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If you are in an intimate relationship, begin by focusing on the "sensual" aspects of the relationship. Sensual aspects include all physically and emotionally pleasing, non-genital contact, such as backrubs and gentle stroking of non-genital body zones. During periods of diminished sex drive, partners often neglect these sensual, non-sexual aspects to their physical relationship. Make a date for a non-sexual but sensual evening. Partners can enjoy each other physically and engage in enjoyable sensual exploration of each other's bodies, without the pressure of working towards sexual intercourse.
Many women with lowered libido find that they can still enjoy a good sexual response and orgasm, but they need to create a new approach for initiating sexual behavior. In other words, the nervous system is frequently sufficiently intact to respond to sexual stimulation even when libido is absent. The issue thus becomes one of sexually "getting started" without libido. This can be accomplished in a number of ways.
First, it is frequently essential to restore the "special person" aspects of a relationship, which include all those behaviours one shows a partner that he or she is special and important. These gestures vary widely, and may include giving flowers, putting a loving note in a lunch bag, offering an unexpected word of appreciation to one's partner, etc. Loving gestures tend to be forgotten amidst the pressures of coping with MS symptoms and other life tasks. Increasing these special acts towards one another sets the stage for increasing intimacy which, in turn, can set the stage for enjoyable sexual behaviors, even in the absence of libido.
A commonly reported reaction to libido loss is to physically withdraw from a love relationship. Couples commonly report that they retreat from sensual touching [e.g., backrubs, kissing, etc] because they are afraid it will "lead to sex," which becomes defined as problematic when sexual desire is absent. Coping with loss of libido requires restoration of sensual touching, of relearning what type of touching feels pleasurable. Participating in the body mapping exercise described previously is a good first step. Next it is required for the couple to take turns touching each other systematically. When the "giver" is touching the partner, one's job is to temporarily suspend interest in receiving pleasure, and attend completely to pleasing the partner. The "receiver" must offer instructions both verbally and non-verbally to maximize the pleasure of the touch. It is recommended for partners to take turns for 20 minutes each (less if fatigue is a problem).
Additional guidelines include:
- Practice the exercise several times a week
- Avoid genital contact the first week, to reduce the "pressure" and "focus" on sexuality. This gives a couple the opportunity to give and receive sensual pleasure without the pressure that accompanies sexuality.
- For the second to fourth weeks, increasing genital contact during the exercise is allowed, but the emphasis on orgasm should be avoided. It is important that the focus on the exercise remains on continuing to enhance sensual communication and pleasure, and not focus on trying to achieve orgasm. This helps to restore emotional comfort and reduce anxiety as well.
- Following week four, increasing genital stimulation to the point of orgasm is allowed, but should not become the focus. Orgasm is considered to be incidental to the primary goal of relearning physical pleasure and sensual communication in the absence of libido.
Sexuality in the absence of libido requires a different set of behaviors and attitudes in initiating sexual pleasure. It frequently requires different patterns of communicating and touching, since "arousal" per se is impaired, but some neural pathways for experiencing sexual pleasure are most frequently intact.
For the person without a current sexual partner, exploration of one's sensual and erotic body zones is an important step in restoring libido. Combining enjoyable cerebral sexual stimulation (achieved via fantasy, sexually explicit videos, books, etc.) with masturbation or sensual physical self-exploration is sometimes helpful. Sexually explicit videos are available by mail order that are produced "by women, for women," since women usually have preferences that are markedly different than men. Use of vibrators or other sexual toys may complement these efforts.
For women, Kegal [pelvic floor] exercises can sometimes enhance female sexual responsiveness, although it is not known whether or not they are helpful in MS. Sensation from the muscles around the vagina contribute to sexual sensation, and female orgasm consists of contractions in several muscles in this area. Kegal exercises are directed at strengthening the tone and responsiveness of these muscles. To perform the Kegal exercise, alternately tighten and release the pubococcygeus muscle (identifiable as the muscle that starts and stops the urine flow in mid-stream). Exercising this muscle 20 or more times a day is recommended. Since urinary retention in the bladder is common in MS, however, it is important to consult one's health care provider prior to starting this exercise. In general, it is advised to conduct this exercise when not urinating, after initially identifying which muscles to tighten. This will help prevent urine retention.
Improving pelvic floor muscle strength is also sometimes accomplished via biofeedback. Biofeedback therapy involves the application of sensors to the genital and/or anal area that measure electrical signals associated with tightening and relaxing the pelvic floor muscles. A feedback "signal" in the form of a light or auditory tone is provided to the person as they tighten the appropriate muscles that enables them to systematically identify and exercise the muscle groups. Pelvic floor training is a rehabilitation approach that is also utilized for enhanced bladder control, but it has not been tested adequately from a research perspective.
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