Hypoactive sexual desire disorder

HSDD has a variety of causes. Some are physical:

  • Underlying medical conditions. Diabetes, heart disease, cancer, psychiatric conditions (depression), neurological diseases (multiple sclerosis), hypothyroidism, and arthritis can all diminish libido.
  • Medications. Many drugs have sexual side effects, including decreased sex drive. The following medications lower libido in some people:
    • Antidepressants (selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants)
    • Antipsychotics (for mental health disorders like schizophrenia and bipolar disorder)
    • Beta-blockers (used to treat high blood pressure, glaucoma, and migraine)
    • Benzodiazepines (for insomnia and anxiety)
    • Oral contraceptives (birth control pills)
    • Opioids (painkillers, such as morphine and oxycodone)
  • Menopause, pregnancy, and breastfeeding. Hormonal changes during these times, especially drops in estrogen during menopause, can trigger HSDD.
  • Lifestyle. Caregiving, work responsibilities, or a hectic social schedule can be tiring and stressful. At the end of a long day, or a particularly demanding stretch of time, people may just be too tired to think about sex.
  • Sexual problems. When sex involves pain or dysfunction, the disappointment and dissatisfaction may reduce desire.

My sexual appetite has vanished…

What is the most important information I should know about ADDYI (add-ee)?

Your risk of severe low blood pressure and fainting (loss of consciousness) is increased if you take ADDYI and:

  • drink alcohol close in time to when you take your ADDYI dose.
    • Wait at least 2 hours after drinking 1 or 2 standard alcoholic drinks before taking ADDYI at bedtime.

Examples of 1 standard alcoholic drink include:

      • one 12-ounce regular beer
      • 5 ounces of wine
      • 1.5 ounces of distilled spirits or shot
    • If you drink 3 or more standard alcoholic drinks in the evening, skip your ADDYI dose at bedtime.
    • After you have taken your ADDYI at bedtime, do not drink alcohol until the following day.
  • take prescription medicines, over-the-counter medicines, or herbal supplements. Do not take or start taking any prescription medicines, over-the-counter medicines, or herbal supplements while taking ADDYI until you have talked with your doctor. Your doctor will tell you if it is safe to take other medicines or herbal supplements while you are taking ADDYI.
  • have liver problems. Do not take ADDYI if you have liver problems.

If you take ADDYI and you feel lightheaded or dizzy, lie down right away. Get emergency medical help or ask someone to get emergency medical help for you if the symptoms do not go away or if you feel like you could faint (lose consciousness). If you faint (lose consciousness), tell your doctor as soon as you can.

What is ADDYI?

ADDYI is a prescription medicine used to treat hypoactive (low) sexual desire disorder (HSDD) in women who have not gone through menopause, who have not had problems with low sexual desire in the past, and who have low sexual desire no matter the type of sexual activity, the situation, or the sexual partner. Women with HSDD have low sexual desire that is troubling to them. Their low sexual desire is not due to:

  • a medical or mental health problem
  • problems in the relationship
  • medicine or other drug use

ADDYI is not for use for the treatment of HSDD in women who have gone through menopause or in men.

ADDYI is not for use to improve sexual performance.

ADDYI is not for use in children.

What should I tell my doctor before taking ADDYI?

Before you take ADDYI, tell your doctor about all of your medical conditions, including if you:

  • drink alcohol, use drugs, or have a history of alcohol or drug abuse
  • have ever had depression or other mental health problems
  • have low blood pressure or a medical condition that can cause low blood pressure
  • are pregnant or plan to become pregnant. It is not known if ADDYI will harm your unborn baby.
  • are breastfeeding or plan to breastfeed. It is not known if ADDYI passes into your breast milk. You and your doctor should decide if you will take ADDYI or breastfeed. You should not do both.

Tell your doctor about all of the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. ADDYI can affect the way other medicines work, and other medicines can affect the way ADDYI works, and can cause serious side effects.

