While something is known about how to generate sexual desire—for example, creation of a new intimacy
in a conflicted relationship, education in how to sexually stimulate one another, and provision of permission
to engage in sensuous activity—the therapist knows far less than the patient thinks about how to
catalyze the appearance of (sexual desire) . . . A sexual desire problem begins as a mystery to both
patient and doctor. . .
A 35-year-old woman described a concern that from the time of her marriage seven
years ago until the delivery of her 21⁄2 year old child, she became depressed and
irritable the week before her menstrual periods and also lost all interest in anything
sexual during that time—thoughts, feelings, or activities. This contrasted with her
“normal” sexual desire at other times, which she felt were a rich part of her personal
life experience and relationship with her husband. She was sexually active and
interested during her pregnancy but since the delivery ceased to be interested in
anything sexual. Her husband was distressed and she missed the sexual feelings
that had been so important to her in the past.
A 45-year-old man was seen with his 41-year-old wife. They had been married for
17 years. Eleven years before, she developed a bipolar illness and had periods of
depression and mania. She was sexually involved with other men on an indiscriminate
and impulsive basis during her manic episodes. The couple had no sexual
difficulties during the years of their marriage before the onset of her illness but the
lack of sexual interest by the husband had become increasingly evident during the
previous decade. His loss of sexual desire did not, for example, extend to looking
at other women he considered attractive nor to masturbating several times each
week when he was alone. He could not explain his diminished sexual interest in his
wife. He clearly proclaimed his continuing love for her and his feeling that her
sexual liaisons with other men held little meaning.
Various words and phrases are used as synonyms for sexual desire, including libido,2
interest, drive, appetite, urge, lust, and instinct. Low sexual desire is variously referred
to as: “sexual apathy,” “sexual malaise,” and “sexual anorexia”3 (p. 315). For consistency
with the DSM system and the wording in most literature sources, the term “sexual
desire” is used here.
Sexual desire disorders are enigmatic and difficult to know how to approach therapeutically,
and the entire concept of sexual desire provokes some critical questions,
• What is “normal” sexual desire? Is it on a bell-shaped curve where, like
height or weight, some people have a lot, some people have a little, and
most people are in the middle? Kinsey and his colleagues attempted to
answer this question in saying “. . . there is a certain skepticism in the
profession of the existence of people who are basically low in capacity
to respond. This amounts to asserting that all people are more or less equal
in their sexual endowments, and ignores the existence of individual
variation. No one who knows how remarkably different individuals may
be in morphology, in physiologic reactions, and in other psychologic
capacities could conceive of erotic capacities (of all things) that were
basically uniform throughout a population”4 (p. 209). Zilbergeld and
Ellison suggest that “To say that there is more or less of something
. . . necessitates a standard of comparison . . . But there are no
standards of sexual desire; we do not know what is right, normal, or
healthy, and it seems clear that such standards will not be forthcoming”5
(p. 67). In a clear and practical, but somewhat contrary, statement,
LoPiccolo & Friedman offered the view that “In actual clinical practice
. . . most cases [of sexual desire disorders] are so clearly beyond
the lower end of the normal curve that definitional issues become
moot”6 (p. 110).
• Is sexual desire the same for men as for women? Bancroft thought not.
He speculated “that there may be a genuine sex difference in hormonebehavior
relationships, with men showing consistent androgen/behavior
relationships across studies (particularly androgen/sexual interest relationships),
whereas in women ‘the evidence for hormone-behavior relationships
is much less consistent, and often seemingly contradictory’.”7
• Does one measure sexual desire subjectively (by thoughts and feelings),
or objectively (by actions), or both? Considering only sexual actions or
behavior ignores the fact that, sometimes, nonsexual motives govern
sexual activity. For example, a person might engage in sexual
activity to please a partner, quite apart from satisfying their own
feelings of sexual desire.
• Should sexual desire disorders be classified as sexual dysfunctions
as they are in DSM-IV?8 Are they really on the same level
as, for example, physiological difficulties such as erection and
orgasm problems, or do they represent a totally different category
of sexual disorders? Some patients distinguish the two by
Some patients explain that (1) erection
and orgasm problems are like automobile
engine troubles and (2) that desire
difficulties are more like a problem with
the starter in that the engine simply
does not turn over.
using the ubiquitous North American symbol of the car, explaining that
erection and orgasm problems are like engine troubles, whereas a desire
difficulty is more like a problem with the starter in that the engine simply
does not turn over.
Disorders of sexual desire are classified in DSM-IV as “Sexual Desire Disorders.”
(SDD).8 This category contains two conditions:
• Hypoactive Sexual Desire Disorder (HSDD or HSD)
• Sexual Aversion Disorder (SAD)
DSM-IV-PC summarizes the criteria for the diagnosis of HSD as: “persistently or
recurrently deficient (or absent) sexual fantasies and desire for sexual activity that
causes marked distress or interpersonal difficulty” (p. 115), and criteria for SAD as:
“(A) persistent or extreme aversion to, and avoidance of, any genital contact with
a sexual partner, causing marked distress or interpersonal difficulty” and “(B) the
disturbance does not occur exclusively during the course of another mental disorder
. . .”9(p. 116).
The separation of SDDs into two groupings began with DSM-III,10 and while Sexual
Aversion Disorder has received some attention in the literature, it has not been the
subject of much research.9
HSD, the focus of this chapter, is often not clinically distinguished from other
problems with sexual function seen in primary care settings. Separating the two phenomena
and determining the chronology of appearance (i.e., whichever developed
first) may be extremely important clinically in considering etiology and treatment.
The assessment of low sexual desire is outlined in Figure 9-1.
Although not categorized as a “disorder” in DSM-IV8 or DSM-IV-PC,9
one of the ways that a sexual desire problem becomes apparent is when
two partners are sexually interested but not at the same level. Identical
levels of sexual desire in sexual partners rarely occur. More usual is the
fact that both are interested but one person is more interested than the
other. Couples generally “work out” different sexual appetites by mutual
acceptance and compromise (or “negotiation”). “Such discrepancies have much in common
with other relationship difficulties—how to raise children, how often to dine out
or have company in, where to spend the vacation, etc. . .”5 (p. 68).
Occasionally, a desire discrepancy becomes a problem so that it results in a concern
brought to a health professional. Couples sometimes focus on sexual problems as a way
of obscuring other tensions, but then the history of the couple relationship should
indicate a change in sexual interest. If the history of discrepancy dates from early in
the relationship (not necessarily the beginning when “limerance” (see p. 182) may be
prominent), one has to ask: why is it that these two people are unable to do what most
Identical levels of sexual desire in two
people rarely occur. Usually both are
interested but one person is more interested
than the other. Couples generally
“work out” different sexual appetites by
mutual acceptance and compromise (or
couples seem to do, that is, accept one another and compromise? The search for the
answer should begin on a primary care level.
A couple in their mid-50s wanted assistance because of a difference in sexual desire.
In talking with them initially together, they candidly said that this discrepancy
existed since they married 30 years ago and both agreed that her desire always had
been greater than his. When seen alone, he elaborated on his initial statements by
saying that, indeed, there had always been a difference in the amount of sexual
activity that each preferred. However, he had not been candid with her in the past
about particular sexual practices which he fantasized about and, in fact, had enjoyed
with other partners before they married. He anticipated resistance from her in telling
her now, but, in fact, found the opposite. The quality of their sexual experiences
improved greatly in the following months, even though the quantity changed
little. When seen in follow-up six months later, the issue of a sexual desire discrepancy
had not disappeared but there was much less concern.
From a clinical viewpoint, this particular form of sexual desire disorder seems to be
found more frequently in women than men. The patient shows little, if any, indication
of sexual appetite in thought, feeling, or action, now or in the past. Sexual experiences
with a partner occur uncommonly and usually on the initiative of the other person.
The patient participates out of recognition of the partner’s sexual needs rather than a
fulfillment of her own. Vaginal lubrication and orgasm may occur but these are not
considered momentous. Masturbation to the point of orgasm might also occur occasionally
but without enthusiasm. The motivation for masturbation is often other than
sexual, such as wanting to diminish feelings of anxiety or as an aid to inducing sleep.
Sexual dreams and fantasies are nonexistent and the patient may describe a response to
romantic stories in books or movies but not a response to depictions of sexual activity
in either. During adolescence, the women thought of herself as different from girlfriends
in not being interested in boys, easily fending off sexual propositions, and
hardly ever thinking about anything sexual. She sums up her present status by saying
that she could live the rest of her life without “sex,” and may add that the only reason
she is seeking consultation is that, implicitly or explicitly, the viability of her relationship
is in jeopardy.
