Hypoactive sexual desire disorder

Hypoactive sexual desire disorder
Classification and external resources
ICD-10	F52.0
ICD-9	302.71
MeSH	D020018

Hypoactive sexual desire disorder (HSDD), is considered as a sexual dysfunction and is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time. For this to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug (legal or illegal), or some other medical condition.

HSDD is listed under the Sexual and Gender Identity Disorders of the DSM-IV.^[1] It was first included in the DSM-III under the name Inhibited Sexual Desire Disorder,^[2] but the name was changed in the DSM-III-R.

There are various subtypes. HSDD can be general (general lack of sexual desire) or situational (still has sexual desire, but lacks sexual desire for current partner), and it can be acquired (HSDD started after a period of normal sexual functioning) or life-long (the person has always had no/low sexual desire.)

History

In the early versions of the DSM, there were only two sexual dysfunctions listed: frigidity (for women) and impotence (for men).

In 1970, Masters and Johnson published their book Human Sexual Inadequacy^[3] describing sexual dysfunctions, though these included only dysfunctions dealing with the function of genitals such as premature ejaculation and impotence for men, and anorgasmia and vaginismus for women. Prior to Masters and Johnson's research, female orgasm was assumed by some to originate primarily from vaginal, rather than clitoral, stimulation. Consequently, feminists have argued that "frigidity" was "defined by men as the failure of women to have vaginal orgasms".^[4]

Following this book, sex therapy increased throughout the 1970s. Reports from sex-therapists about people with low sexual desire are reported from at least 1972, but labeling this as a specific disorder did not occur until 1977.^[5] In that year, sex therapists Helen Singer Kaplan and Harold Lief independently of each other proposed creating a specific category for people with low or no sexual desire. Lief named it "Inhibited Sexual Desire," and Kaplan named it "Hypoactive Sexual Desire." The primary motivation for this was that previous models for sex therapy assumed certain levels of sexual interest in one’s partner and that problems were only caused by abnormal functioning/non-functioning of the genitals or performance anxiety but that therapies based on those problems were ineffective for people who did not sexually desire their partner.^[6] The following year, 1978, Lief and Kaplan together made a proposal to the APA’s taskforce for sexual disorders for the DSM III, of which Kaplan and Lief were both members. The diagnosis of Inhibited Sexual Desire (ISD) was added to the DSM when the 3rd edition was published in 1980.^[7]

For understanding this diagnosis, it is important to recognize the social context in which it was created. In some cultures^[which?], low sexual desire may be considered normal and high sexual desire is problematic. In others, this may be reversed. Some cultures try hard to restrain sexual desire. Others try to excite it. Concepts of "normal" levels of sexual desire are culturally dependent and rarely value-neutral. In the 1970s, there were strong cultural messages that sex is good for you and "the more the better." Within this context, people who were habitually uninterested in sex, who in previous times may not have seen this as a problem, were more likely to feel that this was a situation that needed to be fixed. They may have felt alienated by dominant messages about sexuality and increasingly people went to sex-therapists complaining of low sexual desire. It was within this context that the diagnosis of ISD was created.^[8]

In the revision of the DSM-III, published in 1987 (DSM-III-R), ISD was subdivided into two categories: Hypoactive Sexual Desire Disorder and Sexual Aversion Disorder (SAD).^[9] The former is a lack of interest in sex and the latter is a phobic aversion to sex. In addition to this subdivision, one reason for the change is that the committee involved in revising the pyschosexual disorders for the DSM-III-R thought that term "inhibited" suggests psychodynamic etiology (i.e. that the conditions for sexual desire are present, but the person is, for some reason, inhibiting their own sexual interest.) The term "hypoactive sexual desire" is more awkward, but more neutral with respect to the cause.^[10] The DSM-III-R estimated that about 20% of the population had HSDD.^[11] In the DSM-IV (1994), the criterion that the diagnosis requires "marked distress or interpersonal difficulty" was added.

