Around 15% of men have low desire at any one time, and the real figure is higher, because it is the thing men are least likely to say out loud. Sometimes it’s a testosterone problem. Often it’s not. It is rarely all in your head.
Most men who ask me why their sex drive has gone have been carrying it alone for a long time, often after a dismissive encounter somewhere else. It affects around 15% of men at any one time and the real number is higher, because it is so rarely disclosed. It is sometimes a testosterone problem. Frequently it is not, and it is very rarely all in your head.
So the first thing that happens is that you get a proper hearing, which most men have never had. I am not going to be shocked. Having talked to thousands of men about their sexual lives there is very little I have not heard before. What I then look at is the medical, the psychological and the relational together, because in most men the answer sits across all three.
Before any of that, though, one question is worth asking: is desire actually the problem? Sometimes it has faded because sex itself became stressful, through erection difficulties, ejaculation problems, performance anxiety, or a run of disappointing experiences. Avoidance then slowly takes the place of desire, not because the desire has gone but because sex no longer feels safe or relaxed. Past trauma, and sexual trauma in particular, can do the same thing, tying sex to fear rather than to pleasure in a way that lasts.
Good sex makes you want more sex, and the reverse is just as true.
There is no single normal. Some men have no desire at all and no distress about it, which is asexuality. Others want sex daily. Both are normal. The only questions that matter are whether this is a change for you, and whether it is causing you distress or difficulty in a relationship. If it is neither, it may not be a problem at all.
It is also worth knowing about responsive desire. Some men have spontaneous desire and simply wake up feeling sexual. Others do not, and the wish arrives in response to something sexual actually starting. Men with a responsive pattern often think something is wrong with them, because the cultural expectation is that a man should want sex constantly and out of nowhere. Usually nothing is wrong. You may have a lower baseline, or a responsive pattern, and both are workable.
They are different problems that often travel together, and telling them apart shapes everything that follows. Low libido means the interest has gone: you are not having sexual thoughts and do not feel sexual. Erectile dysfunction means the interest is there but the erection is not reliable. You can have perfectly good erections and no desire, or strong desire and difficult erections.
Worth taking seriously where desire has faded gradually, especially alongside fatigue or erection changes.
Testosterone above all, but also thyroid disease and raised prolactin.
Diabetes, obesity and the changes that travel with them.
Chronic illness and vascular disease both reduce desire, often early.
Blood pressure drugs, several antidepressants, and finasteride.
Depression and anxiety, which are among the commonest drivers of all.
Poor sleep and untreated sleep apnoea, which suppress testosterone directly.
Illness and medication are both common and both get missed. If your interest disappeared after starting something new, that connection is worth following rather than assuming away.
Weight deserves its own mention, because there is a loop worth understanding. Weight gain lowers testosterone, worsens sleep apnoea and drives fatigue, which makes sex worse, which makes everything else harder. Losing weight tends to reverse it: sleep improves, testosterone often rises on its own, energy returns. Doing that without help is genuinely hard, particularly with low testosterone in the picture, and weight loss medication or testosterone therapy can give you back enough energy to start. The evidence on GLP-1 medication and desire is mixed. For some men better sleep and metabolic health lift it, for others the drug itself dampens it, so it needs watching over time.
It can be, and diagnosing it properly takes more than one number. You need SHBG to calculate free testosterone, the pituitary hormones LH and FSH, and haematocrit and haemoglobin, on tests taken more than once rather than on a single result. A home finger-prick kit will not do it.
What the guidance actually says, where you also have symptoms such as low desire or loss of morning erections:
Androgen receptor genetics matter too. A normal level with symptoms can mean receptors that respond poorly, and genetic testing of the receptor is occasionally worth doing.
That happens often, and it is genuinely informative rather than a dead end. The effect of testosterone on desire tends to plateau once you are in the normal range, roughly 12 to 25 nmol/L, and adding more within that range is not usually transformative. So a normal result moves the question elsewhere, to your sexual history, your erotic world, the relationship and what has changed over time. That is the part an online clinic will not do with you.
Yes, where the deficiency has been diagnosed properly and the other factors have been thought about rather than skipped. If you want children in future, we use HCG or clomiphene alongside it. If not, it is more straightforward: injections, gels or capsules. Where you are genuinely deficient and being replaced to a normal level, there is no evidence of increased prostate cancer or cardiovascular risk. The TRAVERSE study gives good reassurance on gels; injections carry slightly more risk.
Stress and depression both do this, and considerably. Desire behaves like a life-force: when you are depressed the appetite for connection, excitement and novelty drops across the board, not only in bed. Antidepressants reduce desire as well, though so does under-treated depression, and working out which is driving it matters because the two need opposite things. I work closely with consultant psychiatrist Dr Jamie Arkell, and where mental health and sexual difficulties overlap we can review it together and look at whether a change of medication would help.
What I ask about beyond that is your erotic history, which is the part that rarely gets explored anywhere else. What your early sexual experiences were. What makes a good sexual experience for you now. What your needs and your fantasies are. How present you are during sex, and whether you are in the moment or watching yourself. Unpacking those is usually where the understanding starts.
Where something specific is sitting underneath, EMDR is worth considering: a sexual assault, a humiliating experience, an HIV diagnosis, a bereavement, or shame about what you want that was absorbed long before you had words for it. Desire is one of the first things to go quiet when the body is braced against a memory. Reprocessing it takes the charge out rather than erasing it, and desire often has room to come back once it is not competing with that.
Frequently, and the man in front of me has usually had the whole thing placed on his shoulders and been told to go and sort himself out. Unresolved conflict kills desire. Anger, unspoken resentment, feeling criticised or controlled, and it tends to evaporate. So does a long relationship with no novelty left in it: desire needs some mystery and some difference, and when two people become entirely merged there is no erotic space between them.
