As a clinical psychologist who later completed training in somatic sexology, I’ve sat with countless women who ask, almost apologetically, if this is the right space to talk about sex, followed by: I just don’t feel like it anymore, the lack of sex is straining my relationship, is there something wrong with me? There’s nothing wrong with her, or you. In this post, I’ll use a biopsychosocial framework to explore the changes in sexual response and desire that can occur in midlife for women. These changes do not occur for all midlife women of course, but the statistics are compelling.
In a large-scale study published in The Lancet in 2025, almost 5,500 women aged 40 to 69 were surveyed; nearly half reported sexually related personal distress. Not a niche subgroup, not a clinical outlier. Half. Of those, low desire affected around 25% and low arousal 21.5%. An important distinction here: desire is the cognitive and emotional motivation to seek sexual experience, whereas arousal is the psychophysiological response to stimulation – feeling sexually excited, blood flow to the genitals, lubrication, etc. Desire and arousal can, and often do, operate independently. A woman can want sex but not get wet, and vice versa. What are the factors that are driving half of midlife women to report sexually related personal distress? The answer is a complex mix of biological, social and psychological factors, and the interaction between them, hence the biopsychosocial framework.
The hormonal landscape of midlife can have a significant influence on desire and arousal. Oestrogen and progesterone begin their chaotic decline during perimenopause, up to a decade before the final menstrual period. As oestrogen drops, vaginal walls thin, lubrication decreases, and vulval tissue becomes fragile and easily irritated. This is part of the Genitourinary Syndrome of Menopause (GSM) and it is very common. GSM makes sex uncomfortable and sometimes genuinely painful; some women with GSM describe penetrative sex as feeling like barbed wire. Testosterone, a key driver of libido, also declines steadily from the mid-reproductive years. Add in the sleep disruption and fatigue that accompany midlife hormonal fluctuation; not to mention the sexual side effects of medications such as antidepressants, plus the onset of health conditions that typically begin in midlife and affect sexual function (e.g., Type 2 diabetes), and…. the biological conditions for desire and arousal are not ideal.
Biology alone, however, doesn’t explain why two women with similar hormonal profiles can have profoundly different experiences of sexual desire and arousal. A woman’s psychology and social context matter, and enormously so. The Dual Control Model of sexual response is helpful in explaining the psychosocial factors that influence how women (and men, but focusing on women here) respond to sexual cues. According to the model, there are two neurological processes running simultaneously: the Sexual Excitation System (SES) or the sexual accelerator, and the Sexual Inhibition System (SIS) or sexual brake. The accelerator picks up on sexually relevant cues and pushes the system toward desire and arousal, whereas the brake scans for reasons not to proceed with sex, such pain, threat, anxiety, & distraction. The balance between brake and accelerator determines how she feels about sex at any given time, and brake pressure is far more powerful than accelerator pressure. Some women naturally have a more sensitive brake, but this is not a wholly fixed setting. Both systems are flexible, and heavily influenced by context, life stage, and circumstances.
In midlife, the brakes get a lot of pressure. Pain anticipation. Body image concerns. Exhaustion. Partner resentment. Cognitive overload. A room full of scented candles and champagne isn’t going to do much when she’s just finished a phone call about her ageing parent’s continence products, the house is a mess, sex was cut-glass painful last time, her joints ache, and she’s navigating weight redistribution, brain fog and wondering why she just doesn’t feel like herself. In that case, the brake is firmly applied.
Beyond the brake pressures already named, the research literature points to several additional SIS activators at midlife: mood disorders and sexual dysfunction are highly comorbid, with up to 75% of women with depression reporting sexual problems; a history of sexual trauma, affecting close to half of all women, carries risk that is not fully explained by anxiety or PTSD alone; and medications increasingly prescribed at midlife, particularly antidepressants, can quadruple the odds of sexual dysfunction. The brake is rarely being pressed by just one thing.
The Dual Control Model also helps explain the difference between spontaneous and responsive desire, a difference that is not spoken about anywhere near enough by general practitioners and other first port-of-call healthcare professionals. Spontaneous desire is the out-of-nowhere wanting that popular culture treats as normal, she’s doing the dishes and suddenly feels like a romp. It’s more common in younger people, new relationships, and men. Responsive desire emerges in response to sexual stimulation and context; it’s the desire that can show up after sexual activity has begun. Many midlife women, especially in long-term relationships, have shifted to a predominantly responsive pattern, which is perfectly healthy and normal. Just an explanatory note here: responsive desire is emphatically not a prescription nor encouragement for women to push through disengagement or nonconsent and hope for the best. It’s more about understanding that desire may not arrive as a spontaneous spark, so that she can stop pathologising herself for not wanting sex out of nowhere, and can choose, on her terms, whether the conditions are right to let desire emerge.