What are the possible side effects of ADDYI?

ADDYI can cause serious side effects, including:

  • Sleepiness is a common side effect of ADDYI and can be serious. Taking ADDYI can increase your risk of sleepiness if taken during waking hours, if you drink alcohol, or take certain medicines or herbal supplements.
  • Low blood pressure and fainting (loss of consciousness) can happen when you take ADDYI even if you do not drink alcohol or take other medicines or herbal supplements. Your risk of low blood pressure and fainting (loss of consciousness) is increased if ADDYI is taken during waking hours, if you drink alcohol within 2 hours of taking ADDYI, or if you take certain medicines or herbal supplements.

The most common side effects of ADDYI include:

  • Dizziness
  • Difficulty falling asleep or staying asleep
  • Nausea
  • Dry mouth
  • Tiredness

These are not all of the possible side effects of ADDYI. Call your doctor for medical advice about side effects. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

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Low Sex Drive in Women: Symptoms, Diagnosis, and Treatment

It’s common for premenopausal and postmenopausal women to experience changes in estrogen levels. This is due to a reduction of blood flow to the vagina.

If lowered estrogen levels are causing your symptoms of HSDD, estrogen therapy may be suggested. Your doctor will recommend applying a cream, suppository, or ring that releases estrogen in the vagina. This can increase blood flow without the unwanted side effects that come with taking an estrogen pill.

Another treatment option is the pill flibanserin (Addyi), which has been approved by the Food and Drug Administration (FDA). This medication has been shown to boost sex drive in premenopausal women with low sexual desire.

However, the drug is not for everyone. Possible side effects include hypotension (low blood pressure), fainting, and dizziness.

The injectable medication bremelanotide (Vyleesi) has also been FDA-approved to treat low sex drive in premenopausal women. Possible side effects include severe nausea, reactions at the site of the injection, and headache.

Lifestyle changes could also relieve stress and help improve a woman’s libido. These include:

  • exercising regularly
  • setting aside time for intimacy
  • sexual experimentation (such as different positions, role-playing, or sex toys)
  • avoiding substances that affect sexual desire, like tobacco and alcohol
  • practicing stress-relieving techniques, such as mindfulness-based interventions

Don’t underestimate the effect a decreased sexual desire can have on your well-being. If you feel symptoms of HSDD have impacted your quality of life, talk to your doctor. There are treatment options available.

Sometimes you want sex, sometimes you don’t. That’s normal. Every woman has her own level of what is considered “normal” based on their own experiences and biological drive. But when a woman has a low libido or low sexual desire and is bothered by this lack of interest in sex, she may have a condition called hypoactive sexual desire disorder (HSDD).

HSDD is defined as the absence of sexual fantasies and thoughts, and/or desire for or receptivity to, sexual activity that causes the personal distress or difficulties in her relationship. This distress is an important component. After all, some women with what is considered a low libido may not have any distress or problems with a partner as a result.

While prevalence rates vary, The Society for Women’s Health Research estimates that about one in ten women have HSDD, making it one of the most common female sexual difficulties.

What causes HSDD?

There are many potential causes, both physical and psychological.

  • There are a number of physical conditions associated with HSDD, including breast cancer, diabetes, depression, urinary incontinence, thyroid problems, and multiple sclerosis, among others.
  • An imbalance of neurotransmitters (chemicals) in the brain may be the cause, as the chemicals that can cause (or inhibit) sexual desire and excitement may be out of balance.
  • Diminished libido may be a side effect of certain medications, including medications used to treat depression, anxiety and high blood pressure, as well as some medications to treat pain.
  • Relationship issues may play a role for some women. If there is conflict or a lack of trust in a relationship, women may lose interest in sex with that partner as a result. (Although it should be noted that a woman may experience HSDD and not be in a relationship).
  • Some psychological conditions may be associated with the development of HSDD, including depression, anxiety and low self-esteem.

Can HSDD be treated?

