INTRODUCTION
Hypoactive sexual desire disorder (HSDD) is a general or common problem that is frequently treatment stubborn. This recalcitrance to treatment is pensive of our lack of knowledge about the determining factor of sexual libido in women and men. A persistently reduced sexual drive or libido, not attributable to depression where there is reduced desire, sexual activity and reduced sexual fantasy.
Hypoactive sexual desire disorder may be
- Lifelong or acquired,
- Generalized (global) or
- Situational (partner-specific).
It occurs in 20% of women and in 10% of men.
HSDD is characterized by a combination of factors including persistently diminished or absent sexual fantasies or desire for sexual activity, and can affect both men and women; a person diagnosed with HSDD can still function sexually.
HSDD IN MEN
One consequence of the availability of medication that allows men to enhance their erection is that male hypoactive sexual desire disorder (HSDD) is erroneously presented and treated as erectile dysfunction (ED). The lack of public education on sexual health issues, the myth that men are always motivated to be sexual, insufficient sexological knowledge of health-care providers, and the lack of tools to comprehensively assess male HSDD, are causative factors of this misconception, which may partly explain the high proportion of failures of treatments for symptomatic ED.In population-based studies HSDD has been reported in 0–15% of men, and ED in 10–20% [1]. Recently, Simons and Carey [2] analysed52 studies published between 1990 and 2000; community samples indicate a prevalence of0–5% for ED and 0–3% for male HSDD, while prevalence estimates from primary-care and sexuality clinic samples are characteristically higher. With the aim of putting HSDD on the agenda of providers of male sexual healthcare, here we review publications on the path physiology of male HSDD, and its biological and psychological correlates.
According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) classification, HSDD is the persistent or recurrent absence or deficit of sexual fantasies and desire for sexual activity, accounting for factors that affect sexual function, e.g. age, sex and life context Although many studies have been conducted, especially of female HSDD, the lack of methodological rigor of many studies limits the confidence in the findings [2]. HSDD is currently recognized as the most difficult sexual disorder to operationally define, evaluate and treat.
THE ASSESSMENT OF SEXUAL DESIRE AND DESIRE PROBLEMS
HSDD is associated with a wide variety of biological and psychological causes. At present, no single instrument for diagnostically assessing HSDD prevails .Sexual healthcare providers who wish to be alert to a diagnosis of HSDD are advised to pose direct and unambiguous questions to their patients, to probe for aspects of sexual desire and motivation. Patients often will not reveal sexual problems unless explicitly invited. Collateral information may be obtained through questionnaires, completed before or after the consultation. Several reliable and valid questionnaires are available for assessing sexual desire problems, with easy-to-follow instructions. The Sexual Desire Inventory was designed specifically to measure level of sexual desire, the International Index of Erectile Function provides a subscale to measure sexual desire, and the Golombok Rust Inventory of Sexual Satisfaction provides subscales of sexual avoidance, and of infrequency of sexual contact.
THE INTERFACE BETWEEN BIOLOGY AND PSYCHOLOGY OF MALE SEXUAL DESIRE
The investigation of male sexual behavior has been greatly influenced by Beach’s concept of the ‘dual nature of sexual arousal and performance’, derived from his extensive research on male rats. He postulated that sexual behavior depends on two, relatively independent, processes controlling motivation and consummation. Motivation involves a sexual arousal mechanism that determines a male’s sexual response to perception of a receptive female. Its main function is to stimulate the male rat to approach a female and to raise his sexual excitement to the threshold necessary for consummatory elements of sexual behavior, i.e. mounting and intromission. Thereafter, the consummatory mechanism controls the intromission and ejaculatory elements of the male rat’s sexual behavior, integrating the sequence of mounts and intromissions, thus amplifying the male’s arousal until ejaculation occurs. Recent animal research has expanded Beach’s model, and, for instance, motivational and consummatory processes have been shown to involve separate brain regions, independently modulated by androgenic and dopaminergic agents. Animal studies suggest that an intricate interplay between steroid hormone actions in the brain maintains central sexual arousability and the organism’s individual experience with sexual gratification. From this, expectations of competent sexual functioning have been developed, including sexual activity, sexual desire, arousal and sexual performance. However, the validity of extrapolating findings to human sexual functioning remains to be evaluated in empirical studies. Recent work in neurobiology has allowed conceptualizations of sexual motivation and performance, the complexity of which far exceeds the models based on Beach’s concept. The linear model of the human sexual response as postulated by Masters and Johnson has dominated clinical research for several decades. This model omitted sexual desire and problems of hypoactive desire completely, probably because Masters and Johnson studied individuals who were highly motivated to engage in sexual activity. Later authors added the concept of sexual desire, but still adhered to the linear model, proposing that sexual desire is needed to initiate subsequent sexual arousal and orgasmic release. They considered the presence of sexual thoughts and fantasies, and an innate urge to experience sexual tensions and release, as markers of desire .Over time, the linear model of the sexual response acquired normative properties, prescribing that the personal experience of lustful desire in both sexual partners should precede any initiation of sexuality. However, real-life experiences of numerous ‘steady’ couples show almost universal differences in the experience of sexual desire between partners, regarding both timing and frequency of sexual activity, and sometimes giving rise to serious marital conflicts. Moreover, humans engage in sexual contacts for countless motives, only one of