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Hypoactive Sexual Desire Disorder DEFINITION, DIAGNOSIS, AND PREVALENCE The DSM-IV-TR refers to clinically low levels of sexual desire as hypoactive sexual desire disorder (HSDD). In order to meet the diagnostic criteria for HSDD, the person must experience a persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty. Whether a person is distressed by their level of desire is necessarily impacted by whether their partner has similar sexual needs. For example, a couple who both prefer sexual activity only once a month or less would, by most standards, be exhibiting levels of desire below normal. However, because they are well matched in their sexual needs, it is unlikely that they would be distressed by their low levels and, therefore, would not meet the DSM-IV-TR diagnostic criteria. In a random probability sample of 1,410 US men and 1,749 US women, Laumann and associates (Laumann, Gagnon, Michael, & Michaels, 1994) reported 14% of men between the ages of 18 and 29 experienced a lack of sexual interest. Findings from the Laumann et al. study also revealed a number of interesting aspects with respect to sexual drive mechanisms. Men reported lack of sexual interest as they aged, particularly after age 50, and married men were significantly less likely to report inhibited desire compared to divorced or never married men. Same-sex couples show different patterns of sexual desire compared to heterosexual couples; men in relationships with men are more likely to report low sexual desire when they view their sexual orientation more negatively. FACTORS ASSOCIATED WITH HSDDCases of low desire in men are often related to medical conditions or pharmacological treatments that affect hormone levels, particularly testosterone. Men receiving testosterone replacement therapy because of a deficient secretion of gonadal hormones show a significant drop in sexual interest when treatment is stopped, and a return in sexual interest when hormone treatment is reinstated. This indicates that very low testosterone levels may impair sexual desire in men. However, once testosterone levels reach a certain threshold, additional testosterone does not further enhance sexual desire. In other words, testosterone administration to men with normal testosterone levels will not increase sexual desire even if they are experiencing low sexual desire. In adolescent males, higher testosterone levels are associated with increased frequency of sexual fantasies and sexual activity but this relationship does not hold true in adult men. Possibly, during and around puberty internal factors including hormones trigger sexual appetite, while in adulthood external cues such as relationship factors play more of a key role in facilitating desire. Some evidence suggests that estrogen and progesterone administration reduces sexual desire in men with excessive or inappropriate desire, although few studies have been published on this topic (Meston & Frohlich, 2000). It is well known that many psychoactive medications affect sexual drive. Selective serotonin reuptake inhibitors (SSRIs), used most commonly for treating depression, increase serotonin levels and produce a variety of sexual side effects including decreased desire. Sexual dysfunction secondary to SSRI use is believed to result, in part, from activation of the serotonin 2 receptor. Newer generations of antidepressants that act as antagonists (blockers) at the serotonin 2 receptor (e.g., naphazodone) are associated with fewer sexual side effects. Drugs that facilitate dopamine activity, such as the antiparkinsonian medication levodopa, tend to increase sexual desire in men; the role of dopamine activity in female sexual desire is not known. HSDD has also been linked with a number of psycho-social factors. Daily hassles such as worrying about children and paying the bills, and high stress jobs are offenders for suppressing sexual desire, as are a multitude of relationship or partner-related issues. With regards the latter, couples reporting sexual difficulties, compared to non-clinical control couples, have been characterized as having less overall satisfaction within their relationships, an increased number of disagreements, more communication and conflict resolution problems, and more sexual communication problems including discomfort discussing sexual activities. They also tend to display less playfulness and spontaneity within their relationships, less closeness, intimacy, and feelings of mutual love, and more aversive feelings and thoughts within their sexual interactions. Warmth, caring, and affection within the relationship are undoubtedly linked to feelings of sexual desire. Psychological conditions most commonly associated with a lack of sexual desire include social phobia, obsessive compulsive disorder, panic disorder, and mood disorders - depression in particular. It is feasible that sexuality at large becomes of secondary importance when an individual is experiencing substantial distress in other areas of his life. With regards depression, it is feasible that rumination of negative events, a common cognitive aspect of depression, may contribute to the decrease in desire noted in depressed persons by causing an exclusive focus on aspects of sexuality that are unpleasant. Also, it is well known that people with depression are prone to interpret negative events as caused by stable, global causes (Hankin, Fraley, & Abela, 2005) and this cognitive style could certainly negatively affect one’s perception of sexuality.
ASSESSMENT AND TREATMENT OF HSDDDiagnosing HSDD is difficult because of the subjective nature of what constitutes sexual desire. Diagnosis of HSDD needs to be carefully considered within the context of the dyadic relationship, and must take into consideration factors known to affect sexual functioning such as the person’s age, religion, culture, the length of the relationship, the partner’s sexual function, and the context of the person’s life. Assessment of HSDD should comprise a complete sexual, medical, and psychosocial history which can be obtained through standardized interviews and validated self-administered questionnaires. The clinician should explore the onset of the sexual problem keeping in mind dates of surgeries, medication changes, and diagnoses of medical conditions. Laboratory testing may be warranted, given the close relationship between androgens and sexual desire. A complete psychosocial history should include: situational problems, relationship history, sexual problems of the partner, mood, sexual satisfaction, and psychological disorders. Testosterone treatment is effective for restoring desire in men with abnormally low levels of testosterone. Psychological treatments for HSDD include education about factors that affect sexual desire, couples exercises (e.g., scheduling times for physical and emotional intimacy), communication training (e.g., opening up about sexual issues and needs), cognitive restructuring of dysfunctional beliefs (e.g., a good sexual experience doesn’t always end with an orgasm), sexual fantasy training (e.g., training people to develop and explore mental imagery), and sensate focus. Sensate focus, introduced by Masters and Johnson in the 1970’s, is a behavioral technique in which couples learn to focus on the pleasurable sensations that are brought about by touching, while decreasing attention on goal directed sex (e.g., orgasm). For persons in satisfying relationships, treatment may include identifying potential distracting, negative thoughts and helping them let go of these thoughts during sexual activity. Behavioral techniques designed to help men explore their sexual likes and dislikes, alone or with their partners, can be used to help them associate sexual behaviors with positive affect and experiences. For individuals who are distracted by feelings of shame or embarrassment about their bodies, cognitive restructuring might involve helping them to identify their fears (e.g., a fear of rejection) and dysfunctional beliefs (e.g., “My partner thinks my body isn’t sexy”) and then test the accuracy of these beliefs through a series of strategically designed behavioral experiments. The experiments aim at reducing avoidance behavior and provide corrective experiences to counteract dysfunctional beliefs.
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