make them feel less feminine, less healthy, or less young. We note that these concerns are focused more on the needs of romantic partners than the women themselves and are rooted in traditional ideas about gender and aging. Researchers, anthropologists, and healthcare providers that work with midlife and older women should recognize that women’s experiences with changes in sexuality and aging vary widely, and women experience varying levels of distress when changes occur. A focus on the degree to which symptoms impair function and quality of life, as opposed to a focus on whether changes are normal or abnormal, will better meet the needs of aging women. Recognition that women’s response to sexual changes in aging is colored by culture, especially Western culture’s emphasis on youth, femininity, and the dominance of male sexuality, allows us to have a more nuanced understanding of women’s sexuality with aging.

Acknowledgements

The authors thank the women who participated in this study. This work and its authors are supported by grants from the National Institute of Health (KL2TR001856), the National Institute on Aging (K23AG052628), and the National Heart Lung and Blood Institute (K24HL123565). The University of Pittsburgh Clinical and Translational Science Institute’s research registry is funded by the NIH (UL1TR001857). The University of Pittsburgh Claude D. Pepper Older Americans Independence Center is funded by the NIH’s National Institute on Aging (P30AG024827). The funding sources did not have a role in study design, data collection, analysis, interpretation, or writing.

Conflict of interest

H. T. received a research award from the North American Menopause Society funded by AMAG Pharmaceuticals. R. C. serves as a consultant for Astellas Pharma, Pfizer, and Procter & Gamble.

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