The social context a woman inhabits at midlife can be as inhibitory to desire as anything happening in her body. Research consistently identifies relationship quality as one of the strongest predictors of sexual desire and satisfaction in midlife women. After two decades with the same partner, familiarity, accumulated resentment, and unresolved conflict are potent brake activators. Esther Perel, whose work on relationships and sex is world renowned, argues that eroticism, the erotic charge and aliveness that gives sex its fire (as distinct from desire, which is the wanting), requires a degree of separateness, novelty, and unknowability to survive. It is difficult to fetishise someone whose bathroom noises have been part of her morning routine for the past 20 years. Desire needs space; eroticism needs it even more.
Then there is midlife caregiving. Many women at midlife find themselves providing care for the people who shaped their earliest ideas about bodies and sex. That contact can activate early trauma and sexual shame. Add in full-time work, the exhaustion of having spent decades meeting everyone else’s needs, and inhabiting a world that has few realistic models of sexual, sensual women beyond 45, and it is no wonder that the brakes are floored for so many women at midlife.
Once we take a nuanced view of midlife sexual function, it becomes clear that for most women with a flattened libido, it is a complex interaction of biological, psychological, and social factors that are at play. Despite what Instagram would have one believe, a testosterone prescription alone is often not the whole answer. Effective support for midlife desire problems might comprise a mix of self-education, a GP who takes it seriously, a psychologist with a good understanding of sex, and a sexologist or somatic sex therapist who works with midlife women. The reference list at the end of this article has a few starred references which are an excellent place to start.
References
Calabrò, R. S., Cacciola, A., Bruschetta, D., Milardi, D., Quattrini, F., Sciarrone, F., Rosa, G., Bramanti, P., & Anastasi, G. (2019). Neuroanatomy and function of human sexual behavior: A neglected or unknown issue? Brain and Behavior, 9(12). https://doi.org/10.1002/brb3.1389
Cleland, L., Schluter, P. J., & Arnold, E. P. (2022). Childhood maltreatment and the menopause transition in a cohort of midlife New Zealand women. Menopause, 29(5), 565–573. https://doi.org/10.1097/GME.0000000000001976
Faleschini, S., Tiemeier, H., Rifas-Shiman, S. L., Rich-Edwards, J., Joffe, H., & Perng, W. (2022). Longitudinal associations of psychosocial stressors with menopausal symptoms and well-being among women in midlife. Menopause, 29(11), 1247–1253. https://doi.org/10.1097/GME.0000000000002056
Faubion, S. S., Sood, R., & Kapoor, E. (2021). Genitourinary syndrome of menopause: Management strategies for the clinician. Journal of Obstetrics and Gynaecology Canada, 43(8), 976–987. https://doi.org/10.1016/j.jogc.2021.07.011
Wang, Y., Islam, R. M., Bond, M., Skiba, M. A., & Davis, S. R. (2025). Sexual dysfunction in women at midlife: a cross-sectional study of data from the Australian Women’s Midlife Years study. The Lancet Obstetrics Gynaecology & Women S Health, 1(3), e198–e208. https://doi.org/10.1016/j.lanogw.2025.100024
Janssen, E., & Bancroft, J. (2023). The dual control model of sexual response: A scoping review, 2009–2022. The Journal of Sex Research, 60(7), 948–968. https://doi.org/10.1080/00224499.2023.2219247
Nagoski, E. (2015). Come as you are: the surprising new science that will transform your sex life. Scribe Publications.
Perel, E. (2006). Mating in captivity: Unlocking erotic intelligence. HarperCollins. Sarmento, A. C. A., Costa, A. P. F., Vieira-Baptista, P., Giraldo, P. C., Eleutério, J., & Gonçalves, A. K. (2021). Genitourinary syndrome of menopause: Epidemiology, physiopathology, clinical manifestation and diagnostic. Frontiers in Reproductive Health, 3, 769950. https://doi.org/10.3389/frph.2021.769950
StatPearls. (2024, October). Genitourinary syndrome of menopause. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559297/
Thomas, H. N., Neal-Perry, G. S., & Hess, R. (2018). Female Sexual Function at Midlife and Beyond. Obstetrics and gynecology clinics of North America, 45(4), 709–722. https://doi.org/10.1016/j.ogc.2018.07.013
Tremblay, A., Mbuagbaw, L., & Wolfman, W. (2025). Treatment patterns for genitourinary syndrome of menopause: A TriNetX analysis. Sexual Medicine Reviews. https://doi.org/10.32604/cju.2025.067575
Ussher, J. M., Perz, J., & Parton, C. (2024). Women’s experiences of their sexuality during the menopausal transition and the support offered to them by healthcare providers: A systematic review and meta-synthesis. BMC Women’s Health. https://pmc.ncbi.nlm.nih.gov/articles/PMC12445056/
