WOMEN’S EXPERIENCE OF LACK OF SEXUAL DESIRE IN RELATIONSHIPS, AND IMPLICATIONS FOR INTERVENTION

INTRODUCTION Sexual desire disorders are both the most common and the most challenging of all the sexual problems confronting practitioners. International statistics suggests that between 33% and 67% of women indicate low sexual interest (Brezsnyak & Whisman, 2004; Davies, Katz & Jackson, 1999; Hicks, 2006; Pridal & LoPicollo, 2000). Little if any attention has been paid to the subject of low sexual desire in women in South Africa, and the paucity of local research in the field of sexual disorders (Robinson, 2005) means that there is a need for local perspectives on the issue and for the development of local expertise in the realm of sexual health (Craig, 2002; Smit, 1997).


RESEARCH DESIGN AND METHODS
The qualitative study with an interpretative phenomenological analysis (IPA) is aimed at achieving new insights into, and comprehension of, the phenomenon of low sexual desire in women (Babbie & Mouton, 2001;Creswell, 1994;Fouché, 2005). IPA is characterised as "an attempt to explore the participant's perspective" (Smith, Jarman & Osborn, 1999;Willig, 2001). The researcher therefore brackets the phenomenon to set aside presuppositions, and engages in critical self-monitoring to prevent bias (through the process of reflexivity) to arrive at an understanding of the lived experience of the participant (Shaw, 2001;Willig, 2001). This analysis reveals the idiosyncratic, subjective aspects of experience, i.e. those aspects that are unshared and unique to an individual. It also reflects the shared aspects of experience, i.e. those that are constructed by external forces within a culture and a subculture (the environment) (Shaw, 2001).
Qualitative research, on the other hand, makes meaning from the research data by conveying the raw empirical information into a "thick description", which is the rich, detailed description of a phenomenon that includes the researcher's interpretation (Henning, 2004:6). In the context of this study, detailed descriptions of women's subjective experiences of desire disorder, from the participant's perspective, were used to derive a more complete description of the general phenomenon.
Involvement of participants was voluntary and based on informed consent obtained at the start of each face-to-face interview. A semi-structured interview schedule was used for data collection, which was tape-recorded and later transcribed for analysis. The semi-structured interview allowed the introduction of unanticipated answers, which were then further probed using "funnelling" techniques (Grinnell, 1998:276).
IPA proposes a small sample size of up to about ten participants (Smith et al., 1999); therefore the number of participants was limited to ten. I made use of "purposive sampling", (Singleton et al., 1988:153, as cited in Strydom & Venter, 2005), selecting "typical" persons (Grinnell, 1988:278) who met the criteria of the phenomenon being researched for inclusion in the study. The sample therefore reflected women who typically present with low desire at practitioners' offices. The criteria for inclusion were being a woman between 35 and 55 in age, having low or no desire to engage in sexual activity with her partner, being in a relationship for more than two years and intending to continue the relationship.
• Perception of the impact of lack of desire on self and/or the relationship; • Relationship factors in sexual desire; • Experience of sexual desire within a specific sub-culture.

Theme one: Experience of sexual desire
The participants 1 described histories of strong desire towards their partners and frequent sex (Levin, 2002;Schwartz & Masters, 1988).
At twenty when we got married it was highly exciting, very vibrant, very busy … (Gwen). It was wild, warm, exciting. It was frequent… (Anna).
In the first year of the relationship my desire was very very strong, very physical. We did it all the time! … (Cathy).
However, they all reported a decline in their sexual desires towards their partners, which research studies point out to be "normal" and "inevitable" with relationship duration (Basson, Brotto, Laan, Redmond & Utian, 2005;Levine, 2002;Money, 1986 This decline occurred even though the participants mostly sustained positive and loving relationships with their partners, and it was evident that this did not culminate in sustained sexual desire contrary to other research findings (Bresznyak & Whisman, 2004).
An interesting and surprising finding of the study was that more than half of the participants had, or were still having, extra-marital affairs, within which they experienced passionate and lustful sexual urges, in stark contrast to their total lack of desire towards their husbands. Thus, their lack of desire was specifically towards their partners, and most of them found men other than their husbands desirable, as described by two of the participants: These women impressed as moralistic and upholding of ordinary middle-class values, but from the descriptions of their wild affairs and raucous sexual activities it was evident that their lustful feelings had little place for logical thinking and "moral sensibilities" (Levine, 2003:283). Moreover, the women revealed that when they have had, or still engage in, sexual relations with their partners, they would fantasise about other men. Most of the participants had a vivid fantasy life to which they also masturbated (see Friday (1973) for verification of women's erotic fantasies), for example:

