What's the Deal with Hypoactive Sexual Desire Disorder (HSDD)?

Emily: [00:00:00] Perry. You know, I'm not sure if people know this, but you and I, uh, we went to college together, and we were like, uh, like, we knew each other. We were acquaintances. We dated each other's roommates at various times.

Perry: [00:00:13] Yeah. Yeah. Correct. Yes.

Emily: [00:00:16] If you had told me at that time, like one day you and Francis Perry Wilson the third will do a podcast about sexual disorder. Like I would have told you you were crazy person. I did not have this on my bingo card.

Perry: [00:00:31] Oh, that's that's funny because I, you know, for the past 25 years have been thinking to myself, you know, someday Emily and I are going to sit down and talk about sexual dysfunction together. Um, so, you know, but that's whatever. Different strokes for different folks, no pun intended strokes. Uh, it's.

Emily: [00:00:48] It's totally right. So, um, I'm excited and somewhat apprehensive to discuss this complicated and nuanced topic.

Perry: [00:00:56] Do we need to say that although this isn't [00:01:00] an explicit podcast, it is going to acknowledge the existence of sex and sexual function. And if you're listening with your kids, be aware of that.

Emily: [00:01:08] Absolutely. This is probably not the episode for the car.

Perry: [00:01:12] Let's do it. Let's fall in love. Okay.

Emily: [00:01:16] I'm Emily Oster, I'm an economist and a data expert.

Perry: [00:01:19] And I'm Perry Wilson. I'm a medical doctor.

Emily: [00:01:22] It's Thursday, June 11th, 2026. And this is Wellness, Actually.

Perry: [00:01:27] Because you're getting a staggering amount of health and wellness information nowadays from every source imaginable. And some of it is awesome.

Emily: [00:01:35] And some of it is, well, actually bullshit. Fortunately, we're both people who know how to read studies, how to parse the data, and can tell you what's worth thinking about and what you can safely ignore.

Perry: [00:01:48] But before we dig in a note that this podcast is for educational purposes and should not be construed as medical advice. We don't know your unique situation, so talk to your doctor for personal health decisions.

Emily: [00:01:59] This [00:02:00] week we're asking, what's the deal with Hypoactive sexual desire disorder? Perry and I will give the official smash or pass, and then we'll get to your question of the week. I like the idea that we're going to smash or pass a disorder about sex. That's fine. Okay. We're good. But first, let's do the health news roundup after the break. Now for the health news of the week. Perry, there was an American Diabetes Association conference this week, and police removed people for handing out an editorial. This is not something that typically happens at our conferences. Can you please enlighten me?

Perry: [00:02:47] Yeah. Traditionally, at medical conferences, people only get escorted out for being just too drunk or hungover from the night before. So this is this is definitely outside the box. The American Diabetes Association Conference, [00:03:00] the largest diabetes conference in the world. What was happening was scheduled to speak was our friend, Doctor Jay Bhattacharya, the head of the NIH. Now, the backstory actually, is that he had canceled. I don't think the people who were handing out the editorial knew that. And he has he was going to send a deputy from the NIH. But the plan was Doctor Jay was going to speak. And so several members of the Ada were handing out a recent editorial which criticized NIH policies and the Trump administration in terms of their, you know, medical science. So this editorial was I mean, this wasn't just like some random editorial. This was an editorial in Diabetes Care, which is the flagship journal of the American Diabetes Association. And it criticized drastic cuts in funding opportunities from the NIH. This thing where they're doing multi-year grant forwarding, which is limiting the amounts of grants that can be funded at any given time. Decimation [00:04:00] of the NIH workforce, promotion of pseudoscience, conspiracy theories. And I think, maybe most importantly, the politicization of funding decisions, taking funding decisions out of the hands of scientific peer review. Now, these people who were escorted out by the police were not randos. One of them was Stephen Kahn. He's a professor of medicine at the University of Washington and the editor in chief of Diabetes Care, as well as a co-author of that editorial. So he's handing out his own work. He's the editor in chief of the most important diabetes journal in America. The Ada did come out with a statement saying, look, this isn't political, but people are not allowed to hand out materials like, you can't disseminate materials at our conference, which I like. Look somewhat askance at because people kind of are handing out materials all the time, like handing out an editorial. Just come on.

Emily: [00:04:56] Yeah. I mean, it feels to me like there's there's a letter of the law which perhaps [00:05:00] says you can't hand out materials. But my guess is that frequently people are handing out a variety of random materials, and there are no consequences for doing that. So it's sort of obviously a political, uh, obviously a political decision. Um, yeah. Not really sure what is accomplished. What is a, I was wondering what is accomplished by this. Surely there's more attention to this editorial now that this news has been covered than.

Perry: [00:05:26] Oh, sure.

Emily: [00:05:26] I mean, if you just let them give out this editorial to a bunch of people who probably already saw it.

Perry: [00:05:31] Yeah, yeah, yeah, exactly, exactly. It's always sort of like it's the Streisand effect where, you know, you draw attention to something. Now it can never be lost. But actually this was somewhat brilliant on the part of these editorialists. I think the conferences, particularly scientific conferences, need to think a little bit more carefully about who they're inviting, particularly if they don't want to engender any kind of backlash. You know, scientific conferences like to have famous people giving keynote [00:06:00] addresses and having leaders of scientific organizations like the NIH is, is a long and storied part of that. But in an era where the NIH has become somewhat hostile to the people in the room who are trying to get funding and get grants and advance science, the committees that are deciding on these speakers might want to think just reasonably about the not that they shouldn't have leaders of the NIH, but they should be prepared that there's going to be some tough questions and pushback from the audience.