which is the awareness of an intrinsic urge for sexual activity. Many motives are not sexual, such as pleasing or appeasing a partner, banishing gloomy thoughts, chasing away boredom, or monetary or other material rewards. Recognition of this gave rise to the notion of a ‘receptive sexual desire’, as opposed to ‘active desire’. Thus the linear model of sexuality gave way to circular or multifactorial hypotheses regarding the interrelationships of sexual desire, arousal and performance, and the influence of unconscious, involuntary and automatic processes, along with conscious motives and deliberations, was recognized. Building on new findings from neuroscience, Janssen proposed a two-stage information-processing model of sexual arousal, based on the concepts of ‘the multiplicity of meaning of sexual stimuli’ and of ‘the interaction of automatic and controlled processing’ of such information. According to this model, in the first stage, subliminal stimuli render the sexual system receptive to sexual stimuli, and prepare the organism to respond with physical arousal. (Fig. 1). Many psychological and biological factors might preclude the deployment of the genital sexual response, but if processing of stimuli in the limbic centers is such that some degree of arousal is experienced, the individual can continue to focus on sexual stimuli. Depending on the unconscious processing of either the mere erotic meaning of the sexual stimuli, or of many meanings, including negative valence (particularly in sexually dysfunctional men), further arousal might follow in the second stage. After the priming-based and unconscious motivational engagement, the man may become aware of this motivation as a desire to continue the experience for the sake of the sexual tension and enjoyment. In this cycle, sexual stimuli can be processed at a pre-attentive level, and arousal can be experienced before desire.
FIG. 1. The dual-stage information-processing model of sexual responding, adapted from Janssen et al. and Öhman et al.
Mental sexual arousal alters the descending neurotransmission from limbic centers to the lumbar sacral centre of the spinal cord. There is evidence that this involves increasing oxytocinergic signaling from the Para ventricular nuclei of the hypothalamus, with concurrent reduction of inhibitory serotonergic input, particularly from the nucleus paragigantocellularis in the medulla. When this balance of signaling to the pelvic autonomic outflow occurs, the subsequent physical tumescence constitutes an additive or compounding second-level sexual stimulus. The engorgement is usually accurately detected and enjoyed. Men with chronic situational ED typically underrate their physical response, whereas sexually functional men have higher correlations between genital and subjective measures of arousal. In contrast, in women these measures tend to show little overlap. Psycho physiological data of objective increases in vaginal blood flow (in the laboratory) in response to erotic stimulation consistently show no correlation with the female’s subjective arousal. Thus, women may not have this direct confirmation of their genital arousal, which might explain why many women need direct stimulation of their congesting vulvar structures for the second level confirmatory stimulus. Clearly, some sexual styles, particularly intercourse focused, may preclude this. Although the two-stage model remains to be validated by empirical testing; it may guide the present discussion of sexual desire problems in men. The most prominent implications of the Janssen et al. modelare: (i) the unconscious and automatized initiation of genital response preparation upon (subliminal) perception of erotic stimuli; (ii) the nonlinear relationship between sexual desire and sexual arousal, implying the possibility of sexual arousal preceding desire; and (iii) the possible inhibitory effect of mental preoccupation and non-sexual thoughts on both desire and arousal.
PSYCHIATRIC CONDITIONS
Relationship difficulties are often encountered as concomitant to HSDD. The cause-effect relationship is sometimes hard to disentangle, especially if the problem has a long history. It might often be difficult for a man to admit that his lack of sexual desire is associated with his dissatisfaction with the relationship, or with resentment towards his partner; masculine myths in many cultures hold that men are always ready to engage in sexual activity, even in unfavorable conditions, or imply that a lack of desire for sex with his partner reflects the man’s waning love for her. Subtle cases of relationship discord require meticulous history-taking, sometimes including the scheduling of visits to a physician without the partner being present. Anger may be an important mechanism through which sexual desire and arousal are inhibited .For women; both anger and anxiety significantly reduce desire, with anger showing the more marked effect. For men, similar results have been noted, although with fewer differences reported between the anxiety and anger conditions. Significantly more women than men indicate that they would terminate sexual activity during anger. HSDD is the most frequent form of sexual disorder experienced by psychiatric outpatients. Underlying causes are multifactorial in most cases. The patients most frequently affected are schizophrenics on neuroleptic medication, whereas schizophrenic patients on no medication have fewer dysfunctions. Major depression is associated with decreased sexual interest in > 40% of men although Bancroft found that the depressive effect was associated with an increase in sexual desire in 9% of a group of heterosexual men. It remains unclear how these differential effects are mediated. Sexual dysfunction commonly occurs during antidepressant treatment. Although depressed patients care about their sexual function, they may be reluctant, for fear of embarrassment, to report HSDD spontaneously to their physicians. HSDD is probably under-reported and may result in covert non-compliance and relapse into depression. Physicians thus need to assess sexual function during the initial evaluation and throughout treatment. The importance of sexual function to sexually active patients with major depression should be considered carefully when planning antidepressant therapy. Viable options exist to prevent or treat HSDD, including use of relatively new antidepressants and appropriate adjunctive regimens .Improvement in sexual functioning related to antidepressant effects may be more common.