I fantasised about other men whilst we had sex. Sometimes that was all that got me through the process [laughs] (Anna).
So, in short, whilst the women did not have any desire towards their own partners, they experienced desire towards other men.
A significant finding was the supportive evidence of the difference between innate desire and desire ignited after the sex act had commenced (responsive desire), as succinctly explained by Anna.
Arousal can follow, once you get into sexual activity, whether you are really into it or not; there may come a point where your body's physiological responses override emotional reluctance or resilience. Sexual arousal can sometimes occur spontaneously, and it can be triggered by an outside image, but it also does not necessarily translate into a desire to find a means to satisfy the response you have (Anna). Basson (2004) pointed out that, more often, women's desire is ignited after sexual stimulation in long-term relationships, and some of the participants noted that they had on occasion experienced responsive desire in this way. In essence though, the participants supported the notion of the lack of continued spontaneous desire in long-term relationships (Perel, 2007;Schnarch, 1991Schnarch, , 1997.

Some of the participants emphasised the emotional component of sexual desire.
Sexual desire is to be attracted to a person and an eagerness to be intimate, at times not necessarily sexually, but also "closeness" (Karla).
Most women agreed, in line with most research, that sexual desire is the product of both physical and psychological factors (Berman & Berman, 2001;Bertram, 2000;Carey, Koch, Barthalow, Mansfield & Thereau, 2005;Davies, Davidson, Donath & Bell, 2005;Levine, 1987;Northrup, 2004), but it was found that for women the emotional aspects of sexual desire are of more importance.

Theme two: Experience of sex life without sexual desire
It was established that only a minority of women turn down sexual advances, and most others, even when they declined sexual advances, would be pressurised by their partners into sex. So, many of the participants continue to engage in sexual relations with their partners without any desire to do so (in accordance with findings that 97% of women engage in sex without desire (Levin, 2002), as illustrated by these comments: Sometimes I succeed in saying to him, "Look here, I also have a say in this matter -NO! End of story, NO"! I just think, I also have a say in this matter. He will be okay about it, but he will not stop trying. He does not give up, he just does not stop! If I had said "No, not now", then he will just carry on until I give in. No heck!, He doesn't get put off! (Linda).
I tell him, "Leave me alone", but then it just gets too unpleasant. He just carries on and on, then I just do it, then he leaves me alone again [laughs]. He always initiates -I never do. I sleep with him even if it means nothing (Paula).
It was therefore evident that some women did not perceive it as a right to refuse sex and put their partners' wishes and needs for sex above their own need to decline sexual overtures (as according to the findings of Herbst, 2006;Lesch, 2000;Wood et al., 2006).
The participants described these unwanted sexual experiences as entailing varying degrees of offensiveness. Some of them coped with the unwanted sexual encounter by fantasising, some tried to keep it light and fun, and others hoped for the sex to be over quickly. As demonstrated by the quotations, some women experience the sexual encounters as merely boring, whilst others found them unpleasant and evoking anxiety. Some women find the sexual experience downright offensive and repulsive. From the descriptions it was evident that the women at most tolerated the experiences without deriving any pleasure. This finding is supportive of research indicating that 20% of women said sex gave them no pleasure (Levin, 2002).

It's horrible!
The question was raised as to why the participants would be compliant about engaging in sex, if sexual encounters were both undesirable and unpleasant. Their motivation concurred with research indicating that participating in sexual behaviour stems from a wide range of reasons, including for love, fun, power, commitment, to please the partner, feelings of guilt about sexual infrequency and many more (Beck, Bozman & Qualtrough, 1991;Levine, 2002, 3003;Tiefer, 2001;Weeks & Winters, 2002).
He is very good to me … and also he is very good to the children … he really provides very well for us -and that is why I do it (Linda).