Emily: [00:06:29] Yeah. And I mean, I think for me, it's that it's, I, I would definitely say you should be open to having Jay Bhattacharya come and talk to your conference. He's the head of the NIH. Whether you agree with that or not, that's his job. This is an important organization, but you have to understand, some people are not going to like that and be prepared for whatever is the consequence of that activity. And I guess here they prepared by having the police, which is perhaps not the take I would have, you know, used.

Perry: [00:06:54] Not the right move. All right, let's move on. There's a paper making the rounds. Now that [00:07:00] is stressing me out even more about my sleep than, um, than I was before. This is a paper appearing in nature which says that there is a U-shaped curve between the time you spend asleep and various important clinical outcomes. So, like, if you sleep too little, it's bad. If you sleep too much, it's bad. You want to be in that sweet spot of like 6 to 8 hours. Emily, this is keeping me up at night. What do you think?

Speaker 3: [00:07:27] I hate this literature.

Emily: [00:07:30] Okay, so first of all, I want to say sleep is super important. And if you want to know some science about sleep, you can listen to next week's episode where we discuss sleep. Yeah. However, this particular kind of finding, which is not new, like these guys have a different set of outcomes they're measuring. It's things about how well you're functioning, your organs are or are whatever. But there are many parts of this, uh, many pieces of, of literature that will show this U-shaped relationship and people take [00:08:00] from that like, okay, there's an optimal amount of sleep, which is in their case, like between 6.5 and 7.8 four hours or something like that. The problem is people who sleep a lot are generally sick. So if you if there's somebody who's sleeping for 11 hours a day, there's something else that's wrong for, for the most part, or.

Perry: [00:08:20] They're my, my teenager can 100% do this. But that's not who you're talking about.

Emily: [00:08:23] Right? But like, if you take an adult who is sleeping for 11 hours a day, on average, that person has something else going on. It could be mental health, it could be physical health, you know, so to say like, it's unhealthy. That's different from saying if you you a person who typically sleeps seven hours, if you decided to sleep 11 hours, would that be bad for you? That is not what this data says. You probably couldn't sleep 11 hours.

Perry: [00:08:50] Yeah.

Emily: [00:08:51] But the fact is, the people who sleep 11 hours or something else going on, and similarly, people who are sleeping 3 or 4 hours a night generally have a lot of other things that are going on [00:09:00] that's more likely to be shift workers. People are, you know, generally have fewer resources. There's like other things that are happening that make people sleep less. So it's like this complicated thing where the paper sort of wants you to think that this is causal and it wants people to think, you know, you have to get exactly this amount. And if you go outside of it, then you're going to die. But that's really not what the data says. It's much more that we're identifying different groups of people with other different, different things. Now, having said that, I think sleep is very important. So I think people should should prioritize sleep. But like my brother sent me this article and it was like, the headline is like, is like, you don't really need eight hours of sleep. And he was like, oh my God, I'm getting eight hours of sleep. Like, is that bad?

Perry: [00:09:43] Yeah. Get the, get the sleep. You got to give your body the opportunity to sleep the amount that your body wants to sleep, basically. Like that's, that's great for you actually.

Emily: [00:09:52] And for most healthy adults, if you give your body the opportunity to sleep, you will generally sleep something like seven to 7.5 [00:10:00] hours. That is what a typical adult will sleep given the opportunity in a, in a sleep lab. So anyway, if you're sleeping 11 hours a day, it's probably because something else is wrong. That's all. Yeah. Okay. I hate U-shaped things. I, it's like, I hate, I hate, I hate you shapes in research. It just drives me nuts. It's like one of my bugaboos.

Perry: [00:10:20] Okay. Duly noted.

Emily: [00:10:21] Uh. Duly noted. So don't bring me any.

Perry: [00:10:23] I'm bringing you exclusively U-shaped findings from now on. What about BMI and death? Okay, I won't do that right now.

Emily: [00:10:30] Okay. Um. All right, so let's talk about what's going on with HIV in South Africa. There is some very promising new data about, uh, prep shots and their effects on transmission. Uh, although in the US, we don't talk as much about HIV as as we once did in much of sub-Saharan Africa. This is still a tremendously important problem. Is about 8 million people who are HIV positive in South Africa. A lot of the new infections are in adolescent [00:11:00] girls. What is the good data here?

Perry: [00:11:04] Yeah. I mean, this was really encouraging news coming from from NPR. And it's about prep. So pre-exposure prophylaxis for HIV. So this these are medications you take when you don't have HIV, but you're in a high risk environment. And South Africa, as you point out, is very high risk. There are 8 million people living with HIV in South Africa, and there's about 1000 new infections per week almost entirely, unfortunately, in young and adolescent girls and women. And, you know, pre-exposure prophylaxis typically is an oral medication that you either take daily. Some can be less frequent than that. But what South Africa has started using is a every six month injection called Lancashire. And this essentially eliminates the risk of transmission of HIV. So for those six months, regardless [00:12:00] of what's happening to to people. And of course, you know, I should say that a lot of these adolescent women are in exploitative relationships. Um, like this is there's.

Emily: [00:12:12] A lot of transactional sex.

Perry: [00:12:13] Yeah. And this is bad independent of the transmission of HIV, but obviously transmission of HIV makes the situation even worse. And for the six months that you after the injection, you essentially like there's basically no transmission. Um, this as a public health intervention is just way easier, right? You have to get, you got to get Ahold of these, these people who are at risk, you know, twice a year as opposed to getting them drugs much more frequently than that. The big problem now is, is one of funding. Honestly, there's the.

Emily: [00:12:45] Drugs are very shots are very expensive because they're expensive.

Perry: [00:12:48] It's being funded right now by the Global Fund out of the UN, like the Global Fund to Fight Aids. And, you know, funding there is unfortunately limited, but there are a large number [00:13:00] of philanthropies that do have an interest in this area. So to the extent that we can draw attention to this like relatively successful program and scale it up, I think would be ideal. And of course, if people if people feel like donating, you can donate to the Global Fund to fight Aids directly, if that's a choice.