MEDICAL CONDITIONS
Although not a medical condition, ageing is the most significant risk factor for HSDD. In men aged > 40 years there is a gradual, often imperceptible decrease in sexual desire, but although ageing men do not usually experience the strong sexual interest characteristic of youth, most report continued interest from a mild to moderate degree. However, HSDD is frequently experienced by patients with chronic medical conditions, e.g. coronary disease and heart failure, renal failure and HIV. For example, 71% of HIV patients report some degree of sexual dysfunction after beginning their treatment, of which 89% report decrease or loss of libido. HSDD, subjectively ascribed to fatigue, is also common among patients with chronic renal failure. Men on haemodialysis or peritoneal dialysis suffer significantly more often from HSDD than men with kidney transplantation or rheumatoid arthritis.Diemont et al. reported a HSDD prevalence of 56% in men on haemodialysis, 48% in men on peritoneal dialysis and 41% after renal transplantation. Hyperactive sexual desire is a known, although not frequently recognized, side effect of dopaminergic anti-Parkinson therapy, especially levodopa. This side-effect is not life-threatening but can have an enormous impact on the quality of life of the patient, and his or her partner. The mechanism is probably related to the pharmacological action of dopamine [.Bipolar (manic-depressive) affective disorder is also associated with hypersexual desire, specifically in manic episodes, and lithium treatment has been found to reverse the sexual symptoms of this condition although hypo sexuality is a common problem in stroke patients, some may present with hyper sexuality. Patients with isolated symmetric damage to the amygdala and their cortical connections show marked behavioral changes, including visual agnosia, hyper sexuality, hyper-orality, a tendency to react to every visual stimulus, and memory deficits. The cluster of neurobehavioral symptoms is similar to previously reported accounts of Kluver–Bucy syndrome, and suggests the importance of bilateral amygdala involvement in these changes.
Lack of sexual desire is reported significantly more often by both bodybuilders and men with eating disorders than by controls [56]. Bodybuilders show a pattern of eating and exercising as obsessive as that of subjects with eating disorders, but with a ‘reverse’ focus of gaining muscle, as opposed to losing fat.
TREATMENT OPTIONS FOR HSDD FOR MEN
SOMATIC TREATMENT
The search for a pharmacological treatment of HSDD is a search for a sexual drive stimulator. A drive-enhancing drug might act without visual, auditory, olfactory, or social contextual stimuli. On the basis of our current understanding, such a drug would act within several specific nuclei in the hypothalamus. If the drugs in the pipeline prove to be effective, it will be fascinating to learn their mechanism of action. This knowledge will shed light on the mechanism of increased sexual drive found among many persons with mania, alcoholism, substance abuse, or Parkinson disease. For 7 decades, physicians have been prescribing testosterone for men who complain of low libido. Not only is there no clinical evidence of the efficacy of this hormone in eugonadal patients, but also there is no modern scientific evidence of its lasting effect. A rise in testosterone level from intramuscular injection, for instance, can be expected to lower endogenous testosterone production because of the feedback mechanisms between serum testosterone levels and hypothalamic and pituitary hormones. A community-based study of the relationship between low libido and testosterone levels showed only a modest probability that men with low libido had low testosterone levels. Avoid providing androgen in any form to men with severely robust normal testosterone levels. However, one study has shown that in men with erectile dysfunction and low libido whose morning total testosterone levels were less than 300ng/dL, sexual desire increased with placebo and testosterone. The greatest improvements in sexual desire were seen when testosterone levels exceeded 600 ng/dL. Because of several studies performed during the 1980s, bupropion has been mentioned as a treatment for men with HSDD with or without a major or minor depressive disorder. Evidence for bupropion’s effectiveness in HSDD or low levels of drive secondary to an underlying depression is at the level of expert opinion rather than evidence base. It is well known that SSRIs and SNRIs have a strong likelihood of diminishing sexual capacity when used to treat depression; thus, nonserotonergic antidepressants are often a rational choice in men who dread further sexual impairment as a result of antidepressant medication. My clinical experience indicates that very few men with idiopathic acquired HSDD respond robustly to bupropion. There is much accumulated evidence that the 3 phosphodiesterase type 5 inhibitors—sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil HCl (Levitra)—which are dramatically effective in improving erectile capacity, cannot be relied on to improve a man’s sexual desire in a lasting fashion
PSYCHOTHERAPY
There is no specialized form of psychotherapy—cognitive-behavioral, psychodynamic, sex therapy, psychodrama—that has shown a strong capacity to help men and their partners with HSDD.Therapy may be provided for men alone, for men with their partners, or in groups of other men with limited sexual interest in their partners (such as is commonly seen among the so-called sex addicts). Most of these situations involve the motivation to avoid the partner. The therapy is a process for understanding what is motivating the avoidance. While these processes do not generate case reports or controlled studies, they do help men and their partners understand the underlying interpersonal (partner alienation due to disrespect) or developmental issues (paraphilic requirements not being fulfilled by a partner).The patient may consider therapy to have been valuable, even if it served only to help him better understand the underlying problem. This paradox between the helped patient and the failure of the therapy to cure the problem reminds the doctor that sexual life is created by biological, social, cultural, and private psychological forces that often limit medication effectiveness.