A 27-year-old woman was engaged for six months and considering marriage. She
was concerned about her lack of sexual interest and wondered if there was something
wrong with her. Primarily, she wanted to know if anything could be done to
alter her present sexual situation. She experimented sexually to the point of intercourse
on two occasions in the past and had become sexually involved with her
husband-to-be shortly after they met. It was apparent that she found these experiences
to be neither pleasurable nor repellent.
As a teenager she wondered what other girls found so interesting about boys.
Sexual urges were not present then or since. Her interest and energy was directed
toward scholastic studies, at which she excelled. She eventually became a successful
lawyer, specializing in corporate law.
In a separate interview, her fiancee indicated that while sexual experiences were
important to him, he was not willing to forsake the relationship because of this
difficulty. In the one-year follow-up interval, they married, and while her sexual
desire had not changed, she was active from time-to-time as she sensed an increase
in his sexual needs. He preferred more sexual activity but he felt as though they
had adapted in other ways.
The major difference between the acquired and generalized form of a sexual desire disorder
and the lifelong and generalized form is that the present status represents a considerable
change from the past. In the acquired and generalized form of HSD, the
patient describes having been sexually interested and active in the past, but relates
much the same feelings about “sex” in the present as the person with the lifelong form.
That is, she says that in contrast to the past she does not now have sexual thoughts,
fantasies, or dreams and is only infrequently sexually active with a partner or by herself
through masturbation. She may also say that her interest level is such that life without
“sex” does not represent a problem to her directly, although the opposite is usually true
for her partner.
A 47-year-old woman, married for 23 years, described feeling diminished sexual
desire since her hysterectomy five years earlier. She never experienced sexual difficulties
before. Medical history revealed that she had the surgery because of excessive
menstrual bleeding associated with fibroids: her ovaries were also removed and
she was on hormone replacement therapy (not including testosterone) since then.
Intercourse continued after her hysterectomy but what she liked most was the
closeness and affection that was part of this experience. She had little problem
becoming vaginally wet when stimulated but found that intercourse ceased to be
sexually gratifying. She was regularly orgasmic in the past but was not so in the
present. Vaginal pain with intercourse rarely occurred but when it did it was
momentary and disappeared with change in position. Testosterone was given
because of her ovariectomy (see below) and she found that, as a result, her sexual
desire was substantially enhanced.
The most striking feature that differentiates a situational desire disorder from one that is
generalized is the continued presence of sexual desire. The sexual feelings that do exist
in the present occur typically when the person is alone and manifest either in thought
and/or action (through masturbation), rather than in sexual activity with the patient’s
usual partner. The patient characteristically states that there are sexual themes in his or
her thoughts and fantasies, and perhaps attraction to people other than the usual partner.
Sexual activity with their partner is considerably less frequent than sexual thoughts
in general. In addition, the present level of sexual activity often represents a substantial
change from the beginning of the relationship when the frequency was much greater.
However, as one reviews other relationships in the past, it may become evident that
the same sequence of events occurred before. That is, the interviewer might discover
that there was a pattern of initial sexual interest in a partner, followed by a gradual
diminution of sexual interest, resulting in relative sexual inactivity.
The 24-year-old wife of a 29-year-old man described a concern about her husband’s
lack of sexual attention to her. They were married for two years. When they first
met, she was relieved and pleased to find that she did not have to fend him off
sexually and that he was quite prepared to proceed at her pace. When asked about
their premarital sexual experiences with one another, she related having had intercourse
on many occasions but also thought that she was probably more sexually
interested than he.
After their marriage, the frequency of sexual events dropped precipitously. Her
overtures were regularly turned aside, to the point where she stopped asking. She
wondered whether his lack of interest was a result of her becoming less sexually
appealing to him. When seen alone it became clear that far from being sexually
neutral, and unknown to his wife, he masturbated several times each week while
looking at magazine pictures of nude women.
Significant issues in the history of his family-of-origin suggested that psychotherapy
would be the preferred treatment for this man and he was subsequently
referred to a psychiatrist. He accepted this outcome but when they were seen six
months later in follow-up he had a myriad of reasons for not having followed
through on the referral. She was disappointed at the turn of events, but not surprised.
When she then voiced her thoughts about leaving him, he became more
determined to put aside his reticence to seek assistance.
Lack of sexual desire, or sexual disinterest, is probably the most common
sexual complaint heard by health professionals. Studies of the frequency of
sexual disorders tend not to distinguish the different subcategories of
desire disorders, so that separation into syndromes which are lifelong,
acquired, situational or generalized are often based more on clinical
experience than research.
The survey completed by Laumann and his colleagues was particularly
revealing about the subject of sexual interest in the general population (as distinct
from specialty clinics).12 Interviewers asked respondents: “During the last 12 months
has there ever been a period of several months or more when you lacked interest in
Lack of sexual desire, or sexual disinterest,
is probably the most common sexual
complaint heard by health professionals.
having sex?” Overall, 33% of women and 16% of men answered ‘yes.’
The most striking data concerning women revealed that 40% to 45%
who were separated, black, did not finish high school, and “poor”
answered positively (i.e., lacked sexual interest). The equivalent data
concerning men were that 20% to 25% who were in the age group
50-59, never married, black, did not finish high school, and “poor” also
answered positively. Positive responses were also related to physical
health: women and men in “fair” health, 42% and 25% respectively.
Fifty eight percent of women in “poor” health, reported lacking sexual interest. These
numbers provoke one to think about the definition of “normal” sexual interest and the
apparent role of social, educational, and health factors in influencing sexual desire.
Frank and her colleagues’ impressive study of “normal” couples found a rate of sexual
“disinterest” almost identical to the overall figures reported by Laumann et al12: 35% of
wives and 16% of husbands.13
In one specialty clinic, the frequency of presentation of low-desire problems rose
from about 32% of couples in the mid 1970s to 55% in the early 1980s6 (p. 112). In
these same couples, the sex ratio changed so that in the mid-70s, the woman was the
identified patient about 70% of the time; in the early 80s, the man was the focus of
concern in 55% of cases. The authors summarized the reason for this shift as follows:
“Women’s greater comfort with their own sexuality allows them to put sufficient pressure
on their low-drive husbands to get the couple into sex therapy; this was not true
until the woman’s movement legitimized female sexuality.”
In a report on the frequency of HSD in a population recruited for a study of sexual
disorders generally, 30% of the men had HSD as a “primary” diagnosis.14 The same
authors described the frequency in women as similar to that reported by others: between
30% and 50%, although they found the figure to be 89% in their own study. Over one
third of the women and almost one half of the men with a “primary” diagnosis of HSD
had another sexual disorder as well. The authors concluded the following:
1. HSD was much more common in women than men
2. Men with HSD were significantly older than women
3. Desire disorders usually coexist with other sexual dysfunctions
Little empirical information exists on the epidemiology of specific HSD syndromes.
Among men, Kinsey and his colleagues described 147 men (from about 12,000 interviewed)
as “low-rating” (defined as under 36 years of age and whose “rates” [of sexual
behavior] averaged one event in two weeks or less4 (p. 207). Another group of men,
about half the number, were described as “sexually apathetic” in that “they never, at any
times in their histories, have given evidence that they were capable of anything except
low rates of activity” (p. 209). About 2% of women interviewed (of almost 8000) had
never by their late 40s “recognized any sexual arousal, under any sort of condition”12
On the basis of experience in clinical settings that specialize in the assessment and
treatment of sexual problems, the lifelong and generalized form of HSD seems very
unusual; the acquired and generalized form appears to be the most common among
women. Within men who present with HSD, the acquired and situational form seems
to be the most usual.
Interviewers asked respondents: “During
the last 12 months has there ever been
a period of several months or more
when you lacked interest in having
sex?” Overall, 33% of women and 16%
of men answered ‘yes.’
Attempts to understand the nature of sexual desire (other than desire disorders) have
been elusive throughout history. In modern times, Levine conceived of sexual desire as
having three parts16:
1. Sexual drive: “a neuroendocrine generator of sexual impulses [that is] . . . testosterone-
dependent . . .”
2. Sexual wish: “a cognitive aspiration [that] . . . emphasizes the purely ideational
aspect of sexual desire . . . The most important element . . . is the willingness
to have sex [which, in turn] . . . is a product of psychological motivation.”
(An example of a reason why a person would be sexually willing, is to feel connected
to another person and less alone. An example of the opposite is, because
the person may not yet like anyone enough.)
