You’ve Googled it. Maybe at 2am, alone in bed while your partner sleeps beside you. Maybe during your lunch break, after another awkward conversation about “not tonight.” The question feels urgent, almost desperate: Why do I have no sex drive?

And what did Google tell you? Probably something like: “Check your thyroid. Reduce stress. Talk to your doctor about antidepressants. Consider hormone replacement. Have you tried date night?”

Here’s what I’ve learned after working with over 1,200 clients and prescribing testosterone, managing antidepressants, and running comprehensive medical evaluations for low desire: Most of the time, medical causes aren’t the whole story. And sometimes, they’re not the story at all.

That doesn’t mean medical evaluation isn’t important. It absolutely is. But if your doctor stops at bloodwork, you’re only getting half the picture.

What a Comprehensive Evaluation Should Include

When someone comes to me saying they have no sex drive, here’s what I do:

Medical evaluation (yes, this matters):

Run labs: thyroid function, hormones, vitamin D, iron, glucose

Review medications: antidepressants, blood pressure meds, hormonal contraception all affect libido

Screen for: depression, anxiety, chronic pain, fatigue, sleep problems

Assess for: hormonal changes (perimenopause, postpartum, post-hysterectomy)

Check for: medications or medical conditions affecting desire

Then – and this is where most doctors stop – I ask:

Do you feel seen and appreciated in your relationship, or invisible and taken for granted?

When you have sex, is it actually pleasurable for you, or are you just going through the motions?

Do you feel safe saying no? Or does saying no lead to your partner’s disappointment, guilt-tripping, or withdrawal?

Is your life structured in a way that makes you feel like a human being, or like a task-completion machine?

When was the last time you felt genuinely desired (not just needed for sex)?

These aren’t “soft” questions. These are the questions that actually matter.

Because here’s the truth: even when medical factors are present, they’re rarely the whole explanation. And treating only the medical piece usually doesn’t solve the problem.

Understanding “Normal” Sex Drive

Let’s start with something fundamental: if you think you have no sex drive, you’re probably comparing yourself to a standard that doesn’t exist.

There is no universal “normal” sex drive.

The medical community has created diagnostic criteria – Hypoactive Sexual Desire Disorder (HSDD) – for when desire is “persistently or recurrently deficient.” But deficient compared to what? Your partner? Your younger self? Some imaginary standard?

As sexologist Leonore Tiefer argues, the push to pathologize desire has more to do with pharmaceutical profits than with women’s actual sexual experiences.

I’m not saying HSDD isn’t real. Some people do have true medical conditions affecting desire. But most of the time? The diagnostic framework itself is the problem.

The Responsive Desire Reality

Here’s something most doctors don’t explain: 70-80% of women have responsive desire, not spontaneous desire.

Spontaneous desire is when you randomly think “I want sex.” Responsive desire is when desire shows up after arousal starts—not before.

If you never spontaneously “feel like it” but you enjoy sex once you get into it, you don’t have no sex drive. You have responsive desire—which is completely normal.

This is such an important concept that I wrote an entire post about it: Why Don’t I Want Sex Anymore? Understanding Responsive Desire

The short version: Stop waiting to feel spontaneously horny. That might never happen. And it doesn’t mean anything is wrong with you.

Why “Just Communicate” Doesn’t Work

Every article tells you to “talk to your partner about it.” As if you haven’t tried.

As if the problem is simply that you haven’t explained clearly enough that you don’t want sex.

Here’s what they miss: communication only works in a relationship that can actually hear you.

If your partner responds to “I’m not in the mood” with hurt feelings, sulking, or lectures about how long it’s been, you don’t have a communication problem. You have a safety problem.

If every conversation about sex becomes a negotiation where you have to defend your lack of desire, you’re not going to suddenly start wanting more sex. You’re going to want less.

Because desire is not a light switch. It’s a garden. And gardens don’t grow in hostile climates.

What Actually Affects Desire (That Needs Assessment)

After working with over 1,200 clients, here’s what I’ve learned actually affects desire in long-term relationships:

Medical factors (these need proper evaluation):

Thyroid dysfunction (especially subclinical hypothyroidism)

Hormonal changes (menopause, perimenopause, postpartum, PCOS)

Medications (SSRIs, SNRIs, hormonal contraception, blood pressure meds)

Chronic conditions (diabetes, autoimmune disease, chronic pain)

Depression and anxiety

Sleep deprivation and chronic fatigue

Relational factors (these need assessment too):

Feeling like a means to an end: When your partner wants sex from you rather than wanting sex with you, your body knows the difference. And it shuts down.

The invisible workload: If you’re the one tracking everyone’s schedules, remembering birthdays, managing the house, and making sure everyone is fed and functional, your brain literally doesn’t have space for desire. You’re in task-completion mode, not pleasure mode.

Predictable, obligatory sex: If sex has become another item on the to-do list—something that happens the same way, at the same time, following the same script—your brain checks out. Desire needs novelty, presence, and the possibility of surprise.

Unresolved resentment: You can’t want someone you’re furious at. I mean, you can, but not in the sustained, connected way that builds a satisfying sexual relationship.