HSDD IN WOMEN
Hypoactive sexual desire disorder (HSDD) is the leading sexual complaint by women and is characterized by diminished or complete absence of libido. It is found to occur in at least 20% of women in the India. HSDD is an aversion to sex, a sexual apathy and sexual anorexia with inhabited sexual desire. In simple terms, it can be defined as an extreme aversion to sex and absence of and avoidance of all genital sexual contact with a sexual partner. In extreme cases, the patient finds sex repulsive, revolting and distasteful so much so that phobic and panic responses are exhibited.
Hypoactive sexual desire disorder may either be oriented against a single partner in particular, or it may be a lack of sexual interest in anyone in general. Low sexual desire is often associated with aging. It is estimated that 10% of women age 49 or younger have low desire, 22% of women age 50 to 65 and 47% of women age 66 to 74 report low desire.
It has been reported that women are twice as likely as men to experience low sexual desire.(2) Loss of libido can occur at any time during a woman’s lifetime and is especially prevalent during menopause, both natural and surgical (having the ovaries removed).
Studies show that many women experience decreased sexual desire as their testosterone levels decline through the natural aging process or via removal of the ovaries (where half of a woman’s testosterone is produced). Additional factors that may be associated with HSDD include:
- Certain medications, such as some antidepressants and antihypertensive
- Psychological factors (e.g., depression, stress, anxiety)
- Relationship issues
- Certain Chronic diseases, such as diabetes
REASONS FOR HSDD
Often HSDD is the result of either physical or emotional trauma. In general, a woman’s sex drive is guided by a complex system of signals between her brain, ovaries and other reproductive sexual organs. It is a healthy brain, more than a healthy body that dictates desire for sex. Often a disruption in this complex interaction between brain and body may cause decreased interest in sex.
- Decreased sex drive or less interest in sex may occur in a woman at any age. But this sexual dysfunction is more common during and after menopause has ended. Several physical and psychological factors cause sexual dysfunction. These include:
- Physical ailments such as diabetes, vaginal yeast infections, urinary tract infections, heart disease, neurological disorders, pelvic surgery, chronic liver disease, chronic kidney disease, menopause, alcoholism, smoking, drug abuse, breast feeding, and recovery after childbirth.
- Psychological causes such as stress from work and family, anxiety, marital discord, unresolved sexual orientation, depression and previous traumatic sexual experiences.
- In some HSDD may be a primary condition and the patient must have never felt any sexual desire or exhibited interest in sex. This may be due to sexual trauma such as incest, sexual abuse or rape. Sometimes repressive family attitude and rigid religious training may be the cause for this primary HSDD condition.
- Whereas in some patients sexual desire might have occurred formerly but it no longer has interest. Initial attempts at sexual intercourse might have resulted in pain or sexual failure and hence this condition.
- Insufficient levels of sexual hormone, testosterone can cause HSDD in males and females.
- Boredom in relationship with a sexual partner results in acquired HSDD.
- Depression, use of psychoactive or antihypertensive medications may contribute to this problem. Studies indicate that at least 12% of women experience clinical depression at some point of time in their lives. One of the side effects of popular anti depressants is loss of libido. She may feel isolated and overwhelmed and withdraw from sexual activities.