3. Sexual motive: a factor “that depends heavily on present and past interpersonal
relationships. [And which] . . . seems to be the most important element of
desire under ordinary circumstances” (examples of contributors to sexual motivation
include the quality of the nonsexual relationship and sexual orientation)
Biological factors represent one vital component in the understanding of sexual desire
generally (in contrast to disorders of sexual desire). Within the biological domain,
knowledge of the hormonal influence on sexual desire is clearly critical—if for no
other reason than that many people in the general population firmly believe that alterations
in hormones explain changes in sexual behavior. Although this relationship is
unequivocally true in subprimates, this view minimizes the huge impact of social learning
in humans. The enormous quantity of literature on the significance of hormones on
sexual desire in men and women was comprehensively reviewed by Segraves, from
which much of the information included immediately below was taken.17
Much of the evidence concerning the connection between sexual desire
and hormones in men derives from situations that involve decreased
androgens resulting from surgical and chemical castration, aging, and
hypogonadal states. Surgical castration results in a typical sequence of
changes: a sharp drop in sexual drive, subsequent loss of the ability to
ejaculate, and then a lessening of sexual activity. Regarding the effect
of testosterone loss on erections (see Chapter 11), “It appears that
erectile problems are secondary to a decrease in libido and not due to
a specific effect of androgen withdrawal on the erectile mechanism”17
(p. 278). Chemical castration mimics this lack of effect on erections.
In a study of aging, testosterone, and sexual desire, Segraves observed
that while there is “ . . . a strong relationship between aging and
libido, the relationship between libido and androgen activity (in aging
men) was low, suggesting that nonendocrinological factors may explain
Surgical castration results in a typical
sequence of changes: a sharp drop in
sexual drive, subsequent loss of the
ability to ejaculate, and then a lessening
of sexual activity.
“It appears that erectile problems are
secondary to a decrease in libido and
not due to a specific effect of androgen
withdrawal on the erectile mechanism”17
the decline in sexuality with aging”17(p. 281). Examples of nonendocrine factors
• Marital boredom
• Diminished partner attractiveness
• Chronic illness
In hypogonadal states, one can witness the effect of testosterone deficiency
and subsequently the changes that take place with recovery when
a replacement hormone is given. “The clinical literature is consistent in
demonstrating a marked reduction in libido and sexual activity in
untreated hypogonadal men”17(p. 281). To the extent that the provision
of androgens is successful in hypogonadal men, evidence strongly suggests
a primary effect on sexual desire rather than on erectile capacity.
The “impotence” that is seen in hypogonadal men can be explained as
“performance anxiety” superimposed on a biogenic desire disorder.
Studies of the treatment of hypogonadal men show that the sexual
benefits of replacement testosterone disappear as the normal range of
blood values is approached, indicating the clinically vital suggestion
that treating men who have normal testosterone levels for problems
relating to sexual responsivity is likely to be ineffective. In fact, studies
of men who have normal levels of testosterone but who are given an extra
amount for the treatment of sexual difficulties suggest that “ . . . the
effects are subtle and of small magnitude if they exist at all”17 (p. 284).
Elevated prolactin levels also reveal significant information about
hormones and sexual desire in men (and women). One study demonstrates
the futility of attempting to strictly separate sexual problems of
“organic” and “psychogenic” etiology.18 All of the hyperprolactinemic
men described difficulties with sexual desire, as well as erection and/or
ejaculation dysfunction. Of particular significance is that some of the
sexual problems of the men in this group appear as situational difficulties
(e.g., dysfunction exacerbated by psychological factors, which
improved at times of enhanced arousal). Furthermore all of the men experienced
some improvement with sex therapy, which was provided before the hyperprolactinemia
Two areas of investigation help in understanding the influence of hormonal factors on
sexual desire in women:
• The impact of endogenous hormones (e.g., changes during the menstrual
cycle and with menopause)
• The effect of exogenous hormones (e.g., oral contraceptives)
The possibility that sexual interests change during the menstrual cycle precipitated
attempts to discern a relationship between estrogens and progesterone and sexual
activity. A correlation has not been found but some evidence shows that average serum
testosterone levels across all phases are related to sexual responsivity17 (p. 290).
The impotence that is seen in hypogonadal
men can be explained as “performance
anxiety” superimposed on a biogenic
An attempt to strictly separate sexual
problems into “organic” and “psychogenic”
etiology may be an exercise in
futility. In one study, all of the men with
hyperprolactinemia described difficulties
with sexual desire, erection, and/or
ejaculation dysfunction. Of particular
significance is that some of the sexual
problems appeared as situational difficulties.
Also, all of the men experienced
some improvement with sex therapy,
which was provided before the hyperprolactinemia
Studies of men who have normal levels
of testosterone but who are given an
extra amount for the treatment of sexual
difficulties suggest that “. . .the
effects are subtle and of small magnitude
if they exist at all”17 (p. 284).
Changes in sexual desire associated with menopause have also been investigated.
“A minority of women report some decline in sexual activity . . .”17 (p. 295) but this
could relate to factors other than libido (e.g., health and attractiveness of the woman’s
partner). Some psychophysiological studies report little or no change in subjective
sexual arousal of postmenopausal women. Again, in contrast to naturally occurring
menopause, Sherwin and her colleagues demonstrated that diminished sexual
desire and sexual fantasy accompanies early menopause resulting from surgical removal
of a woman’s ovaries.19 The explanation for this observation appears to be decreased
testosterone associated with ovariectomy. She also found that in about 50% of
instances of naturally occurring menopause, the ovary continues to secrete testosterone;
in the other 50%, testosterone secretion is negligible. She suggests the inclusion
of testosterone in replacement hormones after a surgically induced menopause, and
also that, when diminished sexual desire occurs coincidentally with naturally occurring
menopause, it might be reasonable to add testosterone to an estrogen replacement
regimen (see “Treatment of Hypoactive Sexual Desire Disorder” below).20
On the subject of the impact of oral contraceptives on sexual desire, “The evidence
is unclear, but it does not suggest that [they] have a marked effect on libido apart from
other side effects” such as nausea and dysphoria17 (p. 292). Segraves suggests the following
guidelines when faced with a patient using oral contraceptives and complaining
of low sexual desire:
1. If diminished sexual desire and other side effects persist beyond the second
month of use, it might (by implication) be reasonable to change the preparation
2. If diminished sexual desire is a solitary complaint and began after the initiation
of oral contraceptive use, it might be sensible to have a trial period off
3. If sexual desire returns “off medications,” suggest a different drug
When considering sexual desire difficulties (rather than sexual desire),
it seems best to think of these problems as representing a “final common
pathway”6 (p. 116). The linguistic homogeneity implied by the specific
diagnosis of “Hypoactive Sexual Desire Disorder” covers a great deal of
etiological heterogeneity. There is no reason to assume that (1) HSD in
men arise(s) from the same source(s) as in women, (2) a lifelong pattern
is caused by the same problems as those which are acquired, or (3) a
situational disorder has the same genesis as the other two. Although
HSDs in men and women are now usually considered separately, the
same cannot always be said of other subcategories.
The following were noted in a descriptive examination of differences
in men and women seen in a “sex clinic” with a sexual desire complaint21:
1. Men were described as significantly older (50 years old versus 33)
2. Women reported a higher level of psychological distress, although both groups
focused more on the sexual desire concern
When considering sexual desire difficulties
(rather than sexual desire), it seems
best to think of these problems as representing
a “final common pathway”6
(p. 116). The linguistic homogeneity
implied by the specific diagnosis of
“Hypoactive Sexual Desire Disorder”
covers a great deal of etiological heterogeneity.
3. Men’s desire difficulties seemed less affected by relationship discord or dissatisfaction
4. Women reported more domestic stress
Biologically related studies of HSD undertaken by Schiavi, Schreiner-Engel, and their
colleagues are at the forefront of investigations into the etiologies of HSD and represent
important exceptions to the heterogeneity described above. A controlled investigation
was completed on a group of men who demonstrated a “generalized and persistent lack
of sexual desire” but who were otherwise healthy.22 The HSD men were found to have
significantly lower total plasma testosterone levels when measured hourly throughout
the night. (The determination of free testosterone did not show differences between the
HSD men and the controls). When Nocturnal Penile Tumescence (NPT) comparisons
were made between the HSD men who did and did not have additional erectile difficulties,
those who did showed a marked depression in NPT activity when compared to
controls in duration, frequency, and degree. The authors speculated that low sex drive
results in impaired NPT or that both result from some central biological abnormality.
A companion study of women with generalized HSD (lifelong [38%] and acquired)
who were otherwise healthy found no significant differences from controls on hormonal
measures (including testosterone) determined over the menstrual cycle.23 “It is
impressive that these two groups of women, who differed so markedly in their levels
of sexual desire, had endocrine milieus so similar.” The authors summarized by saying
that this and other studies failed “to provide convincing evidence that circulating testosterone
is an important determinant of individual differences in the sexual desire of
Many medical conditions are associated with a loss of sexual desire. These are summarized
in Box 9-1.
As described in Chapter 8, sexual problems that are in general associated with medical
conditions arise from a variety of sources. A loss of sexual desire in particular can
be a result of biological, psychological, or social and interpersonal factors24 (pp.
