Hypoactive sexual desire (HSD) is a condition that is characterized by the absence or notable decrease in the frequency in which the man experiences desire for sexual activity.
In contrast with other conditions related to the sexual life, the key clinical determinants of this diagnosis are not as concrete and readily identified as erection or ejaculation for instance, in the case of hypoactive sexual desire these clinical features refer to a variety of expressions of sexual desire, since the occurrence of sexual desire is an internal and subjective experience. Because of this, hypoactive sexual desire has been historically either not identified, or erroneously diagnosed and presented (and treated) as other sexual dysfunctions like erectile dysfunction.
Hypoactive sexual desire was first defined as a clinical entity in 1977, and recognized as a valid clinical diagnosis with the publication of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSMIII) in 1980. In recent publications, the importance of this condition has been highlighted.
The DSMIV, in its current edition, defines hypoactive sexual desire disorder as persistently or recurrently deficient (or absent) sexual fantasy and desire for sexual activity, leading to marked distress or interpersonal difficulty. However, since the DSM IV is a psychiatric classification, its definition excludes hypoactive sexual desire when it is caused by another medical disorder, or even another sexual dysfunction. There is some discussion in the literature as to this requirement, as the clinical practice illustrates, that the co-existence of hypoactive sexual desire disorder with other sexual dysfunctions such as erectile dysfunction is rather common, and the management of the combined conditions often requires specific clinical decisions and actions.
Epidemiology and Risk Factors
There are two reports in the literature that merit commentary when attempting to answer the question: how prevalent is HSD?
Data from a probability sample study of sexual behavior in a demographically representative, 1992 cohort of US adults, known as the National Health and Social Life Survey, and that included 1749 women and 1410 men aged 18 to 59 years at the time of the survey, was analyzed by Laumann and colleagues. A latent class analysis (LCA) was used to evaluate the syndromal clustering of individual sexual symptoms. Latent class analysis is a statistical method well suited for grouping categoric data into latent classes. Latent class analysis tests, whether a latent variable, or specified as a set of mutually exclusive classes, accounts for observed covariation among manifest, categoric variables. This study reports a 5 % prevalence of low sexual desire, which should be compared to the 5 % prevalence reported for erectile dysfunction (ED).
In a more recent report, named the Global Study of Sexual Attitudes and Behaviors (GSSAB) — an international survey of various aspects of sex and relationships among adults aged 40 to 80 years — an estimate of the prevalence and correlates of sexual problems in 13 882 women and 13 618 men from 29 countries is reported by Laumann and co-workers. Although the figures for low sexual desire are derived exclusively from the participant’s response to a single question, the report has the value of including a rather large variation in countries and cultures. Depending on the geographic area, prevalence of “lack of sexual interest”, a category where respondents answering “occasionally, periodically or frequently” were included, varied from 12.5% to 28.0%. The risk factors that in this study reached statistical significance in a more or less consistent way across the different regions of the world.
The Components of Sexual Desire
Sexual desire is not a single phenomenon. Anyone can say he is experiencing sexual desire for several reasons that do not correspond necessarily to the physiology of desire. In this respect Levine has suggested an interesting division; according to his view it is clinically useful to think of desire as consisting of drive (biologic), motive (individual and relationship psychology), and wish (cultural) components. The drive component of desire is what we could expect to be explained (some day) by the neurochemical mechanisms in the brain. The motivational component of desire might be a result of the interaction of the couple, for instance: “1 want to have sex with her, otherwise she will leave”. And the cultural component of desire can be best represented by what is considered a highly desirable partner in a culture, with whom the man needs to have desire in order to conform to the cultural demand of a “true man”. Both in clinical practice and in the general surveys that explore the level of sexual desire the three components are always interwoven.
Etiology of Hypoactive Sexual Desire
Hypoactive sexual desire is a condition that many times is part of another disease or disorder. Other times, the decrease or absence of sexual desire occurs with no other sexual dysfunction or recognizable pathology. In any event, it is critical that the clinician identifies this condition; lack of success in treatment of other sexual dysfunctions, like erectile dysfunction, can sometimes be explained by the presence and lack of proper treatment of HSD. The list included in Table List of medical and psychologic factors that can cause HSD, taken from Meuleman & Van Lankvled (2005), is a summary of the causes of hypoactive sexual desire seen frequently in clinical practice.