- HSDD may result from impairment of sexual function such as vaginismus on the part of female. Vaginismus is a voluntary contraction or spasm of the lower vaginal muscles resulting from an unconscious desire to prevent vaginal penetration. This may be due to incompatibility in sexual interest between the sexual partners. This can also occur in the presence of a sexually demanding partner.
- Dyspareunia or painful intercourse is another common deterrent to genital sexual activity in women. This is caused by vaginismus or local urogenital trauma or inflammatory conditions such as hymnal tears, labial lacerations, urethral bruising, or inflammatory conditions of the labial or vaginal glands.
- Delayed sexual maturation may be a potential cause of HSDD. In girls, this is characterized by lack of breast enlargement by age thirteen or by a period greater than five years between the beginning of breast growth and onset of menstruation.
SIGNS AND SYMPTOMS OF HSDD
There is an inability to attain or maintain adequate vaginal lubrication and swelling response. Intercourse is painful and involuntary contraction of vaginal muscles, vaginismus occurs. There is delay or absence or orgasm. She avoids having sex and she ignores her own personal hygiene to avoid having sex. She has fewer erotic dreams and sexual fantasies.
HSDD AND MENOPAUSE
During and after menopause, the estrogen level is remarkably reduced in women. This leads to dryness of the vagina which makes sex painful. This in turn leads to reduced motivation in sexual intercourse. The decrease in drive is due to the gradual decline in the hormones estrogen, progesterone and testosterone.
Although this disorder is prevalent in women in all reproductive stages, it is seen that younger, surgically postmenopausal women are at greater risk. Prevalence in naturally postmenopausal women is 9% and in surgically postmenopausal younger women is 26%.
Among the many changes your body undergoes during menopause, reduced sexual desire is one of the most common. For some women, the problem becomes large enough that it’s identified as a condition known as hypoactive sexual desire disorder (HSDD).
“As women age and go through menopause, the ovaries lose their ability to produce a variety of hormones, including estrogen,” says Michael L. Krychman, MD, executive director of the Southern California Center for Sexual Health and Survivorship Medicine in Newport Beach. “The effects of lower estrogen levels are that the vaginal walls, clitoris, and vulva lose their pliability and elasticity and are often noted to be dry and easily irritated. Estrogen deficiency commonly causes vaginal dryness, which may result in uncomfortable intercourse and may also affect orgasmic intensity.”
Testosterone is another hormone that plays a critical role in sexual desire, and it, too, tends to drop off due to menopause. “One common misconception is that women do not have testosterone in their bodies, only men do. That is not correct,” says Dennis K. Lin, MD, physician-in-charge of the Psychosexual Medicine Program at Beth Israel Medical Center in New York. “Both men and women produce testosterone in their bodies, but at different levels. And in both men and women, testosterone is an essential hormone. An adequate level of testosterone is associated with a healthy sex drive, and low testosterone is definitely a cause of HSDD.”
The Role of Hormone Replacement Therapy
The good news about menopause and hypoactive sexual desire disorder is that one of the primary treatments for other menopausal symptoms also helps with the low libido associated with it. And that’s hormone replacement therapy, or HRT.
However, you have to work with your doctor in selecting the right type of hormone replacement therapy for your menopausal symptoms, including HSDD. According to Kent Holtorf, MD, a board-certified endocrinologist and founder of the Holtorf Medical Group in Torrance, Calif., bio identical hormone replacement therapy (BHRT), which uses hormones that are exact copies of those produced by the body, is proving to be a lot more effective than the synthetic hormones (Premarin, Prempro) that were traditionally used.
“In our medical practice’s experience, treating literally tens of thousands of women for more than a decade with bio identical hormone replacement therapies (BHRT), HSDD is safely and effectively improved — or eliminated completely — in 90 percent of the cases,” says Genie James, executive director of the Natural Hormone Institute and chief executive officer of Dr. Randolph’s Ageless and Wellness Medical Center in Jacksonville Beach, Fla.
Other Treatment Options for Hypoactive Sexual Desire Disorder in Menopause
Of course, hormone replacement therapy isn’t the only course of action for treating hypoactive sexual desire disorder related to menopause. “Past sexual experience, as well as how a woman views herself as a sexual being, can also influence the sexual experience,” says Dr. Krychman. “A woman is so much more than the sum of her hormones.”
Other treatment strategies include:
- Attack it with antidepressants. “The antidepressant buproprion (Wellbutrin) has shown some efficacy in treating HSDD,” says Dr. Lin.
- Try therapy. “Couples therapy is also effective by teaching couples skills in conflict resolution and [helping to] work through differences in non-sexual areas, which often contribute to sexual problems,” adds Lin.
- Viva Viagra. Though Viagra is usually viewed as a drug for men, it can help women, too, says Dr. Holtorf. “[It] can effectively improve the cascade of arousal in women and can increase libido and sexual satisfaction for about 30 percent of women,” he says.