356-366). Examples of biological factors include the following:
1. Direct physiological effects of the illness or disability
2. Direct physiological effects of medical treatment and management (e.g., steroid
treatment of rheumatoid arthritis)
3. Physical debilitation
4. Bowel or bladder incontinence
Examples of psychological factors include:
1. Adopting the “patient” role (as an asexual person)
2. Altered body image
3. Feelings of anxiety, depression, and anger
4. Fears of death, rejection by a partner, or loss of control
5. Guilt regarding behavior imagined as the cause of a disease or disability
6. Reassignment of priorities
A DISEASES THAT CAUSE TESTOSTERONE DEFICIENCY STATES IN
castration, injuries to the testes, age-related atrophic testicular degeneration, bilateral
cryptorchism, Klinefelter’s syndrome, hydrocele, varicocele, cytotoxic chemotherapy,
pelvic radiation, mumps orchitis, hypothalamic-pituitary lesions, Addison’s disease, etc.
Conditions requiring anti-androgens drugs, e.g., prostate cancer, antisocial sexual
Bilateral salpingo-oophorectomy, adrenalectomy, hypophysectomy, cytotoxic chemotherapy,
hypothalamic-pituitary lesions, Addison’s disease, androgen insensitivity
Conditions requiring anti-androgen drugs, e.g., endometriosis, etc.
B CONDITIONS THAT CAUSE HYPERPROLACTINEMIA:
pituitary prolactin-secreting adenoma, other tumors of the pituitary, hypothalamic
disease, hypothyroidism, hepatic cirrhosis, stress, breast manipulation, etc., and conditions
requiring Prl raising medication, e.g., depression, psychosis, infertility, etc.
C CONDITIONS THAT DECREASE DESIRE VIA UNKNOWN MECHANISMS:
hyperthyroidism, temporal lobe epilepsy, renal dialysis, etc.
D CONDITIONS THAT CAUSE ORGANIC IMPOTENCE (Indirect cause of low
sexual desire in men):
diabetes mellitus, arteriosclerosis of penile blood vessels, venus leak, penile muscular
atrophy, Peyronie disease, Lariche’s syndrome, steal syndrome, sickle cell disease, priapism,
injury to penis, etc.
E CONDITIONS THAT CAUSE DYSPAREUNIA (Indirect cause of low sexual
urogenital estrogen-deficiency syndrome—normal age-related menopause, surgical
menopause, chemical menopause, irradiation of ovaries; endometriosis, pelvic inflammatory
disease, vaginitis, herpes, vaginismus, cystitis, etc.
herpes, phymosis, post-ejaculatory syndrome, etc.
F ALL MEDICAL CONDITIONS THAT CAUSE CHRONIC PAIN, FATIGUE,
OR MALAISE (Indirect cause of low desire):
arthritis, cancer, obstructive pulmonary disease, chronic cardiac and renal insufficiency,
shingles, peripheral neuropathy, trigeminal neuralgia, chronic infections, traumatic injuries,
(Modified from Kaplan HS: The sexual desire disorders, New York, 1995, Brunner/Mazel, p. 286. Reprinted with permission.)
Examples of social and interpersonal factors include:
1. Communication difficulties regarding feelings or sexuality
2. Difficulty initiating “sex” after a period of abstinence
3. Fear of physically damaging an ill or disabled partner
4. Lack of a partner
5. Lack of privacy
Gynecologic and urologic disorders have a particular association with HSD. Testicular
and ovarian disorders can have direct effects on sexual desire (see previous section
in this chapter on “Hormones and Sexual Desire” and “Treatment of Hypoactive
Sexual Desire” below). Indirect effects on sexual desire can also result from structural
disorders occurring in both body systems. Given the fact that one of the major functions
of both the gynecologic and urologic systems is sexual, it is hardly surprising that
when one function goes awry, sexual function goes awry as well. This may easily result
in the patient being discouraged and experiencing a concomitant (but secondary) loss
of sexual desire.
(See previous section in this Chapter on “Hormones and Sexual Desire” and “Treatment
of Hypoactive Sexual Desire Disorder” below.)
The relationship between psychiatric disorders and loss of sexual desire has not been
so carefully studied as loss of sexual desire with medical disorders. On a clinical basis,
it seems that the association between the two is exceedingly frequent. Of all psychiatric
disorders in which a loss of sexual desire is an accompaniment, depression has
unquestionably received most attention. Other aspects of depression have been scrupulously
scrutinized in the past but this has been only recently true of its sexual ramifications.
The twin issues of depression and sexual desire were carefully studied
in 40 depressed men before and after treatment that did not include antidepressant
drugs (thus avoiding the potentially confusing factor of the
effect of medications).25 Contrary to the expected diminution in sexual
desire, the authors found that the initial level of sexual activity engaged in
by the subjects was not different than the controls. The sexual behavior of
those subjects whose depression remitted with treatment, did not change,
but what was altered was the level of satisfaction derived from sexual experiences.
They concluded that“ . . . the traditional notion of loss of sexual
interest in depressed outpatients is not manifested behaviorally, but rather
reflects the depressed patient’s cognitive appraisal of sexual function as
less satisfying and pleasurable.” When subjects who did not remit, or only
partially remitted, were included in the analysis, there was a “modest”
improvement in the level of sexual activity and “drive.” The authors found the variability
of sexual function in depressed men in this study particularly interesting.
Schreiner-Engel and Schiavi looked at the association of psychiatric disorders and
low sexual desire from a different perspective and found that HSD patients (men and
the sexual behavior of the subjects
whose depression remitted with treatment
did not change but what was
altered was the level of satisfaction
derived from sexual experiences. Investigators
included that “. . . the traditional
notion of loss of sexual interest in
depressed outpatients is not manifested
behaviorally, but rather reflects the
depressed patient’s cognitive appraisal
of sexual function as less satisfying and
women) had significantly elevated lifetime prevalence rates of affective disorder compared
to controls.26 None of the patients or controls had a diagnosable illness at the
time of the study and there were no differences found in lifetime diagnoses of anxiety
or personality disorders. In 88% of the HSD men, and all of the HSD women, loss of
sexual interest occurred at the time of, or following, the onset of the initial episode of
depression. The authors speculated on the possibility that central monoaminergic processes
were involved in both HSD and depression.
The influence of drugs looms large among the various biological factors that can negatively
influence sexual desire. This subject has been reviewed in detail by Segraves who
acknowledges the limitations in information that often exists,3 such as:
1. Bias due to dependence on case reports and questionnaire studies
2. Inconsistent use of terminology
3. A focus on the sexual function of men (and relative neglect of women)
4. Reliance on volunteered (rather than requested) information about sexual sideeffects
5. Lack of clarity about effects on different phases of the sex response cycle
Drugs that are said to cause HSD are noted in Appendix III and Box 9-2.
Drug-related information seems to change more rapidly than any other material in
health care; thus new drugs are promoted for old diseases and side-effects of older
drugs become more apparent. The result of the rapid pace of change in information
about sexual side effects of drugs is the requirement that health professionals remain
informed. An example of this change is the appearance of a negative impact on sexual
desire of the Selective Serotonin Reuptake Inhibitors (SSRIs).27
Other sexual and gender identity disorders may be associated with a loss of sexual
desire. Of particular significance is the simultaneous occurrence of another sexual dysfunction
that may be a cause or a result of HSD. Determining the order of appearance
of the two problems is crucial. If the other sexual function difficulty preceded the loss
of sexual desire, successful treatment of the former would likely result in disappearance
of the latter.
A couple in their late 20s and married for five years was referred because the
woman was sexually disinterested. Detailed inquiry of this complaint revealed that,
unknown to her husband, she regularly fantasized about sexual activity and masturbated
to the point of orgasm using a vibrator several times each month. Her lack
of sexual desire was specific to sexual activity with her husband and dated from
about two years before. In the first three years of their marriage, both freely initiated
sexual activity and she usually become highly aroused but never reached the
point of orgasm. She became physically and psychologically uncomfortable, so
much so that she decided that “it was better not to start what (she) couldn’t finish.”
By her own description, she refused to become aroused at the beginning of their
sexual encounters by deliberately “turning off” her sexual desire. Her husband was
relieved to discover her interest in masturbation and that she was orgasmic. He was
eager to find ways in which that experience could be incorporated into their lovemaking
as a couple.
Commonly Used Pharmacologic Agents That May Decrease Sexual Desire
A ANTI-ANDROGEN DRUGS*:
Cyproterone* and Depo-provera* (for sex offenders), Flutamide* (for prostate cancer
in men, virilizing syndromes in women, precocious puberty in boys, etc.), Lupurin,* a
gonadotropin releasing hormone analog (for prostrate cancer, used together with Flutamide,
also for endometriosis in women); cytotoxic chemotherapeutic agents* (Adriamycin,
Methotrexate, Cytotoxin, Fluorouracil, Cisplatin, etc.)