Table List of medical and psychologic factors that can cause HSD
- Androgen deficiency
- Anger and anxiety
- Relationship conflict
- Antidepressant therapy
- Post-traumatic stress syndrome
- Coronary disease and heartfailure
- Body-building and eating disorders
Hypoactive sexual desire is frequent in men with erectile dysfunction (ED). In a series of 428 men with erectile dysfunction, Corona and co-workers (2004) reported that 43.3% of their participants had the condition. This group found no correlation for patient or partner’s age. Men with hypoactive sexual desire in this study were not diagnosed as hypogonadic more frequently than men without HSD; however ANOVA showed a significant (P< 0.005) difference of total, free testosterone and prolactin levels among patients with different severities of HSD. No significant correlation was found for: follicle-stimulating hormone (FSH) (r = 0.04), luteinizing hormone (LH) (r= 0.04), thyroid-stimulating hormone (TSH) (r = 0.06), or testis volume (r = -0.08). No correlation was found for: prostate specific antigen (PSA), blood pressure, lipid profile, glycemia, and parameters derived from echo color Doppler. The psychologic correlates found were: free-floating anxiety, somatic symptoms, obsessive — compulsive traits, and depressive symptoms.
Diagnosis of Hypoactive Sexual Desire
The diagnosis of hypoactive sexual desire is not difficult if the clinician asks directly about desire or interest for sexual activity. Most patients identify with ease a change in their usual pattern, and this is the way in which the condition is identified most of the time in clinical practice. Sometimes, it is necessary to investigate the indicators of sexual desire, which, although not as direct as the expression of desire, are often good clinical indicators . Table Clinical indicators of sexual desire shows a list of clinical indicators of sexual desire.
Table Clinical indicators of sexual desire
- Sexual frequency
- Sexual fantasies
- Sexual thoughts
- Initiation of sexual activity
The question of how much is too little has not been answered with enough precision. However, some reports in the literature give some light to this. In a group of non-dysfunctional couples, LoPiccolo and Friedman reported that the majority of the participants both desired and had sexual activity between once and four times a week. In a research setting, Schiavi suggested a criteria of sexual activity occurring less than once every two weeks, for persons 55 years or younger, suggests HSD.
Some patients present themselves as having low sexual desire, which in fact is a result of another sexual dysfunction. Erectile dysfunction is sometimes confused by the patient as a sign of diminished desire. Likewise, the avoidance pattern that follows the frustration generated by a persistent dysfunction, like severe premature ejaculation or erectile dysfunction, can also be reported as absence of desire. These clinical situations demand a careful evaluation from the clinician before arriving at a clinical diagnosis.
In addition to identifying the condition, it is recommended that the main causes of hypoactive sexual desire be screened during the initial consultation. The evaluation should include the measurement of serum total testosterone and prolactin as a minimum and, depending on the additional clinical signs, further endocrinologic testing might be appropriate.
Depression and Relationship Conflict Detection
Identification of depression and the presence of relationship conflict should also be part of the initial evaluation. Both can be identified through the clinical interview; however, in many instances the use of screening tools can be useful and helpful.
There are several scales that have been developed for depression detection. A short and useful tool, developed for the geriatric population, might be of help for the clinician unfamiliar with depression or with restricted time during consultation, and is included in Table Five-item version of the Geriatric Depression Scale. The briefness of the scale (only five items) and good psychometric properties make this a useful instrument for the detection of depression among older men.
Table Five-item version of the Geriatric Depression Scale
- 1. Are you basically satisfied with your life?
- 2. Do you often get bored?
- 3. Do you often feel helpless?
- 4. Do you prefer to stay home rather than going out and doing new things?
- 5. Do you feel prettyworthlessthewayyouarenow?
Positive answers for depression screening are “yes” to questions 2, 3, 4 and 5, and a “no” to question 1. A score of 0 to 1 positive answers suggest the patient is not depressed; a score 2 or higher indicates possible depression.