- It all comes back to diet and exercise. Sometimes the advice is simple, and when it comes to HSDD, good old diet and exercise can help, says James. “Some foods are sexy superstars: Flaxseed and flaxseed oil, dark leafy veggies, oily fish — such as salmon, herring, and mackerel — liver, oysters, and whole grains can work through the digestive system to naturally increase the body’s testosterone levels while eliminating some of its age-related overabundance of estrogen,” she says. “Exercise has been found to naturally boost lagging testosterone levels in women and men.”
- Experiment with Zestra. “Zestra is a topical product that has been clinically proven to improve arousal, desire, and satisfaction for women,” says Krychman. “Zestra consists of a patented blend of natural oils and botanical ingredients. It is applied three to five minutes before sexual activity and works within minutes to help women feel more pleasurable sensations.”
TREATMENT OF HSDD
Treatment of HSDD is related to its cause. If the reason for the problem is medical, then necessary therapy and cure is affected. For instance, if the cause is diabetes, improvement in diabetes control should be aimed.
In case of insufficient testosterone, diagnostic tests are done and supplemental replacement therapy is aimed. Testosterone level less than 20 ng/dl in females indicates need for supplemental replacement therapy.
Low dosage testosterone treatment option is well supported by several researchers and doctors although it has not been approved by FDA. There has been enormous success in treating low-libido patients with supplemental testosterone. Several women who have used the testosterone patch have reported significant increase in the frequency of sexual activity and satisfying desire. A study reveals that women in the testosterone group had a 52% meaningful benefit when compared to other treatment options.
Other treatment methodologies include anti depressants, hormone replacement therapy, androgen therapy, herbal remedies, psychotherapy and marriage counseling.
The prognosis is reasonably good, for instance, in case of treatment of a prolactin secreting pituitary tumor; whereas in case of certain genetic defects such as Turner’s syndrome and Klinefelter’s syndrome there can be no attainment of sexual function even after treatment modalities.
But as such, there is no approved pharmacological treatment for HSDD. Even psychotherapy has proved to be only minimally effective. If the underlying cause for HSDD is interpersonal in nature, therapy for couples should help as support and understanding of the sexual partner is essential.
It can be observed that majority of HSDD cases are situational in nature arising out of dissatisfaction and loss of interest in the sexual partner. Although significant assistance can be rendered to couples with marital discord, most of the times there is poor response to such therapy. More often than not, the marriage breaks, and the partner opts to find a new sexual partner after divorce.
SIDE EFFECTS OF TREATMENT FOR HSDD
Possible side effects of treatments for HSDD include sleep disorders, headaches, irritability, and sexual dysfunction in women using antidepressants. Vaginal bleeding, tenderness of breast, weight gain, abdominal bloating can be observed in women using hormone replacement therapy. Acne, greasy skin, excessive hair and elevated cholesterol using androgen therapy are normally observed.
PREVENTION OF HSDD
In women sexual dysfunction is often linked to menopause and its side effects such as depression, she could well see a healthcare professional before HSDD can become a serious problem. Early treatment and management should help minimize her problems.
But a thorough understanding and support from the sexual partner is essential for successful treatment of HSDD. In fact there are therapists who would recommend abstinence from genital sex for a period of time and concentrate instead on non-genital sex for effective treatment of HSDD.
Symptomatic criteria for Hypoactive Sexual Desire Disorder
- Continuing or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person’s life.
- The disturbance causes marked distress or interpersonal difficulty.
- The sexual dysfunction is not better accounted for by another mental disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Statistics on Hypoactive Sexual Desire Disorder
Hypoactive Sexual Desire Disorder is one of the most common presenting problems in the practice of sex therapy. It is estimated that approximately 20% of men and 33% of women are affected by low or absent sexual desire.
Risk Factors for Hypoactive Sexual Desire Disorder
The predisposing factors for HSDD arise from four major areas:
- The individual;
- Family of origin (intergenerational);
- The couple’s relationship (interactional); and
- Medical aspects.
The individual
Psychological risk factors in the individual can be expressed within the context of sexual intimacy, giving rise to the development of HSDD. These involve:
- Anxiety;
- Depression;
- Sexual orientation conflicts;
- Negative thinking patterns;
- Inaccurate beliefs about sex;
- Poor body image;
- A tendency to fuse sex and affection;
- Career overload; and
- Related sexual problems.
Fears can also increase the risk of developing HSDD, since emotional and physical intimacies are closely related. Sexual desire may be hampered by a fear of intimacy, anger, rejection and abandonment, exposure, feelings or dependency.
Physical factors, such as sexual abuse and emotional trauma, can also inhibit desire.
Intergenerational risk factors
Many anti-sexual beliefs are learned within the social familial context. For example, when raised in an extremely religious household, an individual may learn that sex is for procreation and not personal enjoyment. This can lead to feelings of guilt and shame, and may then result in HSDD.