… and he loves me dearly, and I am very lucky. I am. I know lots of women who would give anything to have what I have. I have a good husband -he shows me love and affection, and adores me so much … and I must show him I am grateful (Cathy).
I just feel bad for him. I feel that I owe him … because he loves me so much … and because of everything he does for me, gives me, and provides for me… It is not a mutual wanting, so maybe it is a "gift" …(Dora).

It is important to my husband -it is good for him. I know he feels good afterwards (Anna).
Aside from these quotations, participants indicated that they also gave in to sex so the partners would stop requesting sex for a while, or because they feel pity or guilt, to compensate for the partners' financial input into the marriage, and many of them "give sex" out of a sense of obligation. One woman actually felt that it made her feel like she was "prostituting under another name". Some women saw sex as the husband's "right" not to be "deprived" of sexual release, even though there are in fact no aversive consequences to sexual abstinence (Evaraerd & Laan, 1995). Only a small minority of women mentioned that they (very) sporadically engaged in sex for self-gain, (i.e. fulfilling the need for intimacy and affirmation, and to affirm their own sexuality). By far the strongest motivation to have sex was based on their partners' perceived needs (Beck et al., 1991;Leiblum & Rosen, 1988) and not their own.
From these reasons for being willing to engage in sexual activities it was therefore evident that there was an active conscious decision by the women to be sexual, or to be open to sex, for a multitude of reasons rather than experiencing sexual desire leading to sex. This finding is in accordance with Basson (2005), who pointed out that when women do not experience spontaneous desire, they might become "willing" to experience sex for the secondary gains of an emotionally satisfying outcome. Different to Basson, however, is the finding that the women in this study did not experience the secondary gains (such as increased intimacy and sexual gratification) that they were supposed to derive from the sexual experience, but on the contrary experienced it as distasteful. Importantly also, the notion that women, when willing or open to sexual advances, would react to sexual approaches by arousal and responsive sexual desire (Basson, 2005;Goldmeier, 2001;Hawton, 1985) did not hold true for these women, as they did not derive sexual pleasure and satisfaction. This last aspect speaks directly to diagnosis and classification of their problem, which emerged as one of lack of responsive desire (Goldmeier, 2001), i.e. not responding with desire and arousal whilst having sexual intercourse.
In summary, the women who continue with sexual relations for a variety of reasons (other than having a desire to do so) find the experience boring, unpleasant, or even repulsive. It was established from other research findings that it is unsurprising and predictable that women experience a decrease in spontaneous desire over time. Moreover, the findings speak to the complexities of correct diagnosis and limitations in the classification systems -it was found that as some women continue to desire and fantasise about sex (albeit not directed to their partner), contrary to the criteria in the DSM-1V-TR, this rules out the diagnosis of hypoactive sexual desire disorder. Furthermore, the findings indicate that the women experience features that may point to a diagnosis of a sexual aversion disorder, which includes recurrent avoidance of all/almost all sexual contact with a sexual partner. Of importance is the supporting finding that these women derived no pleasure from the sexual encounters, which specifically indicates a lack of responsive desire.