HSDD is treatable and can be manageable, so the first step if you are concerned about a lack of interest in sex is to talk to a healthcare provider to see what options are available. The provider may ask a series of questions called the Decreased Sexual Desire Screener (DSDS) to help diagnose HSDD. The first four questions are:

  1. In the past, was your level of sexual desire/interest good and satisfying to you?
  2. Has there been a decrease in your level of sexual desire/interest?
  3. Are you bothered by your decreased level of sexual desire/interest?
  4. Would you like your level of sexual desire/interest to increase?

If a woman answers ‘no’ to any of these questions, she likely will not be diagnosed with HSDD. If she answers ‘yes’ to these, she will also be asked about other factors that may be contributing to her low desire, including physical and mental health conditions, recent childbirth, her relationship with her partner, her level of stress and fatigue, and other issues.

Treatment may include sex therapy or counseling, alone or with a woman’s partner, to address any mental health or relationship issues that may be present. Medications may be evaluated as contributing factors, and underlying medical conditions may be addressed.

For women who have not yet gone through menopause, there two FDA-approved treatments for HSDD. One treatment involves taking a once-daily pill while the other is a self-administered shot taken as needed. A healthcare provider can explain the treatment options and help you decide which would be best for you.

Hypoactive sexual desire disorder (HSDD)

  • What is Hypoactive Sexual Desire Disorder (HSDD)?
  • Statistics
  • Risk Factors
  • Progression
  • Symptoms
  • Clinical Examination
  • Treatment

What is Hypoactive Sexual Desire Disorder (HSDD)?

The traditional definition of hypoactive sexual desire disorder (HSDD) is an absence of sexual fantasies and desire for sexual activity. The disturbance must cause marked distress or interpersonal difficulty; cannot be better accounted for by another major mental disorder (except another sexual dysfunction); and is not due solely to the effects of a substance or general medical condition.

This definition is based on the traditional model of human sexual response. It is important to note that this model derived from studies on predominantly male subjects, emerging from the work of William Masters and Virginia Johnson, and later expanded by Helen Singer Kaplan. This linear male based model states that desire precedes arousal, orgasm, and resolution. It has traditionally been used for teaching about human sexuality, for diagnosing dysfunctions and disorders, and for both pharmacological and non-pharmacological treatment planning.

However, research has made it clear that sexual desire that takes the form of sexual fantasising, yearning, and looking forward to sexual experiences – in other words, this ‘spontaneous’ desire – is infrequent in many sexually functional and satisfied women, especially those in established relationships. It is now recognised that sexual desire can be responsive, occurring after arousal or physical stimulation, rather than a spontaneous event before arousal. For many women, it would appear that sexual arousal and a responsive type of desire occur at some point after they have chosen to experience sexual stimulation.

Moreover, studies have confirmed that women mostly accept or initiate sexual interaction for reasons other than desire, such as to increase emotional bonding, or as a response to romantic settings or more specifically erotic cues.

This research has called into question the traditional definition of HSDD and the estimated number of women with sexual desire disorder, which are based on the traditional linear model.When both responsive desire and the many aspects of sexual motivation are reflected in a model of sexual response, the structure is circular rather than linear, and reflects the overlapping of the desire and arousal phases reported by women.

This has resulted in a revised definition of HSDD for women:

Absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies, and a lack of responsive desire. Motivations for attempting to become sexually aroused are scarce or absent. The lack of interest is considered to be beyond a normative lessening with life cycle and relationship duration.

Statistics

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


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

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

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 judgemental 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 behaviours 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

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 individualised. 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 behaviour. 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 psychoeducation at the same time.

Homework assignments

Homework assignments play an important role in treating HSDD, as they address individual, relational, and intergenerational issues associated with the lack of sexual desire. Homework for the individual may include guided imagery, directed masturbation, and exposure to fantasy. For the couple, on the other hand, homework may include sensate focus, communicating sensual and sexual wishes and needs, and conflict resolution exercises.