Emily: [00:13:15] Yet another reason why it was very unfortunate that they cut all the funding for PEPFAR, which has been one of our most successful global health interventions over the past 20 years.

Perry: [00:13:25] It is indeed.

Emily: [00:13:26] On that note, that's it for the health news of the week. And after the break, we'll ask, what's the deal with Hypoactive sexual desire disorder?

Perry: [00:13:40] All right, we are back. We're asking, what's the deal with Hypoactive sexual desire disorder. Okay, Emily, this is one of the topics. Maybe not hsdd per se, but like sexual activity. Sexual function in my age group, in my cohort, presumably [00:14:00] in your cohort as well, is something a lot of people sort of allude to without really digging down on. There's a lot of like, there's a lot of sly comments, like sort of the boomer humor stuff that I hear about, you know, like, ah, you know, my wife's got a headache. Like that kind of thing. But no one ever really sits down and, and compares notes. I mean, I think fortunately, but, but that's sort of what we're here to do. Because if something is a disorder and it's out there, people might naturally wonder, like, do I have it? What do I have it? And, um, I think maybe the place to start before we talk about like a disorder of sexual function is what is normal here. Like when we think about this, especially, you know, for people our age, you know, 40 kids, that kind of thing. Um, you actually have some really interesting data on this.

Emily: [00:14:53] Yeah. So I want to start by, by, I once did a really great podcast with Emily Nagoski, who [00:15:00] is a writer who writes about sex. And I asked the question, you know, what's a normal amount of sex? And she was like, that is the worst possible question. And I came to think that she was right because of course, like, there is no there's average, I can tell you in the data what is the average. But the word normal has this connotation about what is appropriate or what you should do. And I think that's actually not not very helpful in a place where people are going to vary in like what makes them happy. So I'm going to tell you the average, but I'm not going to tell you what's normal.

Perry: [00:15:36] I think that is very well said. It doesn't imply that if you're less than the average or more than the average that you are, per se. Abnormal or pathological. But please.

Emily: [00:15:46] Okay. So, uh, so we, I got very interested in this question a couple of years ago because I talked to a lot of parents of young kids and it comes up all the time the question of, you know, are people having sex and how much are they having? And it's a [00:16:00] place where people just like to have data. So we did this big survey of parents and people were very. I do a lot of surveys actually on my website. And, uh, this was by far the most popular. I got 26000 people to report their sexual.

Perry: [00:16:18] It's pretty amazing.

Emily: [00:16:18] Data.

Perry: [00:16:19] It's pretty amazing. It's one of the largest studies of its type. Like as I was looking through the literature to.

Emily: [00:16:25] So, you know, the answer is that for parents at least, uh, sex varies quite a lot with the age of the youngest kid. So in the data for people with kids under a year, the modal frequency was one once to twice a month for people with kids over five years. The mode was more like 1 to 2 times a week. There's a reasonable share of people who say that they never have sex or less than once a year. It's not very high, but it's it's certainly, you know, for almost 10%, basically for people with very small [00:17:00] children. And there are a very small number of people, like less than 1%, even with older kids who say they have sex every day. So, you know, like, we're kind of if you ask, what's the average? It's something in the range of twice a week to once a month.

Perry: [00:17:18] I think one of the really interesting things that was in your data was this relationship with age of parents and age of kids. So what you found is that if you holding the age of kids steady, like statistically, the older the parents were, sort of the less frequently they would have sex, which kind of makes sense, right? You get older, like things happen. But then the older the kids are, the more often the parents would have sex. And of course, those are correlated because older parents tend to have older children and everything. So it's this really complex interplay between biology, which is as we get older, like the the hormones that drive our sex drive decrease and then like [00:18:00] logistics, which is like, as our kids get older, there's just more opportunity.

Emily: [00:18:06] Do you think that's true? I mean, this is a different topic, but I feel like there are some ways in which having older children presents less opportunity.

Perry: [00:18:15] Okay. I mean.

Emily: [00:18:16] I mean, because then they could catch like it. Well, anyway. Okay.

Perry: [00:18:20] Oh, no. I think this is a critical thing to discuss. Um, and if any of my children are listening to this, uh, please turn it off.

Emily: [00:18:29] Turn it off.

Perry: [00:18:30] Go to bed right now. Go to bed. It's bedtime.

Emily: [00:18:32] Go to bed. Sleep is.

Perry: [00:18:33] Important. Stay in your room.

Emily: [00:18:36] So one of the things I thought was was interesting, which maybe sort of leads into the question of how we sort of pathologize this is actually a pretty large share of people said that they were not having enough sex.

Perry: [00:18:50] This was so.

Emily: [00:18:51] Fast, not as much as they would want to.

Perry: [00:18:54] Right.

Emily: [00:18:55] And so even the people who are having sex 1 to 2 times a week, about [00:19:00] 40% of them said they were having somewhat too little or way too little sex. As you get to people who are having sex a few times a year, almost 100% of them say, that's not enough. And this for me was actually a much more telling piece of the of the data than the frequency. Because I think if you say, you know, we're having sex twice a year and that works for us. Like that's, that feels like enough, then it's great. It, it is more concerning when you have almost everyone saying, well, actually, I'd love to have more, but something else is happening that's getting in the way.

Perry: [00:19:32] Yeah.

Emily: [00:19:33] I and obviously are more likely to say they I don't. They're not having. Men would like to have more sex than women.

Perry: [00:19:40] Oh, yeah. When you stratified when you stratified by sex. But but many women in your survey. In fact the majority are also saying yes, I'd like to have more. So, you know, in theory, you've got these couples, right. Both members of the couple are like, you know, I really wish we would have more sex. And yet we don't.