Interactional risk factors
The extent to which an individual is satisfied with a marriage or relationship is related to sexual satisfaction. For example, women with HSDD tend to report greater degrees of marital distress and less relational cohesion.
Other relational risk factors can include:
- Contemptuous feelings;
- Criticism;
- Defensiveness;
- Power struggles; and
- Toxic communication.
Medical aspects
Deficiencies of testosterone or other hormones, and medical conditions that create hormone deficiencies can have an impact on sexual desire. Chronic medical conditions, physiological changes, and medications can also contribute to HSDD. This includes:
- Depression;
- Medications, such as serotonergic antidepressants;
- Chronic debilitating illnesses, such as chronic renal failure;
- Fluctuations in blood sugar with diabetes; and
- Hyperprolactinaemia, hypo-hyperthyroid states (less common).
Arousability may also be negatively affected by:
- Androgen deficiencies;
- Lamic or pituitary disease; and
- Prolonged high-dose cortisol use.
Symptoms of Hypoactive Sexual Desire Disorder
HSDD can be either lifelong or acquired. When HSDD is lifelong, the absence of sexual desire is a typical state for the person. Acquired HSDD occurs when a change is experienced in sexual appetite.
An individual with a generalised lack of desire does not have a sexual appetite under any circumstances. On the other hand, an individual who experiences selective desire in certain situations or with specific partners is classified as situational type. For example, a person might feel desire toward a partner they have an affair with, but not with their established partner.
It is important to note that males with inhibited sexual desire appear to use fantasy in a different way to females with this complaint. Females with desire phase problems show low levels of fantasy, whereas men with desire phase problems show a high level of sexual fantasy.Males may use sexual fantasy to enhance their sexual performance due to response anxiety. Response anxiety is experienced when there is widespread pressure to feel sexually aroused, but arousal does not occur. Sexual fantasies may be constructed to help generate sexual arousal that is difficult to achieve without the use of fantasy.
Clinical Examination of Hypoactive Sexual Desire Disorder
Clinical assessment of HSDD should take into account a variety of factors related to the individual and the couple, including:
- Level of emotional intimacy;
- Mental and physical health;
- Sexual context;
- Relationship issues or concerns;
- Thoughts during sexual interactions; and
- Messages from families of origin.
Emotional intimacy
The belief that emotional intimacy is highly relevant to the experience of sexual desire is not new. Accepting it as a legitimate driving force, rather than searching in vain for a means of experiencing spontaneous sexual thoughts and sexual neediness, is perhaps new to some. Some 50% of women believe that insufficient emotional intimacy is a relevant factor in their low desire.
Assessment of a couple’s emotional intimacy typically includes questions about their ability to trust, be vulnerable, not be judgmental or highly critical, and to have a sexually attractive balance of power and assertiveness in the relationship.If there is greater desire and response with a new partner, the challenge may then be to remember the behaviors and interpersonal atmosphere that first led to desire for the established partner.
Mental and physical health
Assessment and management of overall mental health is vital, as is assessment of well-being at the time of sexual interaction. This includes energy levels, self-esteem, sense of attractiveness, body image, and freedom from stressful distractions and preoccupations.
Depression is strongly associated with reduced sexual function. Antidepressants, especially those that are highly serotonergic, may lessen sexual desire. Various medical conditions can also impact on a person’s level of desire.
Sexual context
A detailed assessment of a couple’s usual sexual context may lead the health professional to recommend changes. Factors that may be assessed include:
- Time of day;
- Time since last sexual activity;
- What happens in the hours preceding sexual opportunities; and
- What needs to be done after sexual activity.
The couple
Throughout the assessment process, the health professional will evaluate the couple’s emotional contracts, styles of communication, level of discord, conflict resolution style, and ways of defining problems.
When evaluating emotional contracts, the health professional will look at what is important for the couple to feel good emotionally, i.e. what is needed and what they do to feel happy. Western philosophy and psychology generally agree that happiness is good for people and distress is bad, that people seek happiness, and that it is easier to be happy when others are happy as well. To attain such conditions, it is useful to try to maximise pleasant emotions over the long term. Openness to emotion is also recognised as being important, because it permits emotional information to be recognised and coped with, thereby promoting conditions that foster happiness.
The health professional will also assess both sexual and nonsexual relational factors.
Thoughts during sexual interaction
The health professional may assess the individual’s ability to focus on sexual stimuli to determine if help is needed. Distractions regarding day-to-day stresses are common. Other distracting feelings include:
- Stress;
- Resentment;
- Sense of obligation regarding imposed sexual frequency or type of sexual interaction; and
- Prediction of negative outcome such as unwanted pregnancy, further proof of infertility, or lack of sexual satisfaction.