Theme three: The perceived impact on the relationship
As noted in other research, this study also found that men, more than women, are dissatisfied with low frequency of sex (Dunn, Croft & Hackett, 2000;Trudel, Landy & Larose, 1997). Some men reacted overtly, others covertly, with anger, or feelings of hurt and rejection, to the women's lack of sexual desire, as indicated as follows: …I can tell when Chris has not had sex with me for a while …he gets a bit irritated, short with me … and snappy with the kids and with me … (Cathy).
However, as most partnerships were solid and satisfying in other ways, and women mostly "allowed" sex to meet their partners' needs, the partners' continued sexual gratification tempered the potentially acrimonious situation, so that the "interpersonal difficulty" experienced by most of the respondents was marginal.
On the other hand, it was found that that even in the few celibate marriages there were limited negative effects on the marriage, and that both partners seem to have accepted the situation. This finding is contradictory to that of other research studies indicating that low sexual desire is associated with decreased levels of relationship satisfaction, both in the case of the partner with low sexual desire and for their partners (Davies et al., 1999;Fourie, 1984;Trudel, Boulos & Matte, as cited in Brezsnyak & Whisman, 2004).
Theme four: Relationship factors impacting on sexual desire Regan and Berscheid (1999:108) concluded that "it had become clear that the experience of sexual desire is intricately connected to the quality of the relationship between individuals and other interpersonal phenomena". They found that the bulk of the research evidence on sexuality emphasises that relationship issues play a crucial role in igniting and maintaining sexual desire (Basson, 2001;Brezsnyak & Whisman, 2004;Donnelly, 1993;Kaplan, 1997;Stuart, Hammond & Pett, 1987;Traen, Martinussen, Oberg & Kavli, 2007). This finding is most certainly supported by the present study, where the participants spent the majority of the time during the interviews discussing the relationship issues that impact on their sexual desire.
Physical attraction between lovers based on aspects such as physical attributes, intelligence, and social status play an important part in evoking desire (Regan & Berscheid, 1999). Tallis (2004:119-147) explained the well-known notion -confirmed in this study -of "love at first sight" and how the starting point of most relationships is based on both parties finding each other attractive.

I was very physical; I adored the man … he was just so very beautiful. We together discovered sex … and our bodies (Paula).
It was also established that some of the participants still find their partners very attractive, but do not experience sexual desire towards them. Only one factor, such as physical attraction, is clearly not decisive to maintain desire, as explained by Linda:

I find him physically attractive. I find him flippen sexy… And he looks after himself…he can wear a Speedo. Other men can't [laughs]…they should not! [laughs] but he can! No, he looks good; I do find him physically very attractive. But, I do not know why I find other men sexually attractive, and not Johan (Linda).
It was furthermore found that there is a complex and at times paradoxical correlation between physical attractiveness and sexual desire, as some women also find unattractive men sexually desirable (and were, for example, sexually attracted to unappealing and overweight men). From their descriptions it became clear that "attraction" might also include components such as status and intellect, once again pointing to the complexities in understanding the workings of sexual desire.
It was underscored in this study that sexual desire was a crucial component of romantic love (Lewis, 1960;Morin, 1995), but somehow this desire is not maintained in longer-term relationships (Levine, 2003;Schnarch, 1997), despite the expectation that it should.
The empirical study furthermore found that the partner's positive loving behaviour outside the bedroom greatly improves the possibility of women utilising this as a stimulus to enhance their sexual desire. Conversely, a wide range of negative behaviours (including insensitivity, dependency, lack of consideration, moodiness, alcohol abuse and emotional unavailability) leads to sexual withdrawal (Basson, 2001;Hawton, 1995;Hite, 1987;Stuart et al., 1987;Wood et al., 2007), for example: ... don't treat the woman like dirt in the morning and expect her to turn into a sex goddess in the evening -it certainly does not work that way for me … (Anna).
The more insecure he feels, the more he needs sex, becomes a bit … desperate … then you feel you don't want to give it even more … because it almost becomes like a … it is very unappealing … it's like a needy … sort of over-needy sort of a thing … it becomes almost like a leech … you know … feeding off you …(Cathy).
The findings of this study also concur with others indicating that emotional conflict with the marriage partner was cited as the most common cause of diminished desire (Regan & Berscheid, 1999). Triggers for conflict that were mentioned included power imbalances and lack of communication.
Other issues leading to discord were unsatisfactory synchronisation and coordination of the sexual rhythms in the relationship (Davies et al., 1999;Verhulst & Heiman, 1988) and inadequate communication and sexual negations about drive discrepancies (Clement, 2002 This research confirmed that the factor of relationship duration plays a part in the lessening of sexual desire, as was found in other research (Kaplan, 1995;Money, 1986;Perel, 2007). An aspect contributing to this phenomenon in lengthy relationships is that of familiarity (Levine, 2002). Some participants described their relationships with their partners as being "best friends" or loving the partner like a "brother", in which relationships eroticism has no part (Morin, 1995). We are very good friends. We are genuine friends. We enjoy the same things, read the same things, enjoy the same music … we can have a "jol" like absolute teenagers. We really do get along well. I am not ever sorry that I married him (Linda).
It is more the love like towards a brother, like a good friend … I respect Chris…I love Chris, but I don't desire him at all…(Cathy).
The close companionship described by many of the participants had the converse effect on their need for sexual intimacy as, paradoxically, close emotional intimacy might in fact not lead to good sex. Morin (1995) and Perel (2007) pointed out that emotional fusion deadens desire and stipulated that separateness, rather than intimacy, is a prerequisite for emotional connection. Even without the erotic aspect, most women felt happy and satisfied within their marriages. In contrast with other research findings (Donelly, 1993), however, it was evident that marital contentment did not result in maintaining sexual desire.
The complexity of sexual desire is illustrated by the finding that women were not available for sexual encounters unless they were "in an emotionally connected space" (i.e. feeling an emotional closeness and connectedness to their partners) for that. Then again, low sexual desire leads to lower levels of intimacy and satisfaction with the quality of intimacy in individuals' lives (Bresznyak & Whisman, 2004), but which factor comes first remains unclear. In support of other research (Basson, 2005;Leiblum & Rosen, 1988), the relevance and importance of emotional intimacy in the experience of sexual desire is stressed as a crucial factor.
Partners' lack of sexual skills resulted in an active avoidance of disappointing sexual encounters (Goldstein & Brandon, 2004;King, 1997). The participants' partners were described as sexually persistent, selfish and not attuned to the women's emotional and physical needs.