Emily: [00:19:57] Yeah. And I mean, it was it's interesting. [00:20:00] Okay, I'll just say one more thing about this, which is that people left a lot of comments, like thousands and thousands of people left comments. And some of this is just I'll just read this because I think it summarizes a little bit of how people often feel with little kids. It's not that the sex is bad or that I don't love my spouse as much, it's just that we're both so tired all the time that the sex is very bland and feels like something we do quickly, just for basic maintenance while the kids are temporarily asleep. The best analogy I can think of is forcing yourself to eat because you know you should, even though you're not actually very hungry.

Perry: [00:20:33] Okay, that's a little bleak.

Emily: [00:20:35] It's bleak, but I think we should come back to it later, because actually there is some stuff in the data suggesting that that actually may not be a terrible approach to to sex. Right. In some cases. So, uh, that's probably a good place to move into what we actually mean when we say hypoactive sexual desire disorder.

Perry: [00:20:57] Right. So let me start by saying we [00:21:00] don't mean like everyone likes sometimes isn't in the mood, right? Like that's normal. That's natural. It's not, you know, you're not going to be there all the time. This is hypoactive sexual desire disorder is a clinical disorder. Um, and because it's a clinical disorder, it now appears in the DSM five. So the Diagnostic and Statistical Manual is the big book of psychological diagnoses. It's where you find like, oh, what do I, you know, what criteria do you need to fulfill to have major depressive disorder or bipolar disorder or schizophrenia or anything? And as of the fifth edition, which is the most recent. He was put in here, although in the DSM five they call it female sexual interest slash arousal disorder. This actually engendered some controversy, which I'll get to in a second. But just to say it, in order to be diagnosed with this, you need to have decreased or absent three of the following things interest in sexual activity, sexual erotic thoughts or [00:22:00] fantasies, initiation of sexual activity or unreceptive to partner's attempts to initiate sexual excitement or pleasure in almost all encounters. Sexual interest, arousal to erotic cues, genital or non-genital sensations during sexual activity. It needs to be going on at least five months. It needs to not be better explained by something else, like a medical condition or medications you're taking, or stress, or the million other things that obviously can cause all these things. And, and here's the kicker for all psychological disorders, it has to be causing you significant distress. You have to be upset about it.

Emily: [00:22:33] So the piece of this that I find a little hard in, in diagnosis is all of these things are kind of in the abstract, but most of the time we're thinking about sexual behavior in the context of a relationship. And so there's actually maybe an important distinction between like, am I interested in sexual activity or initiation from the person who I am has have available or am I interested at all? Right. Like, I think [00:23:00] there is an important distinction here, which is, would you like to have sex with someone or would you like to have sex with the person that you can have sex with? And those things may not be the same. And in principle, that seems like quite important distinction because a sexual interest arousal disorder is not a it's not a, it's not a marriage problem. It's not like there's a partnership problem. It's supposed to be a thing about your sexual function, not about the other person. But it feels almost impossible to separate those.

Perry: [00:23:28] Yeah. And as I said, there was some controversy about this, um, in two parts. Number one, the DSM five links sexual interest and sexual arousal in the same disorder, which is really not the same thing. One is a physiologic thing, you know, like arousal is a little clearer to document in a man because of penises and erections. And so men have an arousal disorder. Men can have impotence. And there's like a drug to many now drugs to treat that that's different [00:24:00] than interest. And it's the same with women. And so the DSM did get some criticism for that because those things are separable. There are women who are very interested in sex, but just physically don't become aroused in that way. Lumping these together doesn't seem necessarily appropriate. The other controversy is that you'll see some people arguing that Hypoactive sexual desire disorder basically was created to sell drugs by the pharmaceutical industry, and we'll get to what those drugs are, and they're FDA approved and whether or not they work. But this is kind of a new thing, and I think it's important to tease out, as you say, like whether this is truly something inside the woman with hypoactive sexual desire disorder, or if it is a result of external things, whether that's the relationship, whether that's the result of life stress, etc..

Emily: [00:24:51] Yeah. I mean, this feels to me like, you know, if you think about some of the symptoms we associate, say with perimenopause or menopause, like vaginal dryness, it's like a very specific reason [00:25:00] that you might not be like that. You might have trouble having sex or not find it as pleasurable because of this particular symptom. And that is something that deserves treatment and has various kinds of treatment, is totally different from interest, but is going to show up in some sense in the same way. Like if you are not, if you're not going to enjoy this, you're not going to to want to do it again. Those things are not the same. And so you almost want a diagnosis like, well, do you like watching porn? Like if you watch the like, how do you react to that? And that's separate from do you want to do it yourself or would you enjoy doing this?

Perry: [00:25:36] Yeah, absolutely. I mean, that's one of the criteria of, uh, in the DSM five is like a difficulty or decreased or absent arousal to erotic cues. So it is clear that like, you know, this is supposed to be something, right? Regardless of what you're watching, regardless of whether you're reading, you know, um, 50 shades of grey or, uh, you're with a partner that you love or you're with [00:26:00] the partner that you hate, like it's all the same, right?

Emily: [00:26:03] Yeah.

Perry: [00:26:04] Let's talk about distress, though.

Emily: [00:26:05] So can I ask another thing about the diagnosis also, which is are they looking for changes over time? So I think, you know, we can there's so much variation of in just general interest in sex. I think across, across the population, some people have a higher taste for sex than others. Just in general, I would have thought that we'd be looking here for things that are changes from your norm. Is that part of the diagnosis or not?