Kindly written by Desiree Spierings BA (Psych) MHSc (Sexual Health); Sex Therapist; Director of Sexual Health Australia and Editorial Advisory Board Member of Virtual Men’s Health and Virtual Women’s Health.

Hypoactive Sexual Desire Disorder
Cindy Meston, Ph.D. & Amelia M. Stanton

Male Hypoactive Sexual Desire Disorder

Definition, Diagnosis, and Prevalence

Male Hypoactive Sexual Desire Disorder (MHSDD) is defined in the DSM-5 as persistent or recurrently deficient sexual or erotic thoughts, fantasies, and desire for sexual activity. These symptoms must have persisted for a minimum of six months, and they must cause clinically significant distress. The disorder is specified by severity level and subtyped into lifelong versus acquired, generalized versus situational.

In past editions of the DSM, hypoactive sexual desire disorder was gender non-specific and could therefore apply to either men or women. As sexual desire and arousal problems have been combined into a single disorder for women in DSM-5, MHSDD now accounts only for men. Other than the change from a gender non-specific disorder to a gender-specific disorder, there have not been any substantive alterations in the diagnostic criteria from DSM-IV-TR to DSM-5. One small change is worth noting. In DSM-IV-TR, hypoactive sexual desire disorder required “persistent” low interest in sex. The DSM-5 now specifies requires that the symptoms be present for at least six months before a diagnosis can be conferred.

Low desire is less commonly the presenting clinical sexual complaint for men, who are more likely to present with erectile dysfunction. Cultural norms that often portray men as being ever desirous of sex may make it difficult for men to report low sexual desire to their physicians or their psychologists.

Most epidemiological studies have not inquired about the full set of diagnostic criteria for HSDD, making it difficult for researchers to determine accurate prevalence rates for the disorder. Research studies have asked men if they have a lack of interest in sex, but not whether the problem was consistent over a period of 6 months and distressing. One study did examine the prevalence of distressingly low sexual interest in men over at least a two-month period. In this study, 14.4% of men in Portugal, Croatia, and Norway reported a distressing lack of sexual desire lasting at least 2 months (Carvalheira, Traeen, & Štulhofer, 2014). Men between the ages of 30 and 39 were most likely to report low sexual interest.

Self-reported prevalence rates of problems with desire range from 4.8% in the U.S. (Laumann, Glasser, Neves, & Moreira, 2009) to 17% in the U.K. (Mercer et al., 2003). Desire problems appear to increase with age. In a sample of Swedish men between the ages of 66 and 74, 41% experienced low sexual desire (A. Fugl-Meyer & Sjogren, 1999). Prevalence rates typically decrease when studies examine persistent lack of interest in sexual activity. In a sample of 40 to 80 year-old men in the U.S., 4.8% reported an occasional lack of sexual desire, while only 3.3% reported a frequent lack of sexual desire (Laumann, Glasser, Neves, & Moreira, 2009).

Men in community samples are more likely to report desire problems than men in clinical samples. In community samples, reports of desire concerns exceed reports of erectile problems (Fugl-Meyer & Sjogren, 1999; Mercer et al., 2003). Men in clinical settings may feel more comfortable talking about erectile problems than desire problems, especially if they consider their problems to be biological rather than psychological in nature (Kedde, Donker, Leusink, & Kruijer, 2011).

Factors Associated With Male Hypoactive Sexual Desire Disorder

Given that research has not yet examined factors associated with MHSDD as defined in DSM-5, our review will focus on the causes and consequences of low sexual interest (formerly HSDD). Historically, hormones have been the focus of biological research on low sexual desire in men. Recent studies have also investigated the relationship between neurological disorders and poor sex drive. Psychological causes of decreased interest in sexual activity seem to include relationship difficulties and certain mental health problems.