Causes

Low sexual desire alone is not equivalent to HSDD because of the requirement in HSDD that the low sexual desire causes marked distress and interpersonal difficulty and because of the requirement that the low desire is not better accounted for by another disorder in the DSM or by a general medical problem. It is therefore difficult to say exactly what causes HSDD. It is easier to describe, instead, some of the causes of low sexual desire.

In men, though there are theoretically more types of HSDD/low sexual desire, typically men are only diagnosed with one of three subtypes.

• Lifelong/generalized: The man has little or no desire for sexual stimulation (with a partner or alone) and never has.
• Acquired/situational: The man was previously sexually interested in his present partner but now lacks sexual interest in them but has desire for sexual stimulation (i.e. alone or with someone other than his present partner.)
• Acquired/generalized: The man previously had sexual interest in his present partner, but lacks interest in sexual activity, partnered or solitary.

Though it can sometimes be difficult to distinguish between these types, they do not necessarily have the same etiology. The cause of lifelong/generalized HSDD is unknown. In the case of acquired/generalized low sexual desire, possible causes include various medical/health problems, psychiatric problems, low levels of testosterone or high levels of prolactin. One theory suggests that sexual desire is controlled by a balance between inhibitory and excitatory factors.^[12] This is thought to be expressed via neurotransmitters in selective brain areas. A decrease in sexual desire may therefore be due to an imbalance between neurotransmitters with excitatory activity like dopamine and norepinephrine and neurotransmitters with inhibitory activity, like serotonine.^[13] The, New York-based, "New View Campaign" organization has expressed skepticism about too much emphasis on explanations based on Neurotransmitters because emphasis on such explanations have been made largely by "educational" efforts funded by Boehringer-Ingelheim while it was attempting to get the FDA to approve a drug affecting neurotransmitters for treatment for HSDD.^[14] Low sexual desire can also be a side effect of various medications. In the case of acquired/situational HSDD, possible causes include intimacy difficulty, relationship problems, sexual addiction, and chronic illness of the man’s partner. The evidence for these is somewhat in question. Some claimed causes of low sexual desire are based on empirical evidence. However, some are based merely on clinical observation.^[15] In many cases, the cause of HSDD is simply unknown.^[16]

The usefulness of the current nosology in the DSM-IV-TR has been criticized for not taking seriously the differences between male and female sexuality (see section on criticism.) Still, there are some factors that are believed to be possible causes of HSDD in women. As with men, various medical problems, psychiatric problems (such as mood disorders), or increased amounts of prolactine can cause HSDD. Other hormones are believed to be involved as well. Additionally, factors such as relationship problems or stress are believed to be possible causes of reduced sexual desire in women.^[17]

Treatment

HSDD, like many sexual dysfunctions, is something that people are treated for in the context of a relationship. As such, it is common for both partners to be involved in therapy. Typically, the therapist tries to find a psychological or biological cause of the HSDD. Sometimes this is possible and sometimes it is not. If the HSDD is organically caused, the clinician may try to deal with that. If the clinician believes it is rooted in a psychological problem, they may recommend therapy for that. If not, treatment generally focuses more on relationship and communication issues, improved communication (verbal and nonverbal), working on non-sexual intimacy, or education about sexuality may all be possible parts of treatment. Sometimes problems occur because people have unrealistic perceptions about what normal sexuality is and are concerned that they do not compare well to that, and this is one reason why education can be important. If the clinician thinks that part of the problem is a result of stress, techniques may be recommended to more effectively deal with that. Also, it can be important to understand why the low level of sexual desire is a problem for the relationship because the two partners may associate different meaning with sex but not know it.^[18]

In the case of men, the therapy may depend on the subtype of HSDD. Increasing the level of sexual desire of a man with lifelong/generalized HSDD is unlikely. Instead the focus may be on helping the couple to adapt. In the case of acquired/generalized, it is likely that there is some biological reason for it and the clinician may attempt to deal with that. In the case of acquired/situational, some form of psychotherapy may be used, possibly with the man alone and possibly together with his partner.^[15]