We used to kiss and hug each other … but now there is no foreplay and sexual … we just have sex and then it is finished! (Anna)
In summary, interpersonal factors most certainly have a marked influence on women's desire. These factors range over a wide spectrum from being emotionally too close, to emotional distance, and many variations in-between. It was found that in contrast with their male partner, whose desire is more readily accessed through a large variety of prompts, women's desire is more easily repressed if other conditions are not met, which supporting Levine's (2002) findings. Donnelly (1993:2) noted that in our society married people are "expected" to have sex, as the marital relationship is the only avenue for sexual fulfilment that is legally sanctioned. This societal expectation provided the backdrop for the findings of this study, as the participants were in committed relationships. Other contextual aspects are the effects of upbringing, religion and the particular typical middle-class norms and expectations as depicted in the popular media. Importantly, the particular society and culture the individual finds herself in defines what is normal or taboo (Regan & Berscheid, 1999) and which customs prevail around sexuality.

Theme five: The experience within the sub-cultural context of the relationship
This study supported research (Kaplan, 1979;Morin, 1995) that growing up in restrictive households, where negative messages about sex prevail, affects perceptions of sexuality. Some of the women grew up in households where sex was depicted as "sin", shameful and disgusting. The sexual double standard was internalised that for women sex must be rooted in love, while men may have sex for pleasure and fun (Regan & Berscheid, 1999).

I felt guilty all the time for sleeping with him -like a bad girl. I felt all the time like a naughty woman (Karla). …the rest of my body does not exist …It is the only parts that he cares about! (Linda).
It was furthermore evident that women subscribed to scripts prescribing the "right" way to have sex and "normal frequency" for sex, which created unrealistic expectations of their partners to intuitively know how to please them sexually (Hite, 1987;Rosen & Leiblum, 1988;Tiefer, 1995). Scripting focuses also on dimensions of inviting participation for sexual behaviour (Simon & Gagnon, 1986, in Rosen & Leiblum, 1988). There appears to be a mystical "correct" number of times per week to have sex at a certain age (as depicted in the media and popular literature) which Dora, Paula and Gwen referred to. Jana mentioned that her husband tried to find out "how many times" he could "expect" sex per week. She also indicated that she thought about three times per week is "normal" for someone her age, whilst Dora thought once a week was the norm. Karla related that "according to the norm, people in their 40s have sex between one and four times a month", basing this statistic on "general knowledge". Furthermore they internalised societal sex roles regarding sexual behaviour such as women learning to be passive in sex (Barbach, 2000) and men taking charge (Verhulst & Heiman, 1988).
It was evident that there are gender differences with regards to sexual stimulation, reasons to engage in sex, and the sex drive, which concurred with other findings (Bancroft, 1989;Leiblum, 2002;Levine, 2002). It was established that women often yearn for physical intimacy and affection without necessarily taking it to the level of sexual penetration, a finding which is in accordance with other research findings (King, 1997;Perel, 2007;Regan & Berscheid, 1999).
At times the need is more to be cuddled, but then it ends up as sexual. The need is to be cuddled ... and sex stems from there (Jana).
It was found that discussions about sex in social circles are prevalent (Perel, 2007) and often the topic of discussion and debate at parties. It was evident from these social discussions that other women held similar views that men have no understanding of women not needing or wanting sex. Furthermore, the majority of women found that their women friends have an equally low desire for sex, which supports the notion that the occurrence of diminished desire in longer-term relationships is a widespread occurrence (as found by Basson, 2002a;Davies et al., 1999;Evaraerd & Both, 2001;Goldmeier, 2001;Hicks, 2006;Leiblum & Rosen, 2000).