Perry: [00:26:32] No it's not. That's not in any of the criteria. It does have to be persistent for five months. But of course, if that has been your norm forever, that's your norm. And it has been persistent for more than five months. But again, it has to be causing distress. So they actually call out in the DSM five, they call out a sexual orientation. And as like, this is not hypoactive sexual desire disorder. So if you, you know, are asexual, if that's your sexual orientation [00:27:00] and it's not causing you distress and you've been that way, you know, you've been that way, then that's it. You don't have a disorder. That's just who you are. I think the this distress thing, though, is the one I keep getting hung up on. And by the way, this appears in every like DSM five. It's almost like for every diagnosis you can have psychologically, there's always like end. It is harming your everyday life or it's causing you distress or something. Same with like alcohol use disorder and everything. But when it comes to sex, There's other people involved often. And so, you know, I do wonder how you tease out like, this is causing me distress because, gosh, I wish I could get more interested. And it's just a fun, zesty part of life that I'm not engaging in. And I want that to change versus it's causing me distress because my partner is upset with me and like, how do you know the difference?

Emily: [00:27:54] Yeah, I mean, there's a thing in the DSM about, you know, this is not explained by relationship stress. [00:28:00] Yeah, but it seems awfully difficult in the context, particularly of, you know, long term marriage and so on, for this to not be wrapped up in, you know, disconnects between people and in relationship stress. I mean, this is a huge source of stress in many marriages. So I guess I worry with this diagnosis in general that we are pathologizing a set of issues which are really not at all about something physical and are just things we should be trying to address to make people happier. We've gotten to, well, we're going to give you some drug for it.

Perry: [00:28:37] Yeah, yeah, yeah. Well, that's much more profitable than just trying to make people happy.

Emily: [00:28:43] Yeah. So true.

Perry: [00:28:44] You know, you've alluded to the fact that there are baseline libido differences in people. And I think that's true and relatively well established that like there's some kind of libidinal set point that people have. And yes, it changes over time. And generally as you get older, [00:29:00] well, at least post puberty as you get older, that sort of wanes kind of difference between men and women. What that means, of course, is that in partnered relationships, there is the potential to have a discrepancy. And this is, again, where I kind of keep coming back to with HSD is like, is it the discrepancy that's causing the problem or not? And so I was looking into this a little bit into the data and there's actually like a really rich body of literature about like assessing libidinal discrepancies in, in married couples of all genders and sexual orientations. And it's fairly robust. So I'll, let me tell you, I'll go through one of these from the Archives of Sexual Behavior in 2014. And I'm curious what you think here. So this is a study that looked at over a thousand married couples. They assessed the desire like they asked each member of the couple how often they would like to have sex, how often they were having sex. And I wonder if any of these findings are surprising. So [00:30:00] 52% of females indicated the desired frequency was equal to the observed frequency. So they were like, this is we're at the right spot. 37% of males said that, um, 48% of husbands reported a higher desire reality score. So that's like they want more than what is happening than the wives did. 18% of wives reported higher than their husbands Greater discrepancies between this were associated with lower relationship satisfaction, greater conflict, lower positive communication, all with sort of modest effect sizes. So how do you take this literature? I mean, you know, this is both men and women actually saying that they could do more. But men again, men are men wanted more and more than women.

Speaker 4: [00:30:50] I mean, I don't find.

Emily: [00:30:51] Either of these sort of any of this thing in this space surprising. I think exactly what they mean is, again, a [00:31:00] little hard to tease out. So one issue that comes up all the time is the question of what direction is the causality. So is it that people have a discrepancy in their desire. And that's leading to relationship dissatisfaction, which is leading to more desirable discrepancies. Is it that they have relationship dissatisfaction that's leading to the discrepancy, you know? And then when we think about the amounts, the sort of desire for more, there's a glass half full glass half empty, which kind of comes back to some of this discussion of what happens with kids. Like a lot of what happens when people have children, I should say, which is that a, a lot of what people are saying when they talk about wanting to have more sex is almost like a, it's almost a positive frame. It's like, I wish I had more time for this. Yeah, yeah. As opposed to like, I wish I were involved with someone else that I was more interested in having sex with. It's sort of like, I want to do this. When we [00:32:00] do it, it's great. It's like just hard to find the time. But I'm like, but it's, it's a, it's a positive statement. And yeah, that feels different than, you know, I'm frustrated that my partner doesn't want to have sex with me as much as I want.

Perry: [00:32:13] Yeah, I like, I like thinking of it that way. And I think to some extent, even being able to communicate that between partners can be helpful, right? There's like, just like, hey, by the way, we're on the same page here. It's not always going to work. Uh, but, you know, it's still the desire is still there, right? Because there's, there's, you mentioned that, um, one of the comments that you got was someone talking about sex is just kind of like maintenance on a car, right? Just like something that, you know, you got to do periodically to kind of keep things together. And yeah, I said, that feels bleak. But, but the truth is some of the data and maybe you can walk us through this, like suggests before we get to drugs and stuff like that, that this is a strategy.

Emily: [00:32:58] Yeah. So I, before I talk [00:33:00] about the data, I want to read you this quote, which I love so much from someone. We're both so tired, but when we do it, we're always like, man, that's great. We should do that more. I know that made me very happy because I think that is, you know, for some set of people, this is is really about like, you know, we're just it's not a phase of life in which this is a thing we're doing as much as we would as much as we would like. Of course, there are many other people who will say, you know, I just don't want to do this anymore. It doesn't make me happy. So.

Perry: [00:33:30] And of course, there's other things that we don't have time to do that. Like, like I didn't get to go to the gym today. Like I wanted to go to the gym. I didn't have time. You know, I had there was too much other stuff going on. So this is not like exclusive to sex for people with kids.

Emily: [00:33:46] No, totally. People actually also say they want to talk to their spouse more. Yeah.

Perry: [00:33:50] Go on dates.

Emily: [00:33:51] Talk to them, or have sex with them, either one. Um, all right. So both at the same time.

Perry: [00:33:56] Gotta multitask.