Biological Factors

Hormonal factors are often implicated in low sexual desire. In men for whom androgen levels have been suppressed, low testosterone levels have been associated with low levels of sexual interest (Bancroft, 2005). For these men, testosterone replacement has been shown to increase sexual desire; this is not the case for men with normal androgen levels (Giovanni Corona, Rastrelli, & Maggi, 2011; Isidori et al., 2005; Khera et al., 2011). Hypogonadism, diminished functional activity of the gonads, has been observed in 3-7% of men between the ages of 30 and 69 and in 18% of men aged 70 and older (Araujo et al., 2007). This condition may account for the relationship between aging and low sexual interest. Hyperprolactinema, defined as high levels of prolactin, and hypothyroidism have also been associated with low sexual desire in men (Carani et al., 2005; G Corona et al., 2004; Giovanni Corona et al., 2011; Maggi, Buvat, Corona, Guay, & Torres, 2013).

Neurological disorders and other medical conditions are associated with low sexual desire. In a recent study, one quarter of men with multiple sclerosis reported low sexual interest (Michal Lew-Starowicz & Rola, 2014). Men with inflammatory bowel disease (IBD), Crohn’s disease, and ulcerative colitis have also reported low sexual desire. However, decreased desire may result from the medications used to treat conditions like IBD, which have been shown to lower testosterone. Furthermore, IBD is highly comorbid with depression, which may or may not be the underlying cause of decreased sexual interest (O’Toole, Winter, & Friedman, 2014). Coronary disease, heart failure, renal failure, and HIV have also been associated with low sexual interest in men (Bernardo, 2001; Lallemand, Salhi, Linard, Giami, & Rozenbaum, 2002; Meuleman & Van Lankveld, 2005; Toorians et al., 1997). It remains unclear if decreases in desire are due to the conditions themselves, the medications used to treat the conditions, or the psychosocial stressors that often accompany the conditions. Further research in this area is warranted.

Psychological Factors

There are many psychological factors that have been associated with low sexual desire in men. These factors may include relationship problems, concerns about one’s own sexual performance, and comorbid psychological conditions, such as depression and anxiety. In a sample of male outpatients seeking treatment for sexual dysfunction, psychosocial symptoms were more predictive of low sexual interest than hormonal and other biological factors (Corona et al., 2004).

Relationship problems and interpersonal factors have been strongly associated with the male sex drive. Men who have partners with low sexual desire are more likely to have sexual desire concerns than men who have partners without desire problems (McCabe & Connaughton, 2014). Desire problems have also been linked to not finding one’s partner attractive and to long-term (more than 5 years) relationships (Carvalheira et al., 2014).

Individual factors, particularly mental health problems, have also been related to sexual desire problems in men. In a survey of male outpatients who sought treatment for sexual dysfunction, 43% of the men with a history of psychiatric symptoms reported moderate to severe loss of sexual desire (Corona et al., 2004). Many studies have highlighted the correlation between depression and low sexual desire (Carvalheira et al., 2014; McCabe & Connaughton, 2014; Pastuszak, Badhiwala, Lipshultz, & Khera, 2013).

Assessment and Treatment of Male Hypoactive Sexual Desire Disorder

Given that MHSDD is new to DSM-5, there are no assessment tools or treatment studies based on the new diagnostic criteria. However, there are many studies that focus independently on the assessment and treatment of low sexual desire in men. Treatment for MHSDD differs based on the etiology of the disorder, but the most common biological treatment centers on increasing testosterone levels. Though treatments targeting testosterone have been efficacious, they have recently been overprescribed and overused by men with normal testosterone levels. Psychosocial treatment for MHSDD includes cognitive and behavioral components, as well as attention to building strong communication between partners.

Assessment

Assessment for MHSDD should include private meetings with each member of the couple, as well as a couples meeting. Individual meetings with the male partner may reveal a number of diagnostic factors, including atypical arousal patterns that are not being met by his current partner, decreased attraction to his current partner, or a sexual affair that is satisfying his sexual needs outside of his current relationship.