B PSYCHOACTIVE DRUGS:
1. Sedative-Hypnotics: loss of desire dose-related: in low doses, disinhibition may cause
increase in desire; high doses and chronic use reduce desire. Alcohol; Benzodiazepines
(Valium, Ativan, Xanax, Librium, Halcion, etc); Barbiturates (phenobarbital, amytal,
etc.); Chlorol hydrate, Methaqualone, etc.
2. Narcotics* (Heroin, Morphine, Methadone, Meperidine, etc.)
3. Anti-Depressants: (Dopamine blocking and serotonergic) SSRIs* (Prozac, Zoloft,
Paxil); Tricyclics (Tofranil, Norpramin, Amitriptyline, Aventyl, Clomipramine*); MAOIs*
(Nardil, Marplan), Lithium carbonate, Tegretol.
4. Neuroleptics (increase Prl): Phenothiazine (Thorazine,* Thioridazine) Prolixin,* Stelazine,
Mellaril, etc.); Haldol,* Sulpiride.*
5. Stimulants: loss of desire is dose-related: low, acute doses may stimulate libido; high
doses and chronic use reduce sex drive. (Dexadrine, Methamphetamine, Cocaine).
C CARDIAC DRUGS:
1. Antihypertensives: (Hydrochlorothiazide,* Chlorthalidone,* Methyldopa,*
Spironolactone,* Reserpine,* Clonidine, Guanethidine,* etc.)
2. Cardiac Drugs: Beta adrenergic blockers* (Inderal, Atenolol, Timolol, etc.); Calcium
blockers** (Nifedipine, Verapramil, etc.)
D DRUGS THAT BIND WITH TESTOSTERONE:
1. Tamoxifen, Contraceptive agents, etc.
E MISCELLANEOUS DRUGS: Cimetidine* (for peptic ulcer); Pondimin* (serotonergic
appetite suppressor); Diclorphenamine, Methazolamide (for glaucoma); Clofribrate,
Lovastatin (anticholesterol); Steroids (chronic use for inflammatory conditions),
(Prednisone, Decadron, etc.).
*All the drugs listed have been reported to result in the loss of sexual desire and/or in erectile problems. However, the
frequency with which sexual side effects occur varies considerably, and the drugs that have a very high incidence of
decreased libido have been marked with*.
**Long-acting calcium channel blockers are more likely to decrease desire and impair erection than the short-acting preparations.
(Modified from Kaplan HS: The sexual desire disorders, New York, 1995, Brunner/Mazel, p. 287. Reprinted with permission.)
Psychosocial causes of low sexual desire include the following6 (pp. 119-129):
1. Religious orthodoxy (a factor that is “oversimplified at best”)
2. Anhedonic or obsessive-compulsive personality style (accompanied by usual
difficulties of displaying emotion and discomfort with close body contact)
3. Primary sexual interest in other people of the same sex
4. Specific sexual phobias or aversions (after sexual assault as an adult or child28)
5. Masked paraphilia (perversion)
6. Fear of pregnancy
7. “Widower’s syndrome” (sexual function difficulties, usually in the areas of desire
or erection, in a man after his wife has died, resulting from attachment to his
wife or the unfamiliarity of sexual activity with a new partner)
8. Relationship discord (cause, effect, or coexistence with HSD may be difficult
9. Lack of attraction to a partner
10. Poor sexual skills in the partner (“lousy lover”)
11. Fear of closeness and inability to fuse feelings of love and sexual desire (especially
in men [see “Acquired and Situational Absence of Sexual Desire”
On the basis of clinical impression, relationship discord and HSD seem to be frequently
related to each other. When two sexual partners who love each other and
have no sexual concerns are engaged in a dispute, it is commonplace to declare a
sexual moratorium until the conflict resolves. It is as if one says to
the other, ‘I’m angry at you and don’t feel like going to bed with
you while I have these feelings’. It is logical to theorize that some
instances of acquired HSD that are nonspecific in origin may represent
submerged anger about which the person is unaware. Experimental
evidence exists for the idea of suppressed sexual desire in the
presence of anger.29 Such theorizing may provide direction for clinical
care. This observation about anger may, in some instances, relate
to the finding that when woman with and without HSD were compared, the former
“reported significantly greater dissatisfaction with nearly every reported relationship
In the concluding chapter to their multi-authored book on the subject of Sexual
Desire Disorders, Leiblum and Rosen summarized the views of contributors generally,
saying that “ . . . relationship conflicts are viewed by the majority of our contributors
as the single most common cause of desire difficulties”31 (p. 452). From personal clinical
experience, they found that women partners “were more aware of and less willing
to tolerate relationship distress, and consequently that desire in women is more readily
disrupted by relationship factors” (p. 449). At the same time, humility was suggested
with treatment because all-too-often less marital discord resulted without any accompanying
change in sexual desire (p. 451).
It is logical to theorize that some
instances of acquired HSD that are nonspecific
in origin may represent submerged
anger about which the person is
Freud described a man choosing one woman for love and another for sexual activity
and seemingly unable to fuse the two.2 He referred to this idea as the Madonna/
Prostitute syndrome. It seems especially applicable today to many young men who
relate experiences consistent with an acquired and situational form of HSD.
Sometimes HSD seems to result from the operation of only one of the factors described
above: a hormone deficiency or the onset of a debilitating illness. More often than not,
the onset (especially of the acquired form) can probably best be explained by multiple
A couple in their late 20s explained that during the two years before their marriage
and the three years before she became pregnant their sexual experiences were
mutually initiated, frequent, pleasurable, and free of problems. After the delivery of
her child, attempts at intercourse were painful for her. Her husband knew of this
but persisted in approaching her sexually. After telling him of her discomfort on
one occasion, she felt she had little alternative but to “put up with it,” until finally
she became quite disinterested and “shut down.”
Both partners described her as a person who could not candidly and frankly talk
about her feelings, especially when she was angry. Being forthright was discouraged
in her family-of-origin, particularly by her alcoholic father who was verbally
abusive to her when she said something he found unpleasant. It seemed that the
current sexual difficulties were superimposed on some issues concerning her personality
and problems in their relationship as a couple. The treatment program
centered on her expressiveness, as well as “communication” and sexual issues. Her
ability to talk openly about her feelings improved dramatically. Her husband was
upset with himself as he discovered the extent of her vaginal and psychological
discomfort and his own insensitivity. As their sexual experiences resumed, she discovered
that her dyspareunia disappeared. However, although lovemaking was
more frequent than before, her previous sexual urge did not return.
Given the etiological heterogeneity and therapeutic complexity of
HSD, careful investigation of the complaint and establishing the correct
subcategory is often the most important contribution that can be
made by a primary care physician.
Scrutinizing the history of the patient and couple is usually the most
revealing part of the examination. Concerns about sexual desire usually
surface in the context of a couple’s relationship. The patient often
appears unruffled, and the partner seems the one who is more distressed.
The patient becomes upset secondarily if the partner is implicitly or
explicitly threatening to dissolve the relationship. Sexually interested
Given the etiological heterogeneity and
therapeutic complexity of HSD, careful
investigation of the complaint and
establishing the correct subcategory is
often the most important contribution
that can be made by a primary care clinician.
women who are partners of disinterested men may also describe doubts about themselves
and wonder if they are the source of the difficulty, thinking (for example) that
they are sexually unappealing. The disinterested person often does not express worry
about himself or herself but more about the unfulfilled sexual needs of the partner.
Occasionally, the disinterested partner seeks help. The reason is often a feeling of
sexual abnormality because such patients compare themselves, for example, to (1) how
they felt in the past, (2) friends and partners, and (3) depictions of “sex” on TV and the
Complaints about sexual desire are infrequent in patients without partners. One
exception is when a person believes that their lack of sexual interest contributed to a
disrupted previous relationship and is apprehensive about it happening again.
Comprehensive assessment of a complaint about sexual desire involves asking an initial
open-ended question, followed by specific inquiry concerning at least three areas:
• Sexual behavior
• Psychological manifestations of sexual stimuli
• Body changes in response to sexually arousing stimuli
Specific issues to inquire about, and suggested questions include the following:
1. Duration (see Chapter 4, “lifelong versus acquired”)
Suggested Question: “Has a feling of low sexual desire always
ben part of your life or was there a time when this was not
2. Sexual behavior with the usual partner (see Chapter 4, “generalized versus
Suggested Question when Talking with a Heterosexual Man/Woman: “About how
often are you and she/he sexualy involved with each
Additional Suggested Question when Talking with a Heterosexual Man/Woman:
“What kind of thoughts do you have before or during your
3. Sexual behavior with other partners of the opposite sex (see Chapter 4, “generalized
Suggested Question: “Have you had sexual experiences with other
women/men since you’ve ben in this relationship ?”
