Lesbian Bed Death: Fact or Fiction?

This article is a counseling case study which will describe the following: assessment of a lesbian couple’s sexual problem, the clinical description of the sexual disorder as related to the sexual response cycle, and the inter-personal dynamics of the couple. Further, treatment approaches for lesbian sexuality and the subject of ‘Lesbian Bed Death’ will be explored.

Case Study Assessment: Sara was referred to counseling by her gynecologist because she is currently experiencing a lack of desire in a sexual relationship with her partner Amy. The couple state they have lived together for a year and are both in their thirties. Sara is white and Amy is black, both are in good health and employed. They agree they are in love, and happy to be together. However, when Sara lost her well-paying corporate job, she took two jobs to make ends meet, and works long hours. When she comes home, she is so exhausted she has no desire for sex, and Amy is feeling rejected, frustrated and sad about the loss of physical intimacy. As a result, when Amy initiates sex, they fight because Amy raises her voice. Several hours later they can talk again, but the problem remains unresolved. The couple has sex twice a month on average, and Sara expresses enjoying being close to Amy and achieving orgasm over 50% of the time. Sara does not masturbate, and admits refraining from showing affection to Amy, because she doesn’t want it to lead to sex. Amy states she came to counseling at Sara’s request but feels it is, “Her problem.” Sara states she wishes she would desire sex more often because it’s having a negative impact on their relationship. When asked about their families, Sara says she is cut off from them, since they are religious and believe that homosexuality is immoral. Her family also believes that inter-racial dating is immoral. Amy’s family is also moderately religious, but recognizes their relationship.

Clinical Diagnostics: In the Case of Sara and Amy, disruption in their relationship is being caused by Sara’s lack of sexual desire. Though they are sexually functional because they are having infrequent sex, the degree of sexual functionality for Sara’s partner Amy is not sufficient to meet her needs. The Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR, American Psychiatric Association, 2005) lists sexual dysfunctions as, “A disturbance in the process that characterize the sexual response cycle…” and lists: desire, excitement, orgasm and resolution as the healthy sexual cycle. Sara has a dysfunction of the desire cycle, “This phase consists of fantasies about sexual activity and the desire to have sexual activity” and is an “Acquired Type,” (DSM, 2005, p. 536), indicating the onset of the problem developed only after a period of normal functioning. This condition is described as, Hypoactive Sexual Desire Disorder (HSDD) in the DSM (2005). This is distinguished from Sexual Aversion Disorder: “In hypoactive desire there is a lack of desire for something that in itself can be experienced in a positive manner, whereas in sexual aversion, negative emotions (e.g. anxiety, disgust) play important roles” (Both, Laan, Schultz, 2012). Sara admits enjoying sex in the past, so she can be ruled out for aversion to sex, and her lowered sexual desire (HSDD) is a common theme in couples therapy. “One of the most common presenting problems in the practice of sex and couple therapy; approximately 20% of men and 33% of women are affected by low or absent sexual desire” (Laumann, Palik & Rosen, 1999). “Recent epidemiological data and clinical experience clearly indicate that approximately 1 in 10 women may receive a diagnosis of HSDD” (Shifren et al., 2008). The negative feelings associated with decreased sexual interest include: feeling less feminine, feeling like a sexual failure, low self-esteem, insecurity, inadequacy and letting the partner down (Dennerstein et al., 2006; Leiblum et al., 2006). An even higher percentage of women with low sexual desire feel: frustrated, concerned, unhappy, disappointed, hopeless, troubled, ashamed and bitter as compared to women with normal desire and the distress is worse if a current partner is present (Rosen et al., 2009). “While HSDD is prevalent, it is also among the most difficult sexual problems to treat because it can be caused by a number of biopsychosocial factors” (Weeks, Hertlien, Gambescia, 2009). When diagnostics are approached from a holistic perspective, meaning the clinician takes into account the multiple biopsychosocial factors at play, biological causes must be discussed and ruled out before attempting to address the psychological and cultural factors. Biological causes such as: androgens which can cause hypothyroidism, depression and anxiety can disrupt the sexual response cycle. “Women reported that feeling depressed or anxious decrease their interest in sex” (Lykins, Janssen, Graham, 2006). In this case, Sara may be experiencing depression over having lost her corporate job and anxiety about starting two new positions.