In addition to having individual and group? Do you mean couple meetings, clinicians should also assess for changes in health status, life stressors, and relationship factors around the time that the male partner started to experience a lack of sexual interest. These factors may become the target of the clinician’s treatment plan.

Clinicians should also consider the possibility that male patients presenting with complaints of low sexual desire may actually be suppressing their desires. This often occurs in men who are in long-standing heterosexual relationships who either have had sexual relations with men or who have fantasized about sexual relations with men during masturbation (Meana & Steiner, 2014b). The re is also a small possibility that men who report low sexual desire may be asexual, meaning that they may not be sexually attracted to anyone or anything also needs to be explored.

Treatment

Treatment for low sexual desire in men should be etiologically oriented. If low testosterone level is determined to be the likely cause of MHSDD, biological treatment focuses primarily on increasing testosterone levels. As mentioned earlier, hypogonadism in males typically leads to low testosterone production, decreased sexual interest, and difficulties sustaining an erection. Testosterone replacement therapy can be delivered through the skin via an over the counter gel or patch, by injections, or by slow release pellets (Testopel) implanted under the skin. In a couple of studies, increasing testosterone levels has been shown to have beneficial effects on sexual motivations and sexual thoughts (Allan, Forbes, Strauss, & McLachlan, 2008; Wang et al., 2000).

There has been some concern about the overuse of testosterone gels, especially by men who have normal testosterone levels. According to Handelsman (2013), the prescribing of off-label testosterone, particularly transdermal testosterone, has increased in most countries between 2000 and 2011, and the rising trend accelerated over the last half decade of the survey period. One of the likely causes of this increase may be the permissive US and European guidelines for the prescription of testosterone, which promote the use of the drug for age-related functional androgen deficiency (Handelsman, 2013). In some countries, total testosterone prescribing exceeds the maximum amount that could be attributed to pathological androgen deficiency, which is known to occur in about 0.5% of men (Handelsman, 2010). In a study of older men randomly assigned to either daily application of testosterone gel or daily application of a placebo gel, men in the active condition had a greater frequency of cardiovascular, respiratory, and dermatologic events compared to men in the control condition (Basaria et al., 2010). The incidence of adverse cardiovascular events in the testosterone group was significant enough to stop the trial before the completion of enrollment.

If low sexual desire is determined to be caused by elevated prolactin, another endocrinologic disorder, or by depression, or anxiety, there are different biological treatment approaches to consider. Although organic hyperprolactinemia more frequently affects women than men, many psychotropic medications can cause increased prolactin in men (Rubio-Aurioles & Bivalacqua, 2013). Treatment of other endocrinolgic disorders, such as hypothyroidism and hyperthyroidism, can increase sexual desire, as it is often compromised by these conditions. Depression and anxiety may also lead to decreased sexual desire in men. Treatment for depression often entails the use of antidepressants, which have been shown to impact sexual function in both men and women. If a depressed patient is already experiencing decreases in sexual desire before starting an antidepressant regimen, then his doctor should consider prescribing an antidepressant that has more mild effects on sexual function, such as mirtazapine, buproprion, and SNRI’s like duloxetine (Clayton, Croft, et al., 2014).

It is also noteworthy that men with metabolic syndrome commonly report low sexual interest. If low sexual desire appears to be secondary to metabolic syndrome, then clinicians may recommend a combination of lifestyle changes, exercise, healthy diet, and testosterone replacement therapy (Glina, Sharlip, & Hellstrom, 2013).