4. Sexual behavior with other partners of the same sex (see Chapter 4, “'Generalized
Part II Sexual Dysfunctions in Primary Care: Diagnosis, Treatment, and Referral 178
Suggested Question: “Are you sometimes sexualy aroused by
thoughts of other men/women?
Additional Suggested Question if the Answer is, “yes”: “Apart from thoughts,
have you had sexual experiences with other men/women?”
5. Sexual behavior through masturbatory sexual activity (see Chapter 4, “generalized
Suggested Question: “How frequently do you stimulate yourself
or masturbate ?”
6. Psychological manifestations—fantasy (see Chapter 4, “generalized versus situational”)
Suggested Question: “How often do you have sexual daydreams
(or fantasies )?”
Additional Suggested Question: “What do you fantasi ze about when
masturbating ?” ALSO: “What do you fantasi ze about when
you’re in the midst of a sexual experience with another
7. Psychological manifestations—response to pictures with a sexual theme (see
Chapter 4, “generalized versus situational”)
Suggested Question: “What do you think about and fel sexualy
when you se a picture or movie that has a sexual theme?
8. Psychological manifestations—response to stories in literature (see Chapter 4,
“generalized versus situational”)
Suggested Question: “What do you think about and fel sexualy
when you read story in which something sexual ocurs?”
9. Body change—genital swelling [erection or vaginal lubrication] (see Chapter 4,
Suggested Question when Talking with a Man/Woman: “When you think about
something sexual, what hapens to your penis/vagina ?”
Additional Suggested Question: “Does it become hard/do you become
10. Psychological accompaniment (see Chapter 4, “patient and partner’s reaction to
Suggested Question: “When you are sexualy uninterested, what
thoughts are going through your mind?”
Addition Question: “How does your wife (husband, partner )
Patients who regard answers to questions about sexual desire as private should not
be expected to discuss these aspects of the topic (at least initially) in the presence of
their partner (see Chapter 6). When a couple is interviewed together and someone is
asked a question about something generally regarded as private, the fact of not answering
the question might, itself, be revealing (i.e., if one partner does not want to answer
a question about masturbation, the non-answer might convey to the other partner that
there is secret information). Under such circumstances, it is best to avoid the question
altogether. The clinician must be careful not to unwittingly coerce someone to disclose
private information to a partner. Information that was obtained when someone was
seen alone may emerge at a later time when a couple is seen together but this should
occur only if the patient who previously asked for privacy takes the initiative.
Questions about thoughts and sexual fantasies (with masturbation or with a partner)
are often regarded by patients as even more private than actual behavior. As a result,
there may be obvious reticence to talk about what occurs in one’s mind. Information
about thoughts and sexual fantasies can be enormously revealing from a diagnostic
point of view, since it may, for example, indicate a complete absence of sexual thought,
a sexual desire for someone else, or, a different sexual orientation than what the person’s
behavior may have suggested.
The potential significance of the physical examination in HSD is signaled by the
patient’s history. Considering the four subcategories described above,
the acquired and generalized loss of sexual desire is the principal form
in which a diagnostic physical examination is required. The major
contrasting element separating the acquired/generalized pattern from
the others is widespread change. Ordinarily one would not expect to
find physical abnormalities with the other three forms because of the
absence of such change: discrepancy in sexual desire, as well as situational
and lifelong/generalized disorders. With a desire discrepancy, interest continues
to exist by both partners in the present as it was in the past, but it is nevertheless
problematic because the two people function at different levels. Where sexual desire
is situationally absent, interest continues as before except for one particular situation.
In the lifelong/generalized form, if a physical abnormality existed it would also have
been lifelong, a circumstance that is possible (e.g., a congenital disorder) but at the
same time usually obvious.
If a physical examination is part of the evaluation of acquired and generalized loss
of sexual desire, what does one look for? Before attempting to answer this question,
one must ask what loss of sexual desire represents. Is it, in fact, a disorder? Or is it a
syndrome (a collection of symptoms resulting from several causes)? In most instances,
the answer seems to be the latter. In that sense, loss of sexual desire resembles other
phenomena such as loss of appetite for food, or fatigue (both are accompaniments of
many different medical and psychiatric disorders from cancer to depression and neither
are associated with any specific physical findings on examination).
The acquired and generalized loss of
sexual desire is the principal form in
which a diagnostic physical examination
When the complaint is loss of sexual desire and the history does not suggest a specific
cause, one looks for evidence of generalized and previously unrecognized disease
(e.g., renal or cardiac disease) in a physical examination. One would search also for the
physical changes associated with abnormalities in endocrine function. The main endocrine
disorders would be hypoandrogen states and hypothyroidism. Physical signs of
low testosterone in men are often delayed; in women, they are often absent. Signs of
hypothyroidism may be subtle. Since generalized disease and endocrine disorders can
coexist, the presence of the former does not necessarily mean that the explanation for
sexual desire loss has been found and that a search for an accompanying endocrine
disorder is, therefore, unnecessary.
Since HSD is occasionally a result of a hormonal deficiency, laboratory studies usually
become part of the evaluation process. In men, this should always involve a determination
of the patient’s serum testosterone and prolactin levels. Segraves17 (p. 285) justifies
this policy in the following ways:
• Low cost
• Possibility of overlooking treatable cause of a low desire complaint
• Difficulty in distinguishing psychological from endocrinological causation
on the basis of history alone
• Negligible risk (i.e., venipuncture)
He further emphasizes the importance of too quickly attributing the cause of low
desire to interpersonal discord, since low sexual desire may, itself, result in relationship
conflict. In an effort to determine the cause of a low testosterone level and because of
the negative feedback loop in relation to the pituitary gland, a follow-up test should
be performed to determine the patient’s Luteinizing Hormone (LH) status. Other clinicians
propose a somewhat different format. Kaplan suggests that LH testing should
coincide with testing for testosterone, free testosterone, prolactin, total estrogens, and
thyroid status (for men)33 (p. 289). Kaplan, and Rosen & Leiblum, suggest that Follicle
Stimulating Hormone (FSH) be measured as well.32,33
On the subject of laboratory investigation of sexual desire complaints in women,
Segraves suggested that “ . . . extensive endocrinological assessment of every case
of inhibited sexual desire in females is not indicated”17 (pp. 298-99). He adds that,
since many gynecological conditions may interfere with sexual desire in nonspecific
ways (e.g., causing dyspareunia), correction of the condition may be sufficient to
reverse the sexual problem. As well, low sexual desire might occur in postmenopausal
women as a result of uncomfortable or painful intercourse associated with the
diminished vaginal lubrication. This symptom commonly accompanies atrophic vaginitis
and is caused by lack of estrogen stimulation to a woman’s vagina (see Chapter
13). The unusual patient with the complaint of diminished sexual desire but who
also describes absent menstrual periods and galactorrhea should have a serum prolactin
determination test performed. Kaplan differed from Segraves in suggesting
that the hormone profile described in the previous paragraph be used in women as
well as men; the one exception being that estradiol be determined instead of total
estrogens33 (p. 289).
Unrecognized, untreated, or uncontrolled medical and psychiatric disorders may
become evident during the investigation of a sexual problem. Common sense dictates
that, ordinarily, attention to the sexual problems be delayed until these other disorders
are under control. Examples include the following6:
• Alcohol or drug dependence
• Spouse abuse
• Active extramarital relationships
• Severe marital distress with imminent separation or divorce
In many circumstances, the most important role of the primary care health professional
is to carefully delineate the subcategory of desire difficulty and the possible
etiology. While carrying out this task, patients with HSD, regardless
of cause, will usually appreciate the primary care clinician’s initial
step of encouraging them to agree to temporarily stop struggling
with attempts at sexual experiences (no matter how favorable the circumstances)
and to simply enjoy being affectionate with their partner.
The history of the couple often reveals that affectionate exchanges were common
in the past but abandoned with the onset of the desire difficulties, since affection
was interpreted as a prelude to an unwanted (and often refused) sexual encounter.