Inter-Personal Dynamics of the Couple: This lesbian couple agrees on being in love and having been very happy for the year they have been together. They are showing a willingness to make an investment in their relationship by attending couple’s counseling. Amy is feeling rejected, frustrated and sad, but also anger. Her feelings of rejection are reinforced when she initiates sex and is refused. Sara may be feeling guilt and frustration with both her partner and herself due to her inability to “measure up” to Amy’s expectations. Sara may be feeling like she is “the problem,” because Amy has stressed that she is. Understanding the etiology of the sexual dysfunction is of utmost importance in assisting the clients to resolve the issue. Sara has recently lost her corporate job and now works two jobs which require long hours. Amy works at one job in a potentially less-stressful environment. My first hypothesis as to the etiology of the dysfunction would be the level of stress and fatigue that Sara has been experiencing: “The potential effects of stress or fatigue could be explained by the fact that stress or fatigue factors may have caused some women as much or greater stress than HSDD, which may diminish a sense of distress as a result of lack of sexual desire. As expected, the women in our HSDD registry had low Female Sexual Function Index total scores, low levels of sexual desire, and the majority reported frequent to always experiencing personal distress related to their lack of desire. The strong influence of a patient’s age, ongoing stress or fatigue, the patient’s perception of her partner’s desire levels, and oral contraceptive use should be considered or evaluated in each case ” (Conner et al., 2011). Though these clients are not pre-menopausal women, further inquiry into Sara’s stress level and fatigue (environmental causes), whether she takes an oral contraceptive or could have low androgen levels (biological cause), and her perception and feelings about Amy’s reactions to the problem (inter-personal cause) should be investigated. If Amy yells when she is denied sex, and they have been fighting because of it, Amy’s negative and blaming reaction may be reinforcing Sara’s tendency to avoid sex, exacerbating the problem.

Lesbian Sexual Response and ‘Lesbian Bed Death’: “One of the most challenging sexuality issues within the lesbian community and among professionals who treat lesbian women is the presenting problem of hypoactive sexual desire disorder or, colloquially speaking, lesbian bed death” (Nichols, 2004). Early studies showed that of all couples, lesbian couples have sex less frequently than any of the other couples (Blumstein & Schwartz, 1983), and they practice fewer sexual techniques than other types of couples (Jay & Young, 1977). In a meta-analysis of sex research indicating gender differences (Peplau, 2003), lower libido, lower rates of sexual activity in general, and less assertiveness around sexuality were found in women. Therefore, two women together have been theorized to be less sexual than a heterosexual couple because of the absence of ‘a male force’ to drive sexual contact (Nichols, 2004). Popular culture has perpetuated the belief that diminished sexual frequency among lesbian couples makes sense, since there is no man in the relationship to ensure initiation of sex (Angier, 1999; MacDonald, 1998; Nichols, 1987; Schreurs, 1993; Schwartz, 1998). Specific to lesbian couples, clinical journals refer to this problem as, “Inhibited Sexual Response” (ISD), citing, “Current understanding of lesbian cultural realities suggests that gender-specific sex role socialization profoundly affects female dynamics and that lesbians are subject to ISD as the direct result of societal expectations of them both as women and as homosexuals” (Post, Avery, 1995). However, some sex therapists (Nichols, 2004) believe this type of thinking represents a simplistic use of gender socialization theory. Nichols (2004) points out differences in lovemaking when heterosexual and homosexuals are compared: “Masters and Johnson's research (1979) in which lesbian, gay, and heterosexual couples' sexual behavior was compared found that heterosexual couples were more performance-oriented and preoccupied with orgasmic attainment. Lesbian couples took more time having sex, with sexual interaction beginning with whole-body contact and proceeding with kissing, hugging, touching, and holding before breast or genital contact was made. In heterosexual couples, "Rarely more than 30 seconds to a minute were spent holding close or caressing the total body area before the breasts or genitals were directly stimulated" (Masters & Johnson, 1979, p. 66). The point is that it may not be socialization of women which causes less frequent sex among lesbians. Instead, it may not be the quantity, but the quality of sexual relations which accounts for less frequent, but longer and more emotionally intimate sexual relations between lesbians. Defining healthy lesbian sexuality by sexual frequency may be short-sighted: “Rather than using sexual frequency as a measure of the sexual health of a relationship, some have shown that lesbians spend more time on the average sexual encounter than do heterosexuals. Using this criterion of sexual time spent together, lesbians may have lower frequency but would appear ‘healthier’ than heterosexual couples” (Iasenza, 2002). Other researchers dispute ‘lesbian bed death’ as myth: “Another view of ‘lesbian bed death’ is that it is a myth based on insufficient data, and that sexual frequency in lesbian couples is comparable to that of heterosexual couples (Iasenza, 2002). Mathews et al., (2003) found no differences in sexual frequency rates of heterosexuals vs. lesbian women. In fact, Iasenza (1991) found lesbians as compared to heterosexual women tend to be more sexually arousable and more sexually assertive” (Nichols, 2004). 

Conclusion: This couple is unique in that they are a three-way minority: females, lesbians, and biracial. Imposing on them a male standard of sexuality, a heterosexual standard, or a Caucasian standard will be 

ill-fitting, or worse: insulting to their unique place in the world. I propose that clinicians take into careful 

consideration the clients they have before them, and tailor their treatments accordingly. Sexuality is not a 

one-size-fits all proposition. With an openness and willingness to learn from the client’s individual perspectives, 

the astute clinician is in the best possible position to tailor a treatment plan that fits just right, and leave the 

myths and stereotypes behind.

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