Conflict in relationships is easy to identify if the right questions are asked. Sometimes asking directly about the quality of the relationship will give enough information. The questions included in Table Quebec 2000 Abbreviated Dyadic Adjustment Scale can provide good clinical information about the quality of the relationship. Although they were developed in a research setting, the scale provides a good guideline on what to investigate when a couple is being evaluated.
Table Quebec 2000 Abbreviated Dyadic Adjustment Scale
- 1. Do you and your partner agree or disagree on displays of affection?
- 2. Do you often think about getting a divorce or separation, or ending your current relationship?
- 3. In general, wouldyousaythateverything isfine between you and your partner?
- 4. Do you confide in your partner?
- 5. Do you ever regret getting married (or living together)?
- 6. How many times do you and your partner calmly discuss something?
- 7. How many times do you and your partner work together on something?
- 8. Circle the number that best corresponds to your level of happiness as a couple (rate between 1 and 7,7 being perfectly happy).
As in many other areas of medical diagnosis, identifying a condition does not necessarily mean treating the condition. Many of the depressed patients or the distressed couples will have to be referred for proper treatment. However, when these conditions are not identified by the treating physician, the clinical managing of the case cannot be successful.
Treatment of Hypoactive Sexual Desire
Treatment of hypoactive sexual desire is directed to the putative cause of the condition. There are no effective symptomatic treatments for HSD, as there are for erectile dysfunction (i.e. phosphodiesterase-5 (PDE-5) inhibitors). Bupropion, an antidepressant medication that has an effect in the re-uptake of dopamine and norepinephrine, has been studied, and it has shown a modest effect on women with hypoactive sexual desire when compared to placebo (using the slow-release form starting 150 mg/day for one week and then 300 mg/day), An early report by Crenshaw and co-workers included men and women who were not depressed, but who had some form of psychosexual dysfunction (inhibited sexual desire, inhibited sexual excitement or inhibited orgasm), and indicated some positive effect on patient’s rated libido and global improvement, which was statistically significant compared to placebo; unfortunately, it is not clear from the report how many men responded. The response rates, though statistically significant when compared with placebo in all these studies, is low compared with the efficacy of PDE-5 treatment for erectile dysfunction; therefore the clinical use of this alternative is limited.
Testosterone replacement can be of benefit if the patient has hypogonadism. In any event, testosterone replacement therapy should be established with the criteria outlined in the site “Hormones, Metabolism, Aging and Men’s Health” of this book. Likewise, cases of hyperprolactinemia should be further studied and treated; the same site in this book offers guidelines for this treatment.
If depression is identified, then appropriate treatment for it should be established. A number of anti-depressant medications exist, with demonstrated efficacy and safety. Likewise, if a conflict in the relationship is encountered, proper treatment should be established. As mentioned earlier, antidepressant therapy can in its turn decrease sexual desire, This is sometimes a clinical situation that requires careful evaluation. If the antidepressant medication is considered as having a causative role in the low desire condition, changing the dose or considering a different medication might be helpful.
Sometimes, troubled relationships could benefit from relatively simple interventions. Simple suggestions can improve partner interaction for some couples and this can be done in the primary care setting. They include: use of open communication on sexual issues with an open and honest approach; increase of time dedicated to physical intimacy; increase of time dedicated to talk about intimacy issues; and sharing of feelings. Severe conflict should be referred to specialized professionals.
Psychotherapy has a role in the treatment of depression and in conflicted relationships. Specific psychotherapeutic interventions for hypoactive sexual desire have been described as having the following components (1): affectual awareness, that basically strives for identification of positive and negative emotions related to sexual interaction and desire; insight and understanding, where a framework to understand the problem is offered to the patient; cognitive and systemic therapy, when individual psychologic causes are addressed and interaction factors are addressed and corrected; and finally, behavioral intervention, where a number of strategies are utilized to gradually overcome obstacles to sexual interaction.
A very important part of proper management in the primary care scenario is to refer to another professional when the indicated treatment cannot be provided. A referral should be done if either the etiology of hypoactive sexual desire cannot be identified, and/or if proper treatment cannot be provided.