Affection without the “threat” of any sexual consequence is usually a relief and
something that is highly desired by the disinterested partner. This arrangement is
easily accomplished in primary care, and the agreement is best made with both
partners together so that there is no misinterpretation of directions or mutual
Specific treatment of a sexual desire disorder will result from the discovery of a
specific cause. Limits to the involvement of a particular health professional depends
on that person’s skills and pattern of practice. An illustration of a specific cause is
that of testosterone deficiency. For example, Sherwin showed that testosterone is
beneficial in the loss of sexual desire associated with surgically induced menopause
as a result of bilateral oophorectomy.19 Also, testosterone may be helpful in medically
induced menopause that results from the use of some cytotoxic agents and
radiation in treatment of various cancers.34-36 A second and more complex example
of a specific etiology is the discovery and treatment of prostate cancer. In this
instance, sexual counseling has a major role in program of care and would likely
focus on “here-and-now” issues. The treatment program may involve the coordinated
work of a nonpsychiatric physician and sex-specialist or mental health professional
with interest and skills in the area of sexual rehabilitation. A third and potentially
even more intricate example of a specific cause is loss of sexual desire after
Patients with HSD usually appreciate the
primary care clinician’s initial step of
encouraging them to temporarily stop
struggling with attempts at sexual experiences
and to simply enjoy being affectionate
with their partner.
sexual trauma. Counseling is pivotal in treatment and might well extend to past
issues in the patient’s life. The ongoing care of such a patient would optimally be
undertaken by a health care professional with psychotherapy skills and comfort in
talking about sexual issues.
Nonspecific methods for the treatment of a sexual desire disorder must be used if, as is
often the case, specific explanatory factors cannot be pinpointed. Some clinicians and
patients find that self-help books are useful in the initial care of a patient with nonspecific
HSD.37 Unfortunately, few such books exist.
The subcategory of HSD should be considered in nonspecific treatment objectives
Differences in sexual desire among sexual partners are so common as to possibly be
universal. Considered from that perspective, one might then consider such differences
to be “normal” rather than “pathological.” The epidemiology of discrepancies in sexual
desire should be conveyed to patients—not to delegitimize their complaint but to help
them understand that other nonsexual issues may be significant contributors to the
Primary care health professionals can assist partners in the following ways:
1. Understanding the role of extraneous influences on their sexual experiences
(e.g., fatigue and preoccupation, especially in relation to the parenting of young
2. Talking candidly about the sexual expectations that each may have of the other
3. Appreciating the significance of “transition activities” (see following paragraph)
4. “Negotiating” a sexual activity compromise
Even before attempting to alter facets of sexual desire, attention should be paid to the
role of “transition activities” (e.g., sporting activities or dinners alone). “It is no secret
that modern living produces tremendous tension which often inhibits sexual interest,
excitement, and performance . . . The type of transitions employed are of little
moment, the important thing being that they help move [the patient] from a tense,
pressured state to one which feels more comfortable and in which he or she is more
open to sexual stimuli . . . When [transition activities] are done together [with a
partner], they can function as a bridge into a shared building of arousal and enjoyable
sexual activity”5 (p. 95).
Viewing sexual desire discrepancies in the same way as other relationship discrepancies
“ . . . suggests a focus on both partners, rather than the more common practice
of working only on the partner with less interest . . . we (try) to increase the desire
of the one while at the same time trying to decrease that of the other”5 (p. 68).
Careful history-taking sometimes reveals that a difference in sexual desire actually
represents a diminution on the part of one partner. This apparent decrease may actually
represent a lowering of sexual desire to the patient’s usual level after an initial period
of “limerance,” (the passionate intensity of a new romantic relationship). A sexual
desire discrepancy may then appear as a desire disorder that is acquired and generalized.
Altering a lifelong absence of sexual desire is exceedingly difficult at any level of care,
primary or otherwise. If the major treatment purpose is one of substantially enhancing
the patient’s level of sexual desire, an approach at any level will likely, in ordinary
circumstances, not be productive. However, one reasonable treatment objective is the
reversal of any concomitant sexual dysfunction. For example, a woman patient with
this form of HSD may also be anorgasmic. While becoming orgasmic may not result
in much change in her sexual desire level, sexual events may become more pleasurable
for her and as a result cause less tension in the couple’s relationship. (In instances of
low sexual desire, disappointment usually follows an expectation that an improvement
in the quality of sexual experiences results in an increase in the quantity). In the absence
of an associated sexual dysfunction, treatment to help the couple adapt to this situation
could be potentially quite beneficial. Even accomplishing this objective can be difficult
and time-consuming and is probably best undertaken by a sex-specialist with counseling
skills, or a mental health professional comfortable and skilled in talking about
sexual and relationship issues.
Psychological Treatment Methods
Nonspecific treatment methods for HSD are usually psychologically based, involve
counseling or psychotherapy, and involve individuals or couples. Techniques vary and
• Psychodynamic and interpersonal approaches16,39,40
• Cognitive and behavioral methods6,41,42
• Systems and interactional approaches43,44
Unfortunately, little consensus exists concerning treatment approaches to nonspecific
HSD. Also, not all health professional groups have the requisite interest, knowledge,
or training in the use of these various treatment techniques. The situational absence of
sexual desire requires psychologically-based treatment methods only.
Hormonal Treatment: Men
Hormonal treatments have been used for nonspecific HSD. For example, some men
who complain of “impotence” have an HSD rather than an erectile difficulty. Physicians
will sometimes attempt a trial of testosterone for their male patients with the
general concern of “impotence” without ascertaining whether a desire disorder exists
and is, in fact, primary. Segraves is unequivocal in his opinion: “Some physicians routinely
prescribe exogenous testosterone to men with sexual complaints without determining
values or even monitoring the serum testosterone response to exogenous
androgens. There is little justification for such an approach”17 (p. 288). Beyond
this opinion, physicians must be concerned about exogenous testosterone accelerating
the growth of an existing but occult prostatic cancer or the risk of prostate cancer
Hormonal Treatment: Women
There is considerable controversy over the use of androgens in the treatment of a
sexual desire disorder in postmenopausal women. (Kaplan is adamant in saying that
testosterone “has no place in the treatment of premenopausal women” (italics added) with
normal testosterone levels)33 (p. 278).
Other than specific research, Sherwin speculates that testosterone may be helpful to
women who report diminished libido beginning in the perimenopausal time period.20
Kaplan also suggests that physiological doses (of testosterone) present little risk and
that “a brief trial is justified in postmenopausal women with a global loss of libido
whose T (testosterone) levels are abnormally low . . . or in the low-normal ranges. (She
considered 20-25 ng/dl to be the lower limit of normal levels according to her clinical
experience and a survey of medical texts)33 (p. 279).
In contrast to the encouragement of Sherwin and Kaplan, Segraves regards the use
of testosterone in the care of women with a sexual desire disorder to be “clearly experimental”
17 (pp. 294-5) and suggests caution for the following reasons:
1. The studies have not been properly controlled
2. Doses used exceed physiological levels
3. Side effects can be unpleasant
4. There is lack of clarity about the effect on sexual desire of variations in androgens
within the normal physiological (versus subphysiological) range that women
Others have also been circumspect about promoting testosterone for the care of postmenopausal
women with a sexual desire disorder because of evidence for its possible
role in the development of breast cancer. Dorgan and her colleagues conducted a prospective
study that involved examining blood that was donated up to 10 years before.
Women who subsequently developed breast cancer (compared to healthy controls)
had significantly higher serum levels of the adrenal androgens dehydroepiandrosterone
(DHEA), its sulfate (DHEAS), and its metabolite 5-androstene-3b,17b-diol
There is concern about the role of sex steroids in the etiology of cardiovascular
disease in postmenopausal women, particularly over the potentially negative effect of
testosterone on lipid levels. Sherwin et al. reviewed the literature on this subject and
concluded that “the evidence that testosterone decreases HDL (high density lipoprotein
cholesterol) and increases LDL (low density lipoprotein cholesterol) is impressive.”
She nevertheless found a different result in her own subjects.48 She compared the
effect of different hormone treatment approaches on the lipoprotein lipid profiles of
three groups of women who had undergone total hysterectomy and bilateral salpingooophorectomy:
a combined estrogen-androgen preparation (containing 150 mg of testosterone
enanthate), estrogen alone, and an untreated group. She reported “no
between-group differences in total cholesterol, triglycerides, high-density lipoprotein,
or low-density lipoprotein values. Nor was the low density/high density lipoprotein
ratio significantly different between groups. . . .”
Research findings on the effect of testosterone on lipids in postmenopausal women
are contradictory. Phillips and his colleagues found that free testosterone (in contrast
to total testosterone) was significantly related (positively) with coronary artery disease
in a group of 60 postmenopausal women undergoing coronary angiography.49 The
authors speculated that an elevated free testosterone level might be a risk factor for
In her research on women who experienced surgically induced menopause, Sherwin
considered the possibility of an equal and opposite effect of each hormone (estrogen and
androgens) that masked the effect of testosterone alone.48 Another study found that
testosterone prevented (to a small degree) the rise in HDL cholesterol
that was seen in oophorectomized women given estrogen alone.50 The
same authors found in yet another study that testosterone decreased
LDL cholesterol.51 The complexity of the issue was further illustrated by
the unpublished finding that estrogen alone and estrogen-testosterone
implants resulted in lower LDL and increased HDL cholesterol but that
estrogentestosterone implants in heavy smokers produced a fall in HDL
cholesterol.52 Some speculate that the mode of administration of the
hormones may have a role in explaining the contradictory findings.48
In summary, testosterone seems beneficial to women with an androgen
deficit as a result of surgically (and probably medically) induced
menopause and diminished sexual desire. There is no reported evidence
that testosterone is useful in the treatment of sexual desire difficulties
in men or postmenopausal women who have experienced a naturally occurring menopause.
