Case Study

Sexual Attraction

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Jim, 32 years old, and Rebecca (not their real names), 31 years old, were referred to a psychiatrist because of lack of sexual desire on Jim's part. They had been married for 5 years and did not have children. Actually, Rebecca initiated the referral through their family doctor. In tears, she told the doctor of her longing to have children and hearing the ticking of the biological clock. In the course of asking detailed fertility-related questions, the doctor discovered that intercourse was taking place only about once in 2 months. No other couple-related sexual activity occurred in the interval.

In retrospect, Rebecca had always been more sexually interested than Jim prior to their marriage, and in the early days, sexual frequency seemed not to be a problem. In accord with the psychiatrists' usual pattern of practice to see partners separately as part of an assessment, and in an effort to understand Jim's point of view, he saw Jim alone. The psychiatrist discovered in the process that Jim was in fact just as disinterested in sexual matters as his wife described. He had few thoughts about sexual issues, denied having sexual fantasies or dreams, masturbated rarely, and had never had any sexual experiences with other women (or men). Although Jim understood his wife's distress, he also thought that her sexual interest was excessive. With reluctance, Jim accepted the idea of referral to another psychiatrist who had a special interest in the care of people with sexual problems.

The idea of including separate chapters on sexual desire problems in men and women in this book is unusual. The editors evidently considered that such problems in the two gender groups were not identical. However, apart from disorders, is sexual desire itself different for men and women?

In what appears to have been an effort to redress an attitudinal imbalance in much of human history in which men were perceived to be much more sexual than women, Masters and Johnson (1) attempted to make the two genders sexually symmetrical. However, in the early part of the 21st century, attitudes towards sexuality in men and women seem to have evolved (at least in some parts of the world) so as to permit the idea that they may be sexually different without at the same time implying that one is superior to the other. Apart from social attitudes and in spite of some similar determinants, science and the clinical experience of health professionals who care for people with sexual difficulties suggest that there may be major differences in sexual desire for men and women.

Levine (2) has written extensively on the subject of sexual desire generally and although recognizing differences between men and women, has focussed particularly on underpinnings that are common to both. He theorized three components to sexual desire: drive, motivation, and wish. Levine defined drive as "the biological component that has an anatomy and neurophysiology," motivation as the psychological component that is influenced by such issues as personal mental states, for example, joy or sorrow, and interpersonal states such as mutual affection or disagreement, and wish as the cultural component that "reflects values, meanings, and rules about sexual expression that are inculcated in childhood and may be reconsidered throughout life." He further commented that "wishes are mediated through motivation."

In the late 20th century and early 21st, one of the major themes occupying sexuality professionals has been the sexuality of women generally, and women's sexual desire in particular. This focus on women has resulted in, paradoxically, clarification of how men are different from women, particularly in the area of sexual desire.

For example, a study of couples found that lesbian pairs engaged in sexual activity considerably less often than those who were either heterosexual or gay men (3). Explanations might include the notion that sexual events in heterosexual couples often seem to occur on the initiative of men and that men are obviously omitted from consideration in a lesbian twosome. One might therefore reason that a lower level of sexual activity in lesbian couples suggests that sexual desire in women is, from a quantitative viewpoint, less than that in men. Nichols (4) also looked at lesbian couples and not only observed that they "exhibit stereotypical female sexual behavior" but also speculated about women being "wired" differently.

Tiefer (5) has persuasively argued that the sexual concerns of men and women are quite different and that women's sexual voices are largely absent from the classification system for sexual dysfunctions that is commonly used, namely, DSM-IV-TR (6). She incisively argues that there is nothing in the DSM system that is addressed to issues of, for example, emotion or communication, danger, commitment, attraction, sexual knowledge, respect, feelings about bodies, pregnancy, or contraception (p. 101). Moreover, she views the DSM system as "obsessively genitally focused," having a biological emphasis, and constructed in such a way as to reflect the sexuality of men (p. 97-102).

Examining the issue of women's sexual desire from a different perspective, Basson (7) comes to a similar conclusion. She suggests four aspects of women's sexuality that speak to the need for a model that is specific to women: first, women have a lower biological urge; second, context is often crucial in determining a women's motivation (or willingness) to engage in sexual activity; third, women's sexual arousal is represented psychologically and may or may not be accompanied by genital and/or nongenital changes; fourth, orgasm is not necessary to have a feeling of satisfaction, and even when it occurs, can manifest in a variety of forms. "Thus ... sexual arousal and... desire occur simultaneously at some point after... women have chosen to experience sexual stimulation; this choice is based initially on needs other than a desire to experience physical sexual arousal..."

Baumeister et al. (8) have extensively reviewed the literature comparing the strength of the "sex drive" of men and women. They report finding that men think about and fantasize about sexual matters more often than women; want to engage in sexual activity more often regardless of sexual orientation; want a greater number of sexual partners; masturbate more frequently; are less willing to forgo sexual activity; experience earlier onset of sexual desire; are drawn to a wider variety of sexual practices; and are prepared to make more material and pragmatic sacrifices in order to engage in sexual activity. They summarized their findings by saying: "we did not find a single study, on any of near a dozen different measures, that found women had a stronger sex drive than men." In reflecting on possible explanations for this difference, they considered the roles of biology as well as social, and cultural factors, and concluded that "the role of biology is moderated by social factors more for women than for men."

These studies and observations argue that there are substantial differences in sexual desire in men and women; sexual desire in men seems to be quantitatively greater; lesbian relationships represent an informative group in learning about sexual desire in both gender groups; the DSM classification system seems more relevant to men; and while sexual desire usually precedes arousal in men, the opposite may be true in women.

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