Fertility treatment, pregnancy, childbirth, changes in body image and guilt about masturbation all quietly erode it too. Starting to talk about how things have changed, with some curiosity about both people's erotic selves, is often what brings the energy back.
The room is explicitly not about blame, and I will stop a blame cycle early. What I am after is each of you thinking about your own part in it, and about how you might each grow. Learning to talk about sex in a more relaxed and even playful way travels a remarkable distance, because anxiety about talking about it is itself what kills desire and pleasure.
That is mismatched desire and it is very common. Sometimes the person in the room is not the person with the problem: if he were single he would not be distressed by his level of desire at all. Working on it as a couple is usually more effective than treating one person in isolation, and in a monogamous relationship a sexual difficulty is almost always partly a couple's difficulty, because it exists inside a system. I normally suggest bringing your partner to at least one session.
The room is explicitly not about blame, and I will stop a blame cycle early. What I am after is each of you thinking about your own part in it, and about how you might each grow. Learning to talk about sex in a more relaxed and even playful way travels a remarkable distance, because anxiety about talking about it is itself what kills desire and pleasure.
What works depends entirely on what has caused it, which is why the assessment matters more than the treatment list. Genuinely low testosterone may make hormone therapy part of the answer, though rarely all of it. Where the driver is psychological, treating that is what shifts it. Where it is relational, couples or sex therapy with your partner is usually the most effective route. Most often it is a combination, which is the argument against a one way ticket to testosterone replacement.
If it is mainly medical, a clear picture inside a month to six weeks, since the standard is two blood tests four weeks apart. If testosterone therapy is indicated you will know within three to six months whether it is making a real difference. Working individually, six sessions usually gives a clear understanding of what is driving it. With couples work, six to twelve sessions is where communication has usually shifted and a different kind of sexual relationship becomes possible.
Cured implies a disease, and low desire often is not one. Sometimes it is a reasonable response to difficult circumstances, a difficult relationship, or exhaustion. Can it improve? Almost always. Can desire come back? Yes. Is it permanent? Rarely, once the causes underneath it have actually been addressed.
I am a GP with a fellowship in sexual medicine, registration as a psychosexual and relationship therapist, and a PhD in men's sexual health, so the hormones, the psychology and the relationship get looked at in the same consultation rather than across three. Men often arrive from a GP who said everything was normal, or from an online clinic that offered a subscription, without anyone having explored what is actually happening.
I see people of all sexes, genders and orientations, and work with men across every relationship structure, monogamous, open and polyamorous. Gay, bi and queer men often come here because they want someone comfortable with queer sexuality who does not need it explained.
What we are aiming for: that you are enjoying sex again, with a realistic picture of what you want your sexual life to be. That you feel at ease in yourself sexually, with a fuller experience of pleasure. That you have a clear understanding of your physical health and a practical plan for it. And that you feel taken seriously, and no longer alone with it.
If it has lasted three to six months and is causing you distress or difficulty in your relationship. A couple of weeks is usually worth waiting out, because desire fluctuates. And if it has been ten or twenty years and you have never had the chance to look at it properly, it is not too late. My oldest patient is 89. All you need to bring is some curiosity about what might be going on.
Most men are anxious beforehand and almost everyone finds it easier than they expected. The first few minutes are about making it safe. Then a systematic review: medical history, family history, risk factors, and an assessment covering the biological, psychological, relational and cultural sides of it. Examination is sometimes useful and always optional. If you have had bloods already, send them ahead. If not we will arrange them, taken before 11am.
The usual drivers are hormonal, particularly testosterone, thyroid and prolactin; metabolic, including diabetes and obesity; cardiovascular disease; medication side effects; and mental health, especially depression and anxiety.
Everything is discussed with you and nothing is compulsory. I do not suggest anything I would not recommend to my own family.
The clinic is at Central Health London, 23 Devonshire Place, Marylebone, a quiet and discreet address a short walk from Regent’s Park. Most men arrive anxious and leave relieved. You will be welcomed by reception, offered tea or coffee, and given time to settle before we start.
A first consultation is usually an hour. We go through your symptoms, your medical and family history, and your sexual experience, relationships and lifestyle: the medical, psychological and relational picture together rather than one at a time.
I will ask you a lot of questions. You do not have to answer any of them: saying "I would rather not answer that" is a complete answer and nothing follows from it. A physical examination is sometimes useful, particularly for erection problems, and it is always optional. You stay in control of the appointment throughout.
If you have had recent blood tests, send them ahead. If not I will arrange them, and I will tell you which ones need taking before 11am.
If you are in your fifties or sixties, have no GP you know well, do not much like going to the doctor, but recognise it is time to take your health seriously, this is a reasonable place to start. I often find things that matter and have been missed.
If you want help but are wary of seeing someone who is not comfortable talking about gay or queer sex, you can come to someone who does not need it explained, and who will not judge or shame you.
Men who have tried quick fixes, or had a purely medical or purely therapeutic approach that did not help. I see a lot of men for second opinions. And men of any age and in any kind of relationship who want to understand what is going on rather than be handed a prescription.
I am a GP, a sexual medicine specialist and a COSRT-registered psychosexual therapist, working at 23 Devonshire Place, Marylebone, central London, alongside NHS general practice in Hackney.
Most men reading a page like this arrived from a search rather than my homepage, so this is probably the first you have heard of me. The short version: I hold the medical, the psychological and the relational picture together in one appointment, rather than sending you to three people who each see a third of it.
More about how I workIf something doesn’t feel right, it’s worth understanding why, before deciding what, if anything, to treat.
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