Us girls are all the same…it is just the flippen men do not leave you alone…you do not feel like it now, you do not have the strength for it now, but they just keep on and on and on … my girlfriends are all on the same wavelength. There is just no desire for it whatsoever. The girls say "this is the last thing on my priority list", and the men just cannot understand it!! (Linda).
The study therefore concurs with local research findings, supporting international trends, that lack of sexual desire is very common and that the majority of women don't want sex even though they love their husbands (Craig, 2002;McIntosh, 2005).
In summary, this study highlights the findings of other researchers (Basson, 2005;Rosen & Leiblum, 1988;Regan & Berscheid, 1999;Wood et al., 2006) with regards to the impact of scripts providing a "code" which directs sexual actions and anticipation of responses. The findings emphasise that the sub-culture and context that the women find themselves in has a profound effect on their sexuality. Amongst other things, it determines their perceptions of sex and gender roles, and creates expectations of sexual interaction.

Recapitulation of the findings and conclusions
The extent to which the findings of the study can be generalised could be considered as limited both because of the low number of participants, and because the respondents were a group of women who evidently presented with problems of low sexual desire in order to meet the criteria to be included in the research. However, Pidgeon and Henwood (1997:271) argue that if the researcher reports fully on the contextual features of the study, and provides rich and dense information sensitive to diverse levels of abstraction, this "will in itself suggest its own sphere of relevance and application". Similarly, Giles (2002) suggested that it is enough that the findings of a study resonate with readers, so that the readers are able to identify with the experience, and that the findings should be sufficiently sound and understandable to suggest practical application. The findings are therefore relevant for the group of respondents, but in the light of the link and support of both local and international literature, the findings are generalised and deemed applicable also to the broader population of women.
This study yielded insights into whether women experience marked distress or interpersonal difficulties as a result of their lack of sexual desire, and what impact this might have on their marriage or partnership. The conclusions were reached that early in the love relationship the experience of sexual desire is strong and spontaneous, but that sexual desire diminishes over time to the point of loss of desire. Furthermore, the lack of desire was specific towards the partner and excluded the experience of continued situational sexual desire towards men other than life partners. Emotional aspects play a bigger role for women than for men in the sexual interaction.
In addition, the data indicated that sex within marriage is experienced as unpleasant, but even so only a minority of women, as represented in the study, believe that it is their right to refuse unwanted sex. Most women feel disempowered to negotiate their right not to be sexual and therefore engage in sexual behaviour without desire to do so. Sex is experienced as derived from physical pleasure or emotional enjoyment, and tolerated with emotional resistance and at times severe aversion/repulsion. Various coping mechanisms are employed when engaging in sexual activities under duress. Furthermore, the data indicated that women, in negotiating the discrepant need for intercourse made a conscious decision to be willing to engage in sex, based on a plethora of reasons other than having sexual desire. Mostly women are motivated to engage in sex based on their partners' needs, not their own.
Notwithstanding the experience of some negative consequences, the impact of low sexual desire on the individual and the relationship (in these women's experience) was minimal, and the DSM-1V-TR diagnosis for sexual desire disorder (which includes the criteria of "marked distress" or "interpersonal difficulty") is therefore not applicable. It has to be stressed that the limited impact on the relationship has to be seen in the light of the continued sexual fulfilment of most partners due to continued sexual interaction, and that most relationships remain satisfying and intact on other levels. However, it needs to be pointed out that the conclusion that the individual does not suffer marked distress because of her lack of sexual desire does not detract from her (at times extreme) discomfort (i.e. marked distress) when having to make herself available for sexual activities when she does not desire sex herself. The continued sexual incidents are experienced as negative to the degree of repulsion, which is a feature of sexual aversion disorder. The aversion is person-specific, as strong desires may be experienced towards other men. This finding of the experience of repulsion by the majority of women was, however, unanticipated in the light of the otherwise positive relationships and poses a challenge for further research.