Not getting what you want: Desire is about wanting something, right? So, what do you want? Low desire partners often find this question hard to answer, maybe because they haven’t felt like there was space for their authentic answer. But you can’t have reliable desire until you reliably know what you want and value it enough to ask for it from a partner you trust.

When Medical Evaluation Is Essential

Your desire concerns warrant thorough medical workup if:

You have zero interest in sex, even when circumstances are ideal

You’ve lost the ability to become aroused even when you want to be

This represents a significant change from your baseline, and nothing else in your life has changed

You have other symptoms suggesting something systemic: fatigue, weight changes, mood changes, pain, irregular periods

You’re on medications known to affect libido (especially SSRIs, hormonal contraception)

You’re in perimenopause or menopause

In these cases, proper medical evaluation is not optional. It’s essential.

And this is where working with a provider who understands sexual medicine matters. Because giving someone testosterone without checking estrogen levels doesn’t work. Switching antidepressants without considering sexual side effects creates new problems.

If you’re wondering whether testosterone therapy might help, I wrote a comprehensive guide on when it actually works (and when it doesn’t).

When Context Matters More Than Chemistry

But here’s what I see most often: People with perfectly normal labs, appropriate hormones, and no medical explanation for low desire.

In these cases – which are the majority – the problem isn’t chemistry. It’s context.

You probably don’t actually have no sex drive if:

You have desire or arousal in some contexts (fantasy, masturbation, different partners, the beginning of your relationship)

You enjoy sex once you get into it, you just don’t think about it beforehand

You can point to specific relationship dynamics, life circumstances, or patterns that make sex feel unappealing

You feel distressed about not wanting sex, but not distressed about the sex itself

This isn’t low libido. This is your body giving you accurate information.

What Actually Helps

If you’re reading this and thinking, “Okay, but I still have no sex drive and it’s causing problems in my relationship,” here’s what actually helps:

1. Get proper evaluation

This means both medical workup AND assessment of relational/contextual factors. Not one or the other.

Work with a provider who:

• Takes sexual concerns seriously
• Does comprehensive medical evaluation
• Also asks about your relationship, your life, and the sex you’re having
• Understands that biology and context interact

2. Stop treating low desire as the problem

Your low desire is information. It’s telling you something about your relationship, your life, or the sex you’re having. Listen to it.

3. Create conditions for desire

This isn’t about scheduling sex (although that can help). It’s about creating space in your life for pleasure, play, and presence. It’s about addressing the resentments, the invisible labor, the feeling of being taken for granted.

4. Address what needs addressing

If it’s hormones, treat the hormones. If it’s medication side effects, consider alternatives. If it’s relationship dynamics, work on the relationship. If it’s the sex itself, change the sex.

Usually, it’s some combination of all of these.

5. Redefine what “sex” means

If sex has become a routine that centers penetration and your partner’s orgasm, no wonder you’re not interested. Expand the definition. Make pleasure—yours and theirs—the point.

The Comprehensive Approach

Here’s what comprehensive care for no sex drive looks like:

Medical evaluation to rule out or treat:

• Thyroid dysfunction
• Hormonal imbalances
• Medication side effects
• Depression/anxiety
• Chronic conditions

Assessment of relational and contextual factors:

• Relationship dynamics
• Division of labor
• Sexual satisfaction
• Life stress
• Safety and consent

Treatment that addresses what’s actually driving the problem:

• Hormone therapy when indicated
• Medication changes when needed
• Couples therapy for relational issues
• Individual therapy for trauma, anxiety, depression
• Sex counseling for sexual concerns
• Stress management and life restructuring

This is the work I do. Not just bloodwork. Not just “talk to your partner.” Comprehensive evaluation and treatment that takes all factors seriously.

The Bottom Line

Having no sex drive might be medical. It might be relational. It might be contextual. Usually, it’s some combination.

But you deserve evaluation that looks at all of it – not just labs, not just “reduce your stress,” but a comprehensive assessment that treats you as a whole person living a real life.

Before you pathologize yourself, before you start taking supplements or hormones without proper evaluation, before you resign yourself to a lifetime of “just not being a sexual person,” get proper comprehensive assessment.

And if you need help with that – if you need someone who understands that no sex drive is usually a symptom, not a diagnosis – that’s exactly what I’m here for.

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Ready to understand what’s actually going on with your desire?

Individual sex counseling can help you untangle your relationship with your sexuality, complete proper medical evaluation, and address what’s actually affecting your desire – whether that’s hormones, medications, relationship dynamics, or all of the above.

Working through desire discrepancy as a couple? Couples counseling addresses the relational dynamics that affect intimacy, while also ensuring proper medical evaluation for both partners. Learn more about sex counseling here.

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Dr. Lori Davis is a Doctor of Nursing Practice, board-certified Family Nurse Practitioner, and AASECT Certified Sex Counselor specializing in comprehensive evaluation and treatment of sexual concerns. She prescribes hormone therapy, manages medications affecting libido, and addresses relational and contextual factors affecting desire. She teaches sexuality counseling at the University of Michigan and has worked with over 1,200 clients navigating desire, intimacy, and relationship challenges.

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Further reading:

Testosterone for Low Libido: When It Helps, When It Doesn’t

Why Don’t I Want Sex Anymore? Understanding Responsive Desire

My Partner Never Wants Sex: Understanding Mismatched Desire (needs a link)