Emily: [00:33:57] People multitask. All [00:34:00] right. So, uh, there are a bunch of strategies that people have tried to use to mitigate these, these issues, which have some, at least, I would say, survey based evidence that they, they work for some people. So, uh, so one is, is communication Talking about how you feel about things is almost always a good idea, and a very large share of people, more or less. 100% of couples, say that having some communication about differences in sexual desire is helpful. This is why therapy is is helpful. But another thing, perhaps almost as almost as helpful as communication, is an activity people call have sex anyway, which is actually a core part of some marital counseling advice when people are struggling with this, which is just to say, you know, just even though it's like eating your vegetables, [00:35:00] the starting of it may feel like eating your, your vegetables, like just put it on the schedule, say twice a week, we're going to have sex on these times and this is going to be on the schedule. And we're going to do it partly because for many people, you do it, you're like, oh, that was pretty fun. And there's a moment of connection. And then you kind of get are reminded that this is an enjoyable activity. Have sex anyway?

Perry: [00:35:21] Yeah. I mean, this is. You're quoting data. The numbers I'm looking at are pretty, pretty, pretty impressive. So you're quoting data from this study of 230 couples from the Archives of Sexual Behavior in 2020. And as you say, 0%. Not a single couple said communication was unhelpful. Like every single couple said, you should talk about this. That's the number one thing. But coming in hot at number two of the coping strategies, with only 5% of couples saying it's not helpful, was this have sex anyway?

Emily: [00:35:53] Anyway. Anyway, there are other things which, uh, which seem to work, you know, for some people. [00:36:00] So engagement in another activity with the partner. So doing something else to try to connect with your partner. Uh, about 88% of people said that that was helpful. Date night.

Perry: [00:36:10] Yeah.

Emily: [00:36:11] The other thing people say is, you know, to do it by yourself, which this study refers to as engagement and activity alone. Um, masturbate and and I will say 80% of couples here said that that was useful. And I think part of it is, you know, if really the issue is one person just wants more orgasms and the other person, it may be that the compromise is that they get to have some of them by themselves. But it is a thing that people found. No, almost no one found helpful was doing nothing. Disengagement. Nobody likes that. So don't do nothing.

Perry: [00:36:43] Don't do nothing. Um, and it is this can be obviously something that's difficult to talk about, you know, going back to communication in part. And it's not just because it's like, oh, it's a taboo subject and whatever, you know, most people after they've been married for a while have talked about a lot of things, but in part it's because that also [00:37:00] takes time, which we've already established. We don't have a lot of. And so it's like, and by the way, let's cut out some extra time to talk about our sex lives and stuff like that. It is also something else to that fills up the schedule, which I think can be, you know, it's easy to put off, I guess is, is maybe the way to say that.

Emily: [00:37:20] I also think you're understating how difficult people find it to discuss, find, to discuss this with a partner, you know, particularly if it wasn't something that you needed to discuss as much, you know, like in earlier parts of relationships when there was more time and, you know, people were but as we get older, people's bodies change. They want different things. Like maybe they're feeling like the idea of bringing up, you know, well, why aren't we doing this more like, is it because you aren't as excited about me? And, or is it like, I think people have this is hard. Talking about sex and talking about money are really hard even with people that you love.

Perry: [00:37:56] This is fair. And I think we're all afraid of opening a can of worms [00:38:00] too, right? Like, you know, what am I going to hear? And am I going to hear something I don't want to hear especially hard from people you love? So, Emily, let me put on my hat and say, like, talking is tough and takes time. How about you just pop a pill? How about that? You don't even have to do it. You don't even have to tell your partner.

Emily: [00:38:20] Sounds amazing. I mean, look, it worked for me, okay? I think part of the thing here is, you know, this is all coming out of, again, like, a very clear medical diagnosis, right? Erectile dysfunction is like a real thing. It's like a real physical thing. You need the penis to be away. It's not the way we came up with a system to make it the way that you need. Like that was like a solid. And they made a really just an absolute shit ton of money on that.

Perry: [00:38:49] Yeah, yeah. Banger drug. That's a banger drug.

Emily: [00:38:53] One of our best drugs. Probably one of our best drugs.

Perry: [00:38:56] You know, I think most people know this, but just to say that viagra was originally [00:39:00] developed for pulmonary hypertension, it's a vasodilator. And this was just a very pleasant side effect that the initial trials revealed as part of adverse event reporting. People were like, something's going on here. Um, so and, and Pfizer was like, uh, pivot. Pulmonary hypertension.

Emily: [00:39:21] You lungs, those are not important. Um, yeah.

Perry: [00:39:26] Yeah. So, um, so let's talk drugs. We have two FDA approved drugs for hypoactive sexual desire disorder, whatever that may be. One is Flibanserin or Addy. Addy. Addy. Um, which is taken.

Emily: [00:39:43] Why do they why do they name them these things?

Perry: [00:39:46] I, I don't know. Um, it's, it's a pill that is taken daily at bedtime. Um the mechanism. It's always like, it's really interesting, like we don't know enough about sex and arousal and desire and the complexities of [00:40:00] the human mind to actually know why a lot of these drugs work. So like this drug flibanserin is a partial serotonin agonist, which like, okay, serotonin is important, but like we have SSRIs, which, you know, have a well-described side effect of decreasing sexual interest. Like it's way too complicated to fully understand. One of the things I'm curious what you think Emily is in these trials, right? So if you're going to get a drug approved by the FDA, you have to say there's a disease that it treats. Okay. So all right, we've created Hypoactive sexual desire disorder, a disease that treats. And there's an outcome that we can show with statistical tests improves. And so these researchers and pharmaceutical companies had to come up with that outcome, something measurable that they could send back to the FDA and say, look, this thing increased. And the thing that they used in all the Flibanserin trials was an outcome called satisfying [00:41:00] sexual events. So a satisfying sexual event is a sexual event that could happen with or without a partner. It could happen with or without an orgasm, it could, uh, you know, anything that the woman taking the drug would define. But it had to be satisfying. And however she wanted to define that. And the pivotal trial for Flibanserin showed that the change in satisfying sexual events per month was 1.2 in the placebo group. So placebo effect once again rearing its beautiful head. One extra sexually satisfying event in the placebo group. Two extra sexually satisfying events in the Flibanserin group. Is that the correct outcome? Should this have been FDA approved?

