Non-pharmacological routes: CBT, mindfulness and sex therapy

The ISSWSH process of care lists sex therapy — behavioural therapy, cognitive behavioural therapy and mindfulness-based approaches — alongside pharmacological and hormonal options, not beneath them (Clayton et al., 2018). The 2025 international treatment guidelines for low sexual desire in women take the same biopsychosocial line: medication and psychological therapy are both first-order routes, chosen by presentation and preference. For a meaningful share of women, particularly where the screen found psychological or relational drivers, these routes are the treatment.

Education comes first

Much distress about desire is distress about a model. The idea that desire should arrive spontaneously, unbidden, before any touch, is one model. Responsive desire — desire that follows arousal rather than preceding it — is normal, common, and more so in long relationships and later life. Naming that, in one sentence, removes distress for some women without any further treatment.

Cognitive behavioural therapy

CBT for low desire targets the beliefs and behaviours that maintain it: performance and body-image cognitions, avoidance cycles, the loss of non-sexual intimacy that precedes the loss of sexual intimacy. Delivered individually or as a couple, typically 8–12 sessions.

Mindfulness-based approaches

Mindfulness-based sex therapy — developed and trialled principally by Lori Brotto's group — trains attention to present-moment bodily sensation and away from evaluative thought during sexual activity. Randomised trials in women with low desire and arousal difficulties show improvements in desire, arousal and sexual distress; group formats of four to eight sessions are the most studied.

Sex and relationship therapy

Sensate-focus programmes, communication work, and structured treatment of the partner's sexual dysfunction where present. The relationship is often the unit of treatment.

Access in the UK

• NHS psychosexual services exist in some areas, often within sexual health or gynaecology; provision and waiting times vary widely. Know your local route.
• COSRT (College of Sexual and Relationship Therapists) maintains a register of accredited therapists for private referral.
• IAPT / NHS Talking Therapies can address the depression or anxiety that drives low desire, though not usually the sexual problem itself.

How The Desire Clinic uses these routes

Every assessment considers psychosexual therapy as a route in its own right, and as a companion to any medical treatment. Where it is the right answer, we say so and signpost — we do not hold on to a patient whose need is therapeutic.

Reflective learning

1. Can you name your local NHS psychosexual service and its referral route?
2. How would you explain responsive desire to a patient in under a minute?
3. Which patients on your list would benefit more from a therapy referral than from a prescription?

References

• Clayton AH et al. The ISSWSH Process of Care for Management of HSDD in Women. Mayo Clin Proc 2018;93:467–87. doi:10.1016/j.mayocp.2017.11.002
• Rowen TS et al. Treatment guidelines for low sexual desire in women. Sex Med Rev 2025 (international expert panel; UCSF summary 30 Oct 2025). [REVIEW NOTE: PMID not located on PubMed in-session — Nikki/Sorrell to confirm the citation before publishing.]
• Brotto LA, Basson R. Group mindfulness-based therapy significantly improves sexual desire in women. Behav Res Ther 2014;57:43–54. doi:10.1016/j.brat.2014.04.001