As neurotransmitters and sex hormones have modulatory function on sexual desire, treatment intervention has been evaluated in multiple clinical trials. Intrinsa is a testosterone patch that works by releasing the hormone testosterone through the skin into the bloodstream. It is licensed by Procter & Gamble for the use in post-menopausal women with surgical menopause who are also receiving estrogen replacement therapy. Flibanserin, a 5-HT1A receptor agonist and 5-HT2A receptor antagonist, has been investigated by Boehringer Ingelheim as a novel, non-hormonal treatment for pre-menopausal women with Hypoactive Sexual Desire Disorder (HSDD). Development on this medication has since been discontinued by the company.^[19] Preclinical evidence suggested that flibanserin targets these receptors preferentially in selective brain areas and helps to restore a balance between inhibitory and excitatory effects.^[20][21]

Criticism

HSDD, as currently defined by the DSM has come under criticism of the social function of the diagnosis.

• HSDD could be seen a part of a history of the medicalization of sexuality by the medical profession to define normal sexuality.^[22]
• HSDD may function to pathologize asexuals, though their lack of sexual desire may not be maladaptive.^[23] Because of this, some members of the asexual community are lobbying the mental health community working on the DSM-V to regard asexuality as a legitimate sexual orientation rather than a mental disorder.^[24]

Other criticisms focus more on scientific and clinical issues.

• HSDD is such a diverse group etiologically that it functions as little more than a starting place for clinicians to assess people.^[25]
• The requirement that low sexual desire causes distress or interpersonal difficulty has been criticized. It has been claimed that it is not clinically useful because if it is not causing any problems, the person will not seek out a clinician.^[25] One could claim that this criterion (for all of the sexual dysfunctions, including HSDD) decreases the scientific validity of the diagnoses or is a cover-up for a lack of data on what constitutes normal sexual function.^[26]

The current framework for HSDD is based on a linear model of human sexual response, developed by Masters and Johnson and modified by Kaplan consisting of desire, arousal, orgasm. The sexual dysfunctions in the DSM are based around problems at any one or more of these stages.^[18] Many of the criticisms of the present DSM framework for sexual dysfunction in general, and HSDD in particular, claim that this models ignores the differences between male and female sexuality. Several criticisms are based on inadequacy of the current framework for dealing with women's sexual problems.

• Increasingly, evidence shows that there are significant differences between male and female sexuality. Level of desire is highly variable from woman to woman and there are some women who are considered sexually functional who have no active desire for sex, but they can erotically respond well in contexts they find acceptable. This has been termed "responsive desire" as opposed to spontaneous desire.^[18]
• The focus on merely the physiological ignores the social, economic and political factors including sexual violence and lack of access to sexual medicine or education throughout the world affecting women and their sexual health.^[27]
• The focus on the physiological ignores the relationship context of sexuality despite the fact that these are often the cause of sexual problems.^[27]
• The sexual problems that women complain of often do not fit well into the current DSM framework for sexual dysfunctions.^[27]
• The current system of sub-typing may be more applicable to one gender than the other.^[15]

See also

• Asexuality
• Hypersexuality
• Sexual dysfunction
• Diagnostic and Statistical Manual of Mental Disorders