Intergenerational system
Family of origin factors and intergenerational factors are assessed through the use of a genogram. A genogram examines different aspects of familial functioning. Instances of incest, parentification, triangulation and other dysfunctional patterns of familial relationships that impact intimacy and sexuality will often need to be assessed.
Empirical tools
A health professional may use several tools to evaluate female clients. For general sexual dysfunction, the Female Sexual Function Index (FSFI) may be used, or the Sexual Interest and Desire Inventory-Female (SIDI-F) may be used for HSDD.
The FSFI is a validated 19-item self-report questionnaire and contains 6 domains, including desire, arousal, lubrication, orgasm, satisfaction and pain. Higher scores on the FSFI reflect better sexual function.
The SIDI-F contains thirteen items, which will be rated by the health professional (relationships-sexual, receptivity, initiation, desire-frequency, affection, desire-satisfaction, desire-distress, thoughts-positive, erotica, arousal-frequency, arousal-ease, arousal-continuation and orgasm). There are 4, 5, or 6 possible options for each item and each item contributes a score of points toward a SIDI-F total score. The score assigned to an option is based on clinical judgment about the relationship between the particular option and symptom severity. Higher scores on any particular item indicate increased levels of sexual functioning.
As yet, tools have not been developed for men.
Treatment of Hypoactive Sexual Desire Disorder
Because HSDD can be caused by any number of factors, including biological, psychological and social factors, there is no quick and easy method of treatment. Rather, the treatment of HSDD depends greatly on the individual, and must be comprehensive, flexible and individualized. It is therefore one of the most complex and difficult sexual problems to treat. Medical and psychological treatments can often be used in combination.
Medical therapies
Some prescription medications are sometimes used for sexual purposes. For example, bupropion sustained release (SR), an antidepressant, has a positive effect on various aspects of sexual function in women diagnosed with hypoactive sexual desire disorder. Bupropion SR is used to counteract HSDD caused by another group of commonly used antidepressants called selective serotonin reuptake inhibitors (SSRIs).
The side effects of many commonly used prescription medications can be a factor in HSDD. To overcome the sexual side effects of medications, a health professional may suggest:
- Waiting to see if the symptoms disappear;
- Lowering the dose;
- Substituting another medication;
- Adding a supplementary medicine to act as an antidote; or
- Discontinuing the medication for brief periods.
It is important that individuals do not make changes to their medication usage without first consulting their doctor.
Testosterone is important for sexual appetite in men and women as it promotes sexual desire, curiosity, fantasy, interest and behavior. Testosterone deficiency in men can be treated with an assortment of products, with varying results. However, testosterone deficiency in women cannot yet be treated with medication. The relationship between testosterone and sexual desire in women is complicated. HSDD in women cannot be diagnosed by assessing the level of circulating sex hormones such as testosterone; some women with low testosterone levels do not experience desire problems, and most women with HSDD have normal testosterone levels. Testosterone does increase sexual desire and well-being in postmenopausal women with HSDD.
SEX THERAPY
Sex therapy for HSDD may involve a number of treatment strategies.
Personal type of sexual desire
Perceiving oneself to be dysfunctional lowers sexual self-image, thus adding to the problem. A therapist will often begin by explaining the sexual response cycle and the type of sexual desire that is being experienced. Living with a type of sexual desire may be less difficult if there is an understanding that it is ‘within accepted normal limits,’ and if an individual agrees to nurture and enhance it. A sense of hope and of normality can in itself be therapeutic to both partners.
Relationship views
Within a relationship, couples often view the symptomatic partner as the one with the problem. In fact, HSDD is a relationship problem. One technique to help couples realise this is the therapeutic reframe, in which the therapist helps the couple think about HSDD in a different way. The therapist emphasises that the couple struggles together and will need to work together to resolve the problem.
Throughout the process of therapy, couples gradually learn that sexual desire and satisfaction are created, fostered, practiced and nurtured by the self and the partner, and that it is not just something that happens to one of them.
Other issues
Usually the therapist starts by focusing on the problem of sexual desire. However, during the course of treatment, other individual or relationship issues might become more important. These often include anxiety, anger, sexual ignorance or lack of communication.
Lowering response anxiety
One import aspect of HSDD treatment is lowering response anxiety. Several techniques may be used, including cognitive strategies such as thought-stopping or thought substitution, and systemic approaches such as paradoxical intervention.
Cognitive therapy
Cognitive therapy is a necessary part of treating HSDD. Negative thought patterns about sexual intimacy, the self and the partner directly contribute to lack of desire by preventing the emergence of enjoyable sexual thoughts and fantasies. Misinformation about sexual desire, the lack of desire, and sexuality in general must be corrected, so a therapist may provide psycho education at the same time.
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