Some evidence exists that it may be harmful.
Despite the enormity of the problem of HSD in extent (in the general population) and
depth (in the individual), the voluminous scientific literature on the subject, and the
many treatment approaches that have been described (often with confidence in their
utility), there is not a great deal of information concerning treatment results. The two
existing long-term follow-up studies of treatment of low sexual desire are generally
quite discouraging. De Amicis et al. found that three years after treatment, “desire for
sexual contact and frequency of sexual contact, clearly demonstrate a lack of sustained
success for both men and women.”53 Despite the absence of change in the specific
problem, both men and women reported continued improvement in “satisfaction in
[the] sexual relationship,” and women also reported persistent improvement in the
“frequency of orgasm through masturbation and genital caress.” Hawton et al. reported
on a prospective follow-up study of sex therapy undertaken for various sexual disorders.
54 Treatment occurred between one and six years earlier and at least one partner
was interviewed in 75% of cases. The effects of treatment in instances of “female
impaired sexual interest,” “showed a marked deterioration (italics added) . . . when compared
with post-treatment outcome. This finding is accentuated by the fact that even
post-treatment outcome for this problem was relatively modest.”
There are only a handful of controlled treatment studies of HSD. O’Carroll reviewed
the only eight that he could find that met his (gradually expanding) inclusion criteria
for his search.7 These included two psychotherapy studies, three drug or hormone
Testosterone seems beneficial to women
with an androgen deficit as a result of
surgically (and probably medically)
induced menopause and diminished sexual
desire. There is no reported evidence
that testosterone is useful in the treatment
of sexual desire difficulties in men
or postmenopausal women who have
experienced a naturally occurring menopause.
Some evidence exists that it may
studies, and three studies that combined the two methods. Of this review, he concluded
that “if only studies which had specified (and analyzed) a discrete subject group
who presented with low sex interest had been accepted, one would have been left with
a single controlled treatment study which used only ten subjects!”
The one study about which O’Carroll wrote compared ten men with HSD to ten
men with erectile dysfunction.55 All initially had normal testosterone levels and all
were treated with high-dosage testosterone or placebo using a double-blind crossover
design. The HSD men responded with a significantly increased level of frequency of
sexual thoughts. O’Carroll concluded that “high dosage testosterone treatment may
have a modest role to play in the treatment of some eugonadal men who present with
low sex interest.”7
Leiblum and Rosen reviewed factors associated with treatment outcome found by
those who presented case histories in their multi-authored book “Sexual Desire Disorders.”
56 Success was particularly linked (p. 453) to desire problems affecting men who
were in their 30s, 40s, and 50s and who reported concomitant sexual dysfunctions
(especially erectile difficulties) and, in the case of couples, commitment to the marriage
(despite relationship discord) and the treatment process (p. 454). Unsuccessful
outcome of treatment was especially evident (p. 454) when there were secrets in the
marital relationship, history of chronic alcoholism, religious orthodoxy, history of
depression, organic erectile dysfunction, and “major body image problems.”
Etiological heterogeneity of HSD means that therapeutic versatility is a necessity. The
required range of skills will not likely be in the armamentarium of all primary care
clinicians. Referral may become necessary and the kind of health professional to whom
a referral is made will depend on the knowledge and skills of each and the apparent
cause of the disorder.
The capabilities of the primary care clinician may or may not encompass the treatments
required for patients with specific causes of HSD. One or several visits with a consultant
from a different discipline may be needed and may be all that is necessary. However, in
complex circumstances it may also be advisable to complement one’s own care (over an
extended time period) with that of another health professional who has different skills.
• One example of a specific cause of HSD that sometimes requires only a
consultation is the diagnosis of major depression. While most patients
with this diagnosis are entirely cared for by primary care health professionals,
in some instances, physicians in primary care might provide
antidepressant medication and psychotherapy to the patient after consultation
and advice from a psychiatrist or psychotherapist.
• Another example of a specific cause of HSD that may require more than
simple consultation is the loss
of sexual desire associated with the diagnosis and treatment
of prostate cancer. This situation may require asking
the advice of a medical specialist and the continuing cooperative efforts
of the primary care clinician and a sex-specialist with counseling skills.
• A third example of a specific cause of HSD that may involve ultimate
transfer of the patient to another health professional is that of sexual
trauma (see “Sexual Sequelae of Child Sexual Abuse in Adults: Sexual
Issues and Questions” in Chapter 8). A primary care professional may
provide acute care but the needs of the patient may require ongoing
intensive care from a mental health professional who has psychotherapeutic
skills and is also comfortable with sexual topics.
The care of an individual or couple where HSD is a concern, and for which no explanation
has become apparent after investigation, reasonably suggests referral—at least
for brief consultation, and often for continuing care. Despite the great frequency of the
problem in the general population, nonspecific HSD is, generally, not a disorder amenable
to care at the generalist level. Careful subclassification and investigation are the most
important responsibilities of the primary care clinician when considering nonspecific HSD, and they will
determine the direction of referral. In most instances, the most helpful professional is a sex
therapist or sexual medicine specialist with counseling skills.
• Desire discrepancies occasionally do not respond to intervention at the
primary care level. Consideration might then be given to referral to a
mental health professional who is also comfortable with couples and in
talking about sexual issues. Even then, referral should probably be
reserved for circumstances that, if they continue, may threaten the continuity
of the relationship.
• HSD that is lifelong and generalized often presents with questions
about the continuity of a current relationship. Care of the patient or
couple who appear in these complex and potentially turbulent circumstances
should be undertaken by a sex therapist or sexual medicine specialist
with a mental health professional background.
• The acquired and generalized form of HSD arises from several sources
(see above) and the apparent origins (there may be more than one)
influence the direction of referral. Because (1) the nature of such
complaints are perplexing and intricate, (2) etiological clarity is often
lacking, (3) disappointment and (often) anger is generated by the sexual
change, and (4) because the partners are usually disappointed when
they discover that expectations of return to previous sexual desire status
often is not realized, treatment at the primary care level is not suggested.
In most instances sex therapists or sexual medicine specialists,
should be involved in treatment, at least on a consultation level if not
in the continuing care of such individuals or couples.
• HSD that is acquired and situational occurs for a multiplicity of reasons
and each one requires a different referral approach. For example, some
instances are clearly a result of relationship discord, and the appropriate
person to be caring for such a couple would be a mental health professional
interested in relationship therapy. Other instances may represent
a disorder such as the Madonna/Prostitute Syndrome (discussed earlier
in this chapter), for which treatment is quite intricate and warrants
referral to a mental health professional for continuing care. Yet other
cases are a result of sexual issues specific to a couple (e.g., odors) and in
that instance, should be referred to a sex therapist.
The problem of low sexual desire or Hypoactive Sexual Desire Disorder (HSD)
requires subclassification into syndromes that denote at least four possibilities:
• A desire discrepancy
• A disorder that is lifelong and generalized
• A disorder that is acquired and generalized
• A disorder that is acquired and situational
In general, low or absent sexual desire is the most common sexual complaint heard by
health professionals, and about one third of women and one sixth of men answering a
community survey report having had this experience for several months during the last
year. Testosterone seems to be the “libido hormone” for men and women in that withdrawal
of this substance has profound effects on sexual desire in both. Elevated Prolactin
has a similar effect. HSD seems to arise from many different sources, hence the
application of the term: final common pathway. When compared to normal controls, biologically
related studies of healthy people with HSD have found some testosterone
determinations and nocturnal penile tumescence differences in men, but no differences
in women. HSD is associated with the following:
• A variety of general medical conditions
• Gynecologic and urologic disorders
• Psychiatric disorders
• Substance abuse
• Other sexual and gender identity disorders
• Intrapersonal difficulties
• Relationship discord
The investigation of HSD requires history-taking, physical examination for generalized
disorders, and selective laboratory studies. The most valuable contribution
of primary care professionals to patients with HSD is correct subclassification and
investigation of the etiology. Treatment of HSD depends on the reason for the
disorder. The more specific the etiology, the more specific the treatment, and the
more specific the treatment, the more might be reasonably undertaken in primary
care—alone or together with another health professional. Nonspecific HSD (apart
from the problem of a desire discrepancy) generally requires referral to a health
professional who specializes in the counseling and therapy of people with sexual
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