- Hypoactive Sexual Desire Disorder
Hypoactive Sexual Desire Disorder (HSDD), is listed under the Sexual and Gender Identity Disorders of the
DSM-IV. [American Psychiatric Association (2000): "Diagnostic and Statistical Manual of Mental Disorders" (4th ed. text rev), Washington DC.] It was first included in the DSM-III under the name Inhibited Sexual Desire Disorder [ American Psychiatric Association (1980): "Diagnostic and Statistical Manual of Mental Disorders" (3rd ed.), Washington DC] but the name was changed in the DSM-III-R.
HSDD is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time. It must cause marked distress or interpersonal difficulties and is not better accounted for by another mental disorder (i.e. depression), a drug (legal or illegal), or some other medical condition.
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.)
Masters and Johnsonpublished their book "Human Sexual Inadequacy" [Masters, William and Johnson, Virginia (1970). "Human Sexual Inadequacy", Boston: Little Brown] 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 vaginsmus for women. Following this book, sex therapy increased throughout the 1970's. 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. [Irvine, Janice (2005): "Disorders of Desire", Temple University Press, Philadelphia p.265] 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. 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. [Kaplan, Helen Singer (1995): "The Sexual Desire Disorders", Taylor & Francis Group, New York pp.1-2,7] The following year, 1978, Leif and Kaplan together made a proposal to the APA’s taskforce for sexual disorders for the DSM III, which both Kaplan and Leif were members of. The diagnosis of Inhibited Sexual Desire (ISD) was added to the DSM when the 3rd edition was published in 1980. [ibid p.7-8]
For understanding this diagnosis, it is important to recognize the social context in which it was created. In some cultures, 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. [ Leiblum, Sandra and Raymond Rosen "Sexual Desire Disorders" The Guilford Press 1988. p.1 ]
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). [ Irvine (2005) p.172 ] 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 DMS-III-R thought that term "inhibited" suggests 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. [ Apfelbaum, Bernard: "An Ego Analytic Perspective on Desire Disorders" in ed. Lieblum Sandra and Raymond Rosen "Sexual Desire Disorders" The Guilford Press 1988 ] The DSM-III-R estimated that about 20% of the population had HSDD. [ American Psychological Association (1987)] In the DSM-IV (1994), the criterion that the diagnosis requires "marked distress or interpersonal difficulty" was added.
Low sexual desire is not equivalent to HSDD because of the requirement that the low sexual desire causes marked distress and interpersonal difficulty and because of the requirement that the low distress is not better accounted for by another disorder in the DSM or by a general medical problem, it is difficult to say exactly what causes HSDD. It is easier to describe, instead, what causes 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 has 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 prolactine. 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. [ Maurice, William (2007): “Sexual Desire Disorders in Men.” in ed. Leiblum, Sandra: "Principles and Practice of Sex Therapy" (4th ed.) The Guilford Press. New York] In many cases, the cause of HSDD is simply unknown. [Balon, Richard (2007): “Toward an Improved Nosology of Sexual Dysfunction in DSM-V”, Psychiatric Times Vol. 24 No. 9. “http://www.psychiatrictimes.com/display/article/10168/53716?pageNumber=1”]
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. [Warnock, Julia (2002): “Female Hypoactive Sexual Desire Disorder: Epidemiology, Diagnosis and Treatment.” CNS Drugs; 16(11) pp. 745-753 ]
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. [ Basson, Rosemary (2007): “Sexual Desire/Arousal Disorders in Women” in ed. Leiblum, Sandra: "Principles and Practice of Sex Therapy" (4th ed.) The Guilford Press. New York ]
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. [Maurice (2007)]
There is, unfortunately, very limited data on the effectiveness of various forms of therapy for HSDD. [ibid]
HSDD, as currently defined by the DSM has come under substantial criticism from a variety of places for a variety of reasons. Some of these regard the social function of the diagnosis.
*HSDD can be seen a part of a long history of the medicalization of sexuality as the medical profession gives itself the right to define normal sexuality. [ Irvine (2005) pp. 175-6]
*HSDD may function to pathologize
asexuals, despite the fact that despite their lack of sexual desire may not be maladaptive. [ Prause, Nicole and Graham, Cynthia (2007) “Asexuality: Classification and Characterization”, Archives of Sexual Behavior 36. pp.431-356 http://www.kinseyinstitute.org/publications/PDF/PrauseGraham.pdf] 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 [ Bancroft, John and Cynthia Graham, Carol McCord (2001): “Conceptualizing Women’s Sexual Problems.” Journal of Sex and Marital Therapy 27, pp. 95-103 ]
*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 [ Bancroft et al. (2001) ] It has been argued that this criterion (for all of the sexual dysfunctions, including HSDD) decreases the scientific validity of the diagnoses and is a cover-up for a lack of data on what constitutes normal sexual function. [ Althof, Stanley (2001): “My Personal Distress Over the Inclusion of Personal Distress” Journal of Sex and Marital Therapy 27. pp. 123-125. Brunner Rutledge. ]
The current framework for HSDD is based on a linear model of human sexual response, developed by
Masters and Johnsonand modified by Kaplan consisting of desire, arousal, orgasm. The sexual dysfunctions in the DSMare based around problems at any one or more of these stages. [Basson (2007) ] 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. [ Basson (2007) ]
*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 effecting women and their sexual health. [ Tiefer, Leonore; Marny Hall, Carol Travis (2002): "Beyond Dysfunction: A New View of Women's Sexual Problems" Journal of Sex and Marital Therapy 28(s): 225-232]
*The focus on the physiological ignores the relationship context of sexuality despite the fact that these are often the cause of sexual problems. [ibid]
*The sexual problems that women complain of often do not fit well into the current DSM framework for sexual dysfunctions. [ibid]
*The current system of sub-typing may be more applicable to one gender than the other. [Maurice (2007)]
Diagnostic and Statistical Manual of Mental Disorders
* [http://www.soc.ucsb.edu/sexinfo/?article=difficulty&refid=003 University of California, Santa Barbara's SexInfo] information on the causes, symptoms, and treatments of Hypoactive (Low) Sexual Desire
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