References

1. ^ Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington DC: American Psychiatric Association. 2000. 
2. ^ Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington DC: American Psychiatric Association. 1980. 
3. ^ Masters, William; Johnson, Virginia (1970). Human Sexual Inadequacy. Boston: Little Brown. 
4. ^ Koedt, A. (1970). "The myth of the vaginal orgasm". In Escoffier, J.. Sexual revolution. New York: Thunder's Mouth Press. pp. 100–9. ISBN 1560255250. 
5. ^ Irvine, Janice (2005). Disorders of Desire. Philadelphia: Temple University Press. p. 265. 
6. ^ Kaplan, Helen Singer (1995). The Sexual Desire Disorders. New York: Taylor & Francis Group. pp. 1–2, 7. 
7. ^ Kaplan 1995, pp. 7–8
8. ^ Leiblum, Sandra; Rosen, Raymond (1988). Sexual Desire Disorders. The Guilford Press. p. 1. 
9. ^ Irvine 2005, p. 172
10. ^ Apfelbaum, Bernard (1988). "An Ego Analytic Perspective on Desire Disorders". In Lieblum, Sandra; Rosen, Raymond. Sexual Desire Disorders. The Guilford Press. 
11. ^ American Psychological Association (1987)
12. ^ Janssen, E., Bancroft J. (2006). "The dual control model: The role of sexual inhibition & excitation in sexual arousal and behavior". In Janssen, E.. The Psychophysiology of Sex. Bloomington IN: Indiana University Press. 
13. ^ Clayton AH (July 2010). "The pathophysiology of hypoactive sexual desire disorder in women". Int J Gynaecol Obstet 110 (1): 7–11. doi:10.1016/j.ijgo.2010.02.014. PMID 20434725. http://linkinghub.elsevier.com/retrieve/pii/S0020-7292(10)00138-4. 
14. ^ New View Campaign. Fact Sheet: Marketing. "http://www.newviewcampaign.org/media/pdfs/FlibanserinFactsheet_marketing.pdf"
15. ^ ^{a b c} Maurice, William (2007). "Sexual Desire Disorders in Men". In Leiblum, Sandra. Principles and Practice of Sex Therapy (4th ed.). New York: The Guilford Press. 
16. ^ Balon, Richard (2007). "Toward an Improved Nosology of Sexual Dysfunction in DSM-V". Psychiatric Times 24 (9). http://www.psychiatrictimes.com/display/article/10168/53716?pageNumber=1. 
17. ^ Warnock JJ (2002). "Female hypoactive sexual desire disorder: epidemiology, diagnosis and treatment". CNS Drugs 16 (11): 745–53. PMID 12383030. http://content.wkhealth.com/linkback/openurl?issn=1172-7047&volume=16&issue=11&spage=745. 
18. ^ ^{a b c} Basson, Rosemary (2007). "Sexual Desire/Arousal Disorders in Women". In Leiblum, Sandra. Principles and Practice of Sex Therapy (4th ed.). New York: The Guilford Press. 
19. ^ http://www.boehringer-ingelheim.com/news/news_releases/press_releases/2010/08_october_2010_fliba.html
20. ^ Pfaus JG (June 2009). "Pathways of sexual desire". J Sex Med 6 (6): 1506–33. doi:10.1111/j.1743-6109.2009.01309.x. PMID 19453889. 
21. ^ Allers KA, Dremencov E, Ceci A, et al. (May 2010). "Acute and repeated flibanserin administration in female rats modulates monoamines differentially across brain areas: a microdialysis study". J Sex Med 7 (5): 1757–67. doi:10.1111/j.1743-6109.2010.01763.x. PMID 20163532. 
22. ^ Irvine 2005, pp. 175–6
23. ^ Prause N, Graham CA (June 2007). "Asexuality: classification and characterization" (PDF). Arch Sex Behav 36 (3): 341–56. doi:10.1007/s10508-006-9142-3. PMID 17345167. http://www.kinseyinstitute.org/publications/PDF/PrauseGraham.pdf. 
24. ^ Asexuals Push for Greater Recognition. http://abcnews.go.com/Health/MindMoodNews/story?id=6656358&page=1
25. ^ ^{a b} Bancroft J, Graham CA, McCord C (2001). "Conceptualizing women's sexual problems". J Sex Marital Ther 27 (2): 95–103. doi:10.1080/00926230152051716. PMID 11247236. 
26. ^ Althof SE (2001). "My personal distress over the inclusion of personal distress". J Sex Marital Ther 27 (2): 123–5. doi:10.1080/00926230152051761. PMID 11247205. 
27. ^ ^{a b c} Tiefer L, Hall M, Tavris C (2002). "Beyond dysfunction: a new view of women's sexual problems". J Sex Marital Ther 28 (Suppl 1): 225–32. doi:10.1080/00926230252851357. PMID 11898706. 

External links

• Sexual Performance Anxiety
• Hypoactive Sexual Desire Disorder and the Asexual Community: A History of the diagnosis from 1977 to the present, and an account the asexual community's advocacy for a more asexual-friendly version of HSDD
• Hypoactive Sexual Desire Disorder, symptoms, types, and treatment