Emily: [00:41:49] I mean, I don't it's very difficult to say what would be the right outcome. You know, you could say how many times, you know, there's a more direct thing, which is like, how many times did you engage [00:42:00] in a, in a sexual event either alone or with a partner? My guess is that they didn't. The issue with that is that the placebo effects are too strong, particularly if you start taking this drug and people are like. Okay, now I'm taking this. I'm going to have more sex with my partner. My guess is the placebo effect is too big and that you don't get anything right.

Perry: [00:42:18] It's like oysters, right? Which which have no aphrodisiac effect, actually. But like, if you think they do. Yeah.

Emily: [00:42:24] So I can see why they didn't go with just counts and they went with something else. But it's, it's sort of oddly defined. I mean, it's just an unfortunate aspect. Like, I guess you could go with something more sciency, which I would have been inclined towards if you really thought this worked, which was like, you know, put a, there are ways to like probe how much blood flow there is to the vagina. Right. And so you could say like, I'm going to put a probe in the vagina, I'm going to have people watch porn and I'm going to see like, whether this drug gets them more aroused in, in those settings. Like, I think that would have been an interesting alternative approach [00:43:00] to this. It's a little more sciency, a little less real world. You probably also get some placebo effects, but, uh, I suspect that you would get much more minimal effects. So this feels like.

Perry: [00:43:12] Yeah. I mean, these are effects. It's hard to it's hard to know. Like, is that is this I think.

Emily: [00:43:19] Is.

Perry: [00:43:19] This meaningful? Right.

Emily: [00:43:20] Like the meta analysis here is a half a sexual, a half a satisfying sexual event per month. So it's like, I don't know, like every day I got to take this pill every day and then like one half of one time every 30 days, like something good happens. I don't know.

Perry: [00:43:37] Yeah.

Emily: [00:43:37] It feels like, um.

Perry: [00:43:39] And I'll tell you, this pill is not entirely benign. Um, it can cause significant hypotension, low blood pressure and fainting. Um, and I think 40% or so of women in the pivotal trial, uh, complained of nausea, um, on this pill, which I don't know how that is compatible with having more sexually satisfying [00:44:00] events, but here we.

Emily: [00:44:00] Are, one half of the one day when you don't feel nauseous, you have, I don't know.

Perry: [00:44:04] It's like, okay, I'm not nauseous. Let's go.

Emily: [00:44:07] Is there anything else? I'm not this. I the ad campaign for this is. It's so pink. It's like the Pinkest ad campaign I've ever seen. The little pink pill that everyone's talking about. It's so pink.

Perry: [00:44:18] Yeah. They really leaned into this being female Viagra.

Emily: [00:44:20] It's not for. It's not for men. Female ladies. Ladies love pink.

Perry: [00:44:24] Let's say you don't want to take a drug every day. The other FDA approved medication is called Bremelanotide or Vyleesi. It is Emily, a peptide.

Emily: [00:44:34] Um our favorite.

Perry: [00:44:35] Yeah. So one of the few FDA approved stack. It's it's, it's, it's not.

Emily: [00:44:41] In the Wolverine stack.

Perry: [00:44:42] No, it would be the, if we're going to stick with the X-Men, it would be like the rogue or Jean grey stack, I guess maybe the Jubilee stack.

Emily: [00:44:49] The Jean grey stack. That's solid. I like it. Okay.

Perry: [00:44:52] Okay. Jean grey stack. So, um, this is a subcutaneous injection as needed. So the recommendation is take it 45 [00:45:00] minutes beforehand. So maybe a more viagra ish.

Emily: [00:45:04] Like more like viagra.

Perry: [00:45:05] It works by binding another brain receptor we don't fully understand, called the alpha melanocortin receptor. They appear to modulate sexual behavior in mice. It also seems to do something in humans. The trials in this case looked at a survey. Was their outcome called the Female sexual function index. And they used the desire score subscore of that index. So this is a survey asking like how much how's your sexual desire doing? And there was a significant increase in sexual desire, um, by 0.3 points or so. And there's also less distress, uh, by a similar amount. These are very modest effect sizes, but at least it's only it's at least it's taken as needed. I don't know.

Emily: [00:45:59] There's no difference [00:46:00] in sexually satisfying events. It makes 40% of people nauseous and it causes you to tan.

Perry: [00:46:06] It can make you a little tan. Yeah. That's right. It's a variant of, um, you guys might have seen in the, we talked about in the peptide episode, there's a peptide called Melanotan, which literally causes your melanocytes to make more melanin. And like you inject yourself and turn yourself tan. It's kind of crazy. And this is a related peptide. So you don't get quite as tan, but it is listed on the side effects. And, uh, and, you know, tan people have more, have.

Emily: [00:46:30] More sex for sure.

Perry: [00:46:31] 100%.

Emily: [00:46:31] Did you watch Baywatch or whatever? Um, look, my read of let's talk about before we can like overview this. Like, I think the, the third thing that is testosterone, which we talked about in the testosterone episode, which probably does work, uh, actually, right? Not FDA.

Perry: [00:46:48] Approved for this, but.

Emily: [00:46:49] But not FDA approved for this, but there are a bunch of trials that show kind of, I would say, comparable effects to the, uh, little pink, the little [00:47:00] pill, you know, about one increase, one more satisfying event per month.

