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“I need you to see my husband,” Gwen says when she calls for an appointment. “He never seems to want sex anymore.”

“Any idea why?” I ask.

“Not a clue. I’m hoping you can talk to him and figure it out.”

As a psychiatrist and sex therapist, I get a lot of calls from women wondering why their husbands have gone missing in bed. Sometimes the problem is something obvious, like erectile dysfunction. Occasionally it’s low testosterone, or depression. Sometimes he’s gone down the rabbit hole of compulsive porn use. Very often, though, it’s something more subtle. Something more emotional than sexual.

“Are you still physically attracted to her?” I ask Gwen’s husband, David, when I see him in the office.

David says he is, and that when they have sex he still gets turned on.

“So what happens when you try to initiate sex?”

“I’m not really sure. All day long at work, I’ll be thinking about how when I get home I’m going to start something up with her. But the closer I get to home, the less I feel like it.”

He shifts in the chair.

“Most of the time, I just end up shutting her out.”

“I assume she doesn’t like that very much.”

“Yeah, she hates it.”

He stops for a moment and looks around the room.

“To tell you the truth, I don’t think she likes me very much anymore.”

It’s a common pattern among the heterosexual couples I see: men who tend to be terribly afraid of disappointing the women they love, who will often withdraw when they feel they’ve made their partners upset — which, of course, will typically make her even more upset.

From there, I’ve heard enough of the same story to know, it can turn into a vicious cycle: Eventually he’ll withdraw to where he stops initiating sex. Which will make her feel undesirable. Which of course will make her even more upset. Which he’ll see as a sign that it’s no longer safe to approach her. Which of course is absurd, since the main reason she’s upset is because he hasn’t touched her in a month — but that’s the way these things tend to go.

I see Gwen several days later. She tells me that when she first met David, she’d never have guessed things would end up this way. She never met a man who made her feel so special. When David proposed to her, it was at a big event he’d staged — with all their friends looking on. It wasn’t until they got married and moved in together that she noticed something was off.

“Sometimes David and I would be talking,” she says. “He’d ask me a question, and then ten minutes later he’d ask me the same question again. He just wasn’t there. It was like now he had me, he could just forget about me and move on to the next thing.”

“I wondered if David might have adult ADHD,” Gwen says as she studies my diplomas.

I’m wondering the same thing.

ADHD can have a profound impact on a couple’s emotional and sexual relationship, and it’s very common for couples in treatment to have at least one partner with this condition, which can contribute to sexual problems in a whole host of ways. Some people with ADHD have unusually high sex drives. Others hardly seem interested in sex at all. Individuals with ADHD are at increased risk for depression, which in turn can dull desire and cause sexual dysfunction.

Often, though, it’s something else. In my experience, many of the sex and relationship problems faced by ADHD adults seem to be the result of their having been overly criticized as ADHD children. A parent may do their best to be kind, but when everyone else is hurrying to get out the door for an important family occasion — all except one child who has his shoes off in front of the TV, completely unaware of the time or of what’s going on around him — you’re going to hear some yelling.

Many of these kids are naturally resilient. They cope with the criticism they receive by just shutting it out. But this can create problems years later in adult relationships. Let’s say you’re so absorbed with your iPad that you don’t even hear your partner calling your name. Said partner might understandably start to feel a bit lonely. Maybe even unloved. They may try to be patient, but eventually they’re going to complain.

When they do, this will likely bring back memories of your being yelled at as a child. And you may react to your partner the same way you did to your parents — by shutting them out.

In my office, Gwen thinks for a moment about what she’s just said. “He concentrates just fine at work, though, when there’s a big business deal on the table.”

Extreme variability, though, in attention is quite common in people with ADHD. The term “ADHD” itself is misleading, since it’s not really “attention deficit” at all. It’s just trouble focusing on things that aren’t immediately exciting. Some men with ADHD give their partners an extraordinary amount of attention during courtship, then once they’re living together can’t concentrate well enough to remember the last thing she said.

Not every man in David’s situation has ADHD. And not every person with ADHD has relationship problems. But it’s something that, as a clinician, you don’t want to overlook.

The next time I see David, we spend some time with my adult ADHD checklist. David has a few hyperactive symptoms, but it’s his inattentive symptoms that really clinch the diagnosis. Trouble finishing things, chronic lateness, a tendency to tune out during conversations. I’m always amazed that people like David can get to adulthood without anyone suspecting they might have ADHD.

A good sex therapist will learn as much as they can about a patient’s specific mental assets and vulnerabilities. Some people have short attention spans and get easily bored in bed. Some use sex to self-medicate anxiety and need to have it all the time. Some get so distracted by other things that they forget about sex entirely. And some have various other quirks that aren’t so easily categorized but can make them equally frustrating as sexual partners.

All these traits fall under the umbrella of what people in my line of work call “atypical.” Both men and women can be atypical. But for some reason, a woman’s atypicality doesn’t seem to come up as often as an issue in sex therapy.

I end up trying David on several different ADHD medications before we find one he likes. After several months, he marvels to me at how he could ever have managed without it. His work productivity improves, and his stress level goes way down.

Now comes the hard part: healing their marriage. Unfortunately, that takes a lot more than medication. Accurate diagnosis is just the start. David has to learn how not to withdraw when Gwen gets upset with him. And Gwen and David each have to learn how to stand up more for their own needs. Once a couple learns how to do these things, though, the payoff in good sex can be enormous.

Adapted from Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship by Stephen Snyder, M.D. Copyright © 2018 by the author and reprinted with permission of St. Martin’s Press, LLC.