The data indicated that interpersonal relationship factors were major determinants in the experience of loss of sexual interest in women. Sexual desire diminishes in unsatisfying relationships, but curiously even in happy marriages this is the case. In short, it became clear that women are particularly sensitive to a wide range of aspects within the relationship and the partner, which lead to diminished desire. The data indicate that women's motivations for sexual gratification can best be described as "very fragile" (Basson, 2002b:18).
Lastly, it was concluded that societal scripts place pressure on individuals about the "right" way to have sex and "the right feelings" to have in response. These prescriptions make a major contribution towards the development of negative perceptions of sexuality, the creation of unrealistic expectations of sexual relationships and experiences, and idealistic expectations of sex role performance by partners. Gender roles are assigned and internalised, which contributes to less understanding between the sexes, and feelings of alienation and misunderstanding. It was concluded that social communication on the topic of sex is an attempt to compare behaviour to understand and normalise phenomena occurring in the relationship, counteracting confusing scripts. Ultimately, the findings clearly indicated that, in spite of assumptions and expectations that continued sexual intercourse is part and parcel of marriages or partnerships, low sexual desire in women is very common and that many women do not desire continued sexual intercourse.
In short, the "typical" client presenting with this problem at the clinician's office is happily married, wants to remain married (although she may sexually desire other men) and loves her husband but does not want to have sex with him. For various reasons she still allows sex and she employs a variety of coping mechanisms to endure the experience (including finding reasons and motivators for making herself available for sex). However, the experience is devoid of pleasure and merely tolerated with varying degrees of finding the experience offensive. So, the lack of desire does not necessarily impact on the relationship, but does cause the women some degree of distress because of the unpleasantness of the sexual experience.

Accurate diagnosis -hypoactive desire or aversion?
The DSM-1V-TR-diagnosis (APA, 2000) of low sexual desire is not applicable as the women in this study in general were not overly distressed about this state of affairs, nor did it impact hugely on their relationships. However, the continued sexual activity was accompanied for most women with revulsion, which is a feature of sexual aversion disorder, but it should be taken into account that the woman might be repulsed for good reason (for example, because of poor sexual techniques or a non-conducive atmosphere as a result of conflict) and therefore may (at least at times) experience a normal reaction to an inappropriate action. In addition, the aversion is person-specific and strong desires may be experienced towards other men.

Distinction between spontaneous and responsive desire
A good knowledge and broad understanding of the latest models of women's sexual response is required, including the Basson Sex Response Cycle (Basson, 2000), which recognises the importance of women's motivators being based on intimacy, with a distinction between spontaneous and responsive desire, as this particular model was found to be most useful in the understanding of the problems as described by the women in the current study. The more contemporary diagnostic systems include the distinction between spontaneous desire, and responsive desire (Basson, 2000). In this study the women experienced a lack of responsive desire, in other words did not become aroused even in the context of loving circumstances. Of significance is the support of findings that women mostly have sex as they consciously decide to do so, or become willing to do so for reasons other than having sexual desire. This points to the lack of motivating factors or "willingness" that could be the focus in therapy, together with the specific identification of lack of responsive desire, for the practitioner to keep in mind when planning intervention.

