If sex has hurt for months or years, why would you expect your desire for it to still be intact?
Corey Babb is a sexual medicine specialist and gynaecologist who runs the Haven Center in Tulsa, Oklahoma, and writes one of the clearest, most thought-provoking Substacks on sexual medicine and women's health anywhere online. In his second appearance on the podcast, he breaks down desire and arousal - what they actually are, why they are not the same thing, and why desire is almost always the last part of sexual function to come back. It is a conversation that takes low desire out of the realm of personal failing and puts it back where it belongs: something you can understand, explain and treat.
Desire and arousal are not the same thing: the want and the how
A lot of people use the words desire and arousal as if they mean the same thing. They do not. Desire is the wanting - the urge to engage in sex, with a partner or on your own. Arousal is what the body does in response: the heart rate shifts, the pupils dilate, blood moves towards the genitals, and that blood flow is what produces an erection of the penis or clitoris and pushes fluid across the vaginal wall to create lubrication. One lives mostly in the brain. The other is the brain and the body working together.
This distinction matters because the two can come apart completely. You can be physically aroused with no interest in sex, and you can want sex while your body does not respond. Since arousal depends so heavily on blood flow, anything that interferes with that flow can blunt it, which is why desire and arousal have to be assessed as separate problems rather than lumped together. Getting clear on which one is actually struggling is the first step towards treating it properly.
Desire basically is the want to engage in sexual activity with someone else, with yourself. It is literally that desire to do so. Arousal is how the body responds to that desire.
The cascading model of sexual dysfunction: why painful sex has to be treated first
Babb describes sexual function as a waterfall with four domains - pain, arousal, orgasm and desire - that stack in a particular order. Pain sits at the top, and if it is there, it gets treated first. This is the part that reframes everything, because so many people arrive at a clinic reporting low desire when the real driver is painful sex from vulvodynia, vaginismus, pelvic floor dysfunction or endometriosis. Some never mention the pain at all, because they were told long ago that sex is simply meant to hurt for women and that discomfort was theirs to carry.
Once you see the order, the logic is hard to argue with. There is no point chasing desire while penetration still causes pain, because the brain will keep treating sex as something to avoid. Desire tends to be the most socially acceptable complaint to bring through the door, but it is usually downstream of everything else, which means it is often the last thing to return - not because it is the most stubborn, but because it is waiting for pain, arousal and orgasm to settle first. For anyone who has felt their desire quietly disappear after years of dyspareunia, that ordering is validating: of course it faded.
So at the top of it is pain. If pain is there, we always treat the pain first.
Spontaneous versus responsive desire: the brain's accelerator and brake
There is a quiet assumption underneath most worry about low desire - that real desire should arrive on its own, unprompted, and that if it does not, something is broken. Babb traces this back to early research by Masters and Johnson, which simply assumed people began from a baseline of positive desire. Rosemary Basson later proposed something much closer to most women's experience: we often start from sexual neutrality, and desire has to be triggered by something, frequently emotional connection, safety or a sense of being courted. Responsive desire that follows arousal rather than leading it is not a malfunction. It is how a great many people, especially women, are wired.
Underneath this sits the dual control model, which Babb describes as an accelerator and a brake. The accelerator is the sexual excitation system, driven largely by dopamine; the brake is the sexual inhibition system, tied to serotonin. Low desire can come from a weak accelerator, an overactive brake, or both - which is exactly why low libido is such a common side effect of SSRIs. Pain pushes hard on the brake. When sex has hurt, the brain reads it as a threat and shifts into a fight-or-flight state that pulls blood away from the genitals, and through neuroplasticity it learns to associate sex with danger - a pattern that then has to be actively unlearned.
Their brain has learned to associate sexual activity with discomfort. And even when you take away that discomfort, the brain then has to still relearn again that, hey, this can be enjoyable.
What actually helps: pelvic floor therapy, retraining the brain and where medication fits
The practical path follows the waterfall. Pain comes first, and treatments like dilator therapy and pelvic floor therapy do more than stretch tissue - worn for hours a day, dilators teach the nervous system, consciously and subconsciously, that touch is not a threat. Once penetration is no longer painful, the work shifts to rebuilding pleasure, often starting with a question many people have never been asked by a clinician: what actually feels good to you? This is also where a skilled sex therapist can help, by widening the definition of pleasurable, low-pressure sexual activity while the brain relearns.
Medication has a place, but a specific one. There are only two drugs approved for low desire in women: Addyi (flibanserin), which eases the serotonin brake and nudges the accelerator to build more receptive desire, and Vyleesi (bremelanotide), essentially a shot of dopamine for a more direct push. They can be used together, but they only make sense once pain is resolved and the remaining issue is genuinely about desire - in someone who enjoys sex, is bothered by wanting it less, and wants to do something about it. With Addyi, eight weeks is a reasonable benchmark: if nothing has shifted by then, it is unlikely to. The message Babb wants people to leave with is that this is real medicine, there is science behind it, and there are clinicians who know how to help restore sexual function.