Psychosocial treatment for MHSDD mirrors psychological treatment for FSIAD, as MHSDD and FSIAD share many causal psychological factors. Meana and Steiner (2014a) provide a thorough overview of efficacious psychosocial treatments for MHSDD. Cognitive-affective-behavioral therapy is a treatment approach that combines cognitive, emotion-centered, and behavioral strategies. The cognitive component of the treatment includes identifying and challenging maladaptive thoughts and sexual scripts that interfere with sexual desire (Meana & Steiner, 2014a). Therapists may encourage patients with low desire to refocus on sexual stimuli, either before or during sexual activity. The emotional regulation aspect may help men decrease or control emotional reactivity with acceptance techniques like mindfulness. Acceptance techniques come into play in situations when patients may not be able to achieve the sexual function or level of desire that they wish. In these cases, learning to accept certain realities may have as positive an impact as changing what can be modified (Meana & Steiner, 2014a). Effective psychosocial treatment for MHSDD also includes different behavioral activation strategies, such as sensate focus and optimizing the timing of sexual interactions, which help couples refocus on sensuality and encourage them to prioritize sexual activity.

Cognitive-affective-behavioral therapy for MHSDD also includes relationship skills-building and communication training, which are important for men who are having trouble talking about sexual preferences with their partners. Johnson and Zuccarini (2010) hypothesizeconclude that intimate connection between partners is the basis of sexual desire, so their treatment approach highlights the importance of communication. Conflict resolution is an important part of communication training, as therapists may help their male patients with desire concerns by teaching them strategies to minimize blaming and encourage self-soothing (Meana & Steiner, 2014a). Another relational approach to treating sexual desire is the adoption of the Good Enough Sex (GES) model, which embraces the acceptance of individual and couple differences in the meaning and importance of sexual desire within the context of the relationship (McCarthy & Metz, 2008; Metz & McCarthy, 2012).

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Not in the Mood for Sex — Ever? Here Are The Facts About Sexual Desire Disorder (Low Libido) in Women and Men

When your significant other gives you that “come hither” look, is your first thought, “Didn’t we do that once this year already?” Do you pray that if you have sex on New Year’s Eve it can count for two years?

If so, you may be experiencing low libido, a lack of desire for sexual intimacy in any form. Desire is the first part of the sexual response cycle, followed by arousal (excitement), orgasm, and resolution (the body returns to normal functioning).

The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) calls low libido Sexual Desire Disorder, a term encompassing two conditions: Female Sexual Interest/Arousal Disorder and Male Hypoactive Sexual Desire Disorder.

Research published in Sexual Medicine Reviews in April 2016 reveals that a significant percent of women reported a lack of desire: about 9 percent ages 18 to 44; around 12 percent ages 45 to 64; and more than 7 percent over age 65.

Men are having less sex than in the past, and some research suggests they are feeling less desire as well. A study published in the May 2018 issue of The Journal of Sexual Medicine found that the proportion of men reporting sexual activity within the past four weeks decreased from 81 percent in 2005 to 73 percent in 2016, while lack of sexual desire increased from 8 to 13 percent.

Sexual Desire Disorder: It’s Only a Problem if You Think It’s a Problem

While low sex drive is not a concern in and of itself (barring underlying physical illness), it can cause personal distress or lead to relationship issues for people whose partners want more sex. “Most couples do report some level of desire discrepancy, so that’s considered typical,” says clinical psychologist and sex therapist Marianne Brandon, PhD, host of the webinar Reinventing Your Love Life. “The challenge, then, is finding a way to compromise that respects each individual’s needs and preferences.”

Related: 7 Healthy Reasons You Should Have Sex – Right Now!

Causes of Sexual Desire Disorder: Why You May Not Be Feeling It

Men and women may lack sexual desire because of issues in three separate and competing areas, says Kimberly Resnick Anderson, a sex therapist and assistant professor of psychiatry at UCLA’s David Geffen School of Medicine.

  • Biologic/physiologic causes A number of medical conditions can diminish libido, including diabetes, heart disease, hormonal disorders,chronic pain, urinary tract disorders, substance abuse, and chronic physical and psychiatric illnesses. Some medications used to treat depression, anxiety, and psychosis can reduce desire. Women may be affected by menopause; men, by decreased testosterone or problems affecting blood flow (these can be caused by smoking, drinking, obesity, or lack of exercise). Erectile dysfunction can cause men to lose confidence, which takes a toll on their sexual desire.
  • Social causes These factors can include cultural or religious beliefs, media and peer influences, family messages about sexuality, and overscheduling.
  • Psychosocial causes A person’s sex drive can be affected by the quality of their relationship with a partner (including poor communication), past trauma, stress, poor body image, perceptions about aging, depression, and anxiety.