Perry: [00:47:06] Yeah, testosterone clearly works. You can listen to the Hormone Replacement therapy episode to hear more about that. But those are the those are the drug options. Again, if you don't want to talk about it.

Emily: [00:47:16] Look, I think that you should talk about like, I find this space pretty hard to, to think about because it doesn't, it feels like I'm kind of with the people who were complaining that the DSM has, you know, created a disease for a drug because so much of what actually seems to be going on feels like it's just people are struggling through some things in their partnerships that they could do a better job communicating about and telling them, if you just take this pill, it will fix your relationship problems, is misleading and probably will leave them in a worse position. Having not [00:48:00] improved their marriage and having one half of one additional sexually satisfying event per month, possibly alone.

Perry: [00:48:06] Right? Yeah. All right, let's do it then. So, Emily, with that said, smash, this is the this is the this is the most appropriate smash or pass ever. Smash. Okay.

Emily: [00:48:19] What am I.

Perry: [00:48:19] Smashing.

Emily: [00:48:20] Or pass? You got to be like a little more specific here.

Perry: [00:48:22] Uh, like hypoactive sexual desire disorder as a, I don't know, as a as a treatable condition, smash or pass pass.

Emily: [00:48:32] I think this is something people should be talking more about with their partner. If they have one, they should be thinking about it. I am passing on medical treatment options for it, but what I am smashing. If you are listening to this and you are thinking this is really resonating, what I am smashing is Emily Nagoski book Come Together, which is a really, really good book talking about some of these issues in relationships. And I would really, really recommend to [00:49:00] people pass on the drugs.

Perry: [00:49:02] I am going to smash here. Um, I, I think that we've done men.

Emily: [00:49:09] Yeah. This is.

Perry: [00:49:10] A.

Emily: [00:49:10] Gender difference.

Perry: [00:49:12] I think we've done a bad job like exploring female sexuality, understanding female sexuality. And I am cautious about too quickly attributing to like attributing everything to the environment as opposed to acknowledging that there's the possibility that there are underlying biological things that, you know, could be addressed here. Like, I don't want to write that off. So I'm going to smash further research, but probably I would do testosterone before, um, some of these other agents.

Emily: [00:49:46] Amazing. All right. That's it for Hypoactive Sexual Desire Disorder. Your mailbag. Question of the week after the break.

Mailbag: [00:49:58] Hi, Emily and Perry. This [00:50:00] is Tamar, your producer. Um, my question is, even though we all know that sticking Q-tips in your ears is probably the greatest feeling in the world after a the topic of this episode, why shouldn't I do it even though I don't want to know the answer? Thanks.

Perry: [00:50:22] Does this creep you out, Emily? Like, is this one like when you, like, think about it. Yeah, I get a little bit of.

Emily: [00:50:27] Yeah, I don't, uh, I don't, I don't like it. Um, my impression was the bad thing is that it compacts all the wax all the way into your ear where it can be potentially problematic. And I will say, once one of my children had to have like some impacted wax removed from their ear, not because of Q-tips, but like, they'll stick like tweezers into the ear and like, pull. It's horrible. Yeah. Disgusting. Is that is that correct, doctor?

Perry: [00:50:57] Yeah. Yeah. No. So that's that's definitely part of it. Like earwax [00:51:00] naturally, like gets, uh, slowly comes out of the ear and like on its own. Um, but yes, if it gets compacted, it can get stuck in there and build up. There's also risk of damaging the eardrum itself if you push to, to, uh, far that's sensitive area. And lastly, the cotton on Q-tips and particularly on off brand Q-tips, but also on Q-tips can come off the tip and get stuck in there. And then you have cotton in your ear that someone needs to pull out. So there, you know, I know everyone kind of does this because it's satisfying, but you probably shouldn't do it.

Emily: [00:51:33] When I sometime during the pandemic, I started getting fed and I do not know whether this was Covid related or else elsewhere, Instagram started feeding me ads for like this product that was like, it was like it went in your ear and it had like a little camera. And then you could like watch what you were doing on your phone and like, and like, sort of clean out the earwax with like your like phone camera. Is that a good idea?

Perry: [00:52:00] Um, [00:52:00] that seems also dangerous, I think, like the, the middle ear, which you're coming up to when you get to the eardrum is a really important part that gives you hearing and.

Emily: [00:52:14] And balance and stuff.

Perry: [00:52:15] Yeah. Like, well, that's the inner ear is balanced. But, but yeah, like, just don't mess with it.

Emily: [00:52:20] I don't know, nothing larger than your elbow in your ear. Like my mom said, that seems right.

Perry: [00:52:25] Thanks. Emily's mom. All right, that's it for today. Stick with us next week when we'll ask, what's the deal with sleep?

Emily: [00:52:35] Well, this actually is produced in association with iHeartMedia. Our senior producer is Tamar Avishai. Our executive producer at iHeart is Jennifer Bassett. Our theme music is by Eric Deutsch, and our content is for educational purposes only.

Perry: [00:52:50] If you like the show, help other people find us. Leave a rating and review on Apple Podcasts or your podcatcher of choice and help us spread the word about the show. You can follow us on Instagram [00:53:00] at Wellness Pod. And don't forget, we want to hear from you. Head over to wellness.fm and leave us a question for our mailbag or suggest a topic for a future show.

Emily: [00:53:11] We'll let the influencers have the last word.

Influencer: [00:53:13] What the heck is female viagra? Why the heck have I never been offered this medication? Why have I never heard of this medication? What is it? Tell me all the things. Today we're gonna talk about Addy. Addy does not increase blood flow to the genitals like Viagra or Cialis of the world do. It works on your brain and it is less a sexual dysfunction performance drug and more of an increasing your libido and sexual desire. So you actually want to have sex drug.