Broadened conception of sexuality
As noted before, the sexual experience was mostly devoid of pleasure, to the extent of experiencing feelings of loathing. The practitioner should support the emphasis on reasons other than desire for taking part in sexual activities, and provide the client with a broadened repertoire of activities to include more pleasurable actions (e.g. "cuddling" and non-penetrative sexual play) as preferred by the woman. Open communication would enhance an improved understanding of preferences, and a sense of negotiation and right to refuse unwanted sexual advances should be entrenched. As indicated, some men certainly also need some pointers about techniques to improve their poor lovemaking attempts.

Establish the need for treatment
Some participants did indicate that it would have been "easier" if they could address their lack of desire, as it would make the discrepancies in desire between them and their partners more manageable. All in all, most of the women did not express any deep need to change the status quo. Although most women revealed that they experience deep discomfort in having to provide sexual favours when deriving no pleasure from it, they indicated that they would continue to do so. The practitioner should therefore evaluate whether the woman is at all motivated to make changes and, if so, to what extent. The focus of the therapy then would depend on the particular factors indicated as causative, whether personal or relationship issues, or both.

Addressing myths and misconceptions
The majority of the women had unrealistic sexual expectations of themselves and of their partners as a result of socialisation and social scripting. It is recommended that the practitioner seek to dispel these misconceptions by providing information about gender roles and woman's sexual responses, including the differences between spontaneous and responsive desire. In essence, it is crucial to point out the normality of a lack of spontaneous desire in longer-term relationships to ensure realistic expectations of the potential outcome of therapy.

Choice of treatment modality
To address sexual problems many couples choose to engage in marriage/couple therapy (Craig, 2002). Couple therapy is an appropriate therapeutic context through which sexual difficulties can be explored and managed, and implies that psychological treatment may be an appropriate treatment for the causes and effects of sexual difficulties. The practitioner should conduct a thorough assessment based on the women's account to ascertain the main causes for the diminished desire so as to shape the personalised treatment plan, taking eclectic and integrative steps in determining the best treatment models. The practitioner should encourage individuation and differentiation in the relationship in order to enhance possibilities for eroticism, and address the familiarity, the over-closeness and enmeshment that deaden desire.
The distinction between psychological treatment for managing sexual difficulties as opposed to medical treatment, and the interplay between the two, is important, particularly in the context of the recent emphasis of medical remedies. The discovery of sildenafil (Viagra) marked the advent of a new era in sexual pharmacology, and its successes led to a reverting back to an emphasis on physical causality and a renewed focus on medical rather than psychological treatment (Moynihan, 2003). Leiblum and Rosen (2000) cautioned against simple medical solutions for complex problems experienced by individuals or couples. Basically, the concern is that drugs alone cannot address the complex phenomenon of women avoiding sex, and that effective multifaceted approaches should be developed and utilised to manage the common occurrence of discrepancies in sexual desire.

Addressing the need for a broadened perspective
Some participants expressed strong negative feelings about the experience of sexual intercourse, and avoided sex, even though they profess to love their partners. LoPiccolo and Friedman (1988) made the good point that many low-desire patients in fact have an aversion to sex but do not recognise it. They argue that if these patients were feeling "neutral", they would have engaged more readily in sex to avoid conflict -instead, they found that patients actively avoid sex, as did some participants in this study. This led me to question whether sexual aversion disorder would have been a more clinically correct DSM diagnosis for some of the participants, and if so, the aspect of aversion warrants further exploration.
Secondly, women often participate in sex because of the expectation of their partner and/or societal expectations that sexual activities define an intimate loving relationship and should continue in a long-term relationship. I wondered if that script could be challenged, so that women could be relieved of the burden of having to be available for sex when they do not want to do so, and that women's choice not to engage in sex could be recognised as a legitimate option (Perel, 2007;Wood et al., 2007), even in a partnership.

CONCLUSION
The experience of lack of sexual desire by women is very common, but poses a challenge to the practitioner when this is brought up in the therapy room as there are no clear guidelines about management, and also because the dynamics are so complex and the contributing factors so diverse. There is a dearth of local knowledge and studies in the field of sexology, and this study partially addresses this shortcoming in the South African literature, as identified by Robinson (2005) and others. As such, the study attempted to make a constructive contribution to research pertaining to women's sexual experiences and in particular, to make suggestions on how to deal with women's lack of desire in their relationships in sexology and marital therapy.