Related: Research Looks at the ‘Why’ Behind Sexual Dissatisfaction in Postmenopausal Women

How to Rediscover Desire

Reclaiming desire can be a complex process. “Everyone wants a quick fix — ‘Just give me a shot and I’ll be good,’” says gynecologist and sex counselor Terri Vanderlinde, DO. “But if you focus just on sex, you are missing the point; you are not looking at yourself and addressing underlying issues. There are a hundred reasons why people have low desire at any time, and you have to look at all of them and how they work together.”

First, Check in With Your Doctor

If you or your partner are concerned about lack of libido, your first stop should be with a healthcare practitioner for a thorough examination that can ascertain whether undiagnosed disease is part of the problem.

Even when there is no diagnosable condition, medications can help improve desire, though none are cure-alls:

  • Vyleesi (bremelanotide).Approved by the Food and Drug Administration (FDA) in 2019, Vyleesi is a drug that premenopausal women inject before sex. Addyi (flibanserin), another FDA-approved medication for premenopausal women, is a pill taken every night before bedtime.
  • Testosterone. This can be helpful for men but requires close monitoring by a physician. Some women may benefit from off-label use of testosterone, taken under the close supervision of a physician with special expertise in this area, says Dr. Vanderline.
  • Wellbutrin (buproprion). This antidepressant raises norepinephrine levels, which may increase desire in some men and women. (It does not work for everyone.) It can be used alone or to counteract the libido-suppressing action of SSRI antidepressants.

Working with a Sex Therapist or Counselor

No, there is no touching, demonstrating, or “practicing” with a sex therapist. Instead, these professionals help patients figure out what’s dampening their desire.

You can go with a partner, or go alone and bring what you learn back home, but it’s important that both you and your partner are on board. “A lot of times the men send the women in, because ‘You have to get fixed.’ But it takes two,” says Vanderlinde. “We have to fix the whole team; you can’t just fix the goalie. How do they relate to one another? How is the communication?”

In the best-case scenario, the therapist and physician work closely together to tease out the interwoven physical, emotional, and psychological issues. Each case is unique: A patient might have low desire for significant others but feel aroused by casual partners, say, or may not feel desire for others but still masturbate.

“There is a situational component” to low desire, says Resnick Anderson, “which is where sex therapy can help.” Has low libido always been a problem for the patient, the therapist will ask, or did it develop because of a specific issue such as a recent bout of depression or the discovery that a partner is cheating? Sex therapists can help determine if low desire is organic — related to physical issues and requiring a doctor’s care — or psychologic. “Conversely, doctors can rule out organic issues and then refer the patient to a sex therapist,” Resnick Anderson says.

Note: Groups such as the American Association of Sexuality Educators, Counselors and Teachers (AASECT) certify sex therapists. A “sex coach” is not a sex therapist or counselor.

Related: Sex Therapy: What Men and Women Should Know

Orgasmic Meditation May Help You Learn to Connect

Orgasmic meditation (OM) involves the gentle stroking of a woman’s clitoris by her partner for 15 minutes a session. The goal is not to create arousal or build towards orgasm, but to help the person being stroked let go and feel connected to her body and her partner’s body and learn to communicate her needs.

The person doing the stroking often reports that touching this way, done without a specific sexual goal, helps them feel closer to their partner. “Just feeling genuine intimacy and connection without trying to make something happen helps both partners with desire,” says Marissa Ward, OM coach with the Institute of OM.

The Takeaway

“Bottom line: Talk to your doctor, ask for help, and start the discussion,” says Vanderlinde.

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