Hypoactive sexual desire disorder
|Hypoactive sexual desire disorder|
|Classification and external resources|
Hypoactive sexual desire disorder (HSDD) is considered a sexual dysfunction and is characterized as a lack or absence of sexual fantasies and desire for sexual activity, as judged by a clinician. For this to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug (legal or illegal), or some other medical condition.
HSDD is listed under the Sexual and Gender Identity Disorders of the DSM-IV. It was first included in the DSM-III under the name Inhibited Sexual Desire Disorder, but the name was changed in the DSM-III-R.
There are various subtypes. HSDD can be general (general lack of sexual desire) or situational (still has sexual desire, but lacks sexual desire for current partner), and it can be acquired (HSDD started after a period of normal sexual functioning) or lifelong (the person has always had no/low sexual desire.)
HSDD has garnered much criticism, primarily by asexual activists. They point out that HSDD puts asexuality in the same position homosexuality was from 1974-1987. Back then, the DSM recognised 'ego-dystonic homosexuality' as a disorder, defined as having sexual interest in the same sex and it causing distress. Despite the DSM itself officially recognizing this as unnecessarily pathologizing homosexuality and removing it as a disorder in 1987, the DSM has not recognized HSDD as unnecessarily pathologizing asexuality.
In the early versions of the DSM, there were only two sexual dysfunctions listed: frigidity (for women) and impotence (for men).
In 1970, Masters and Johnson published their book Human Sexual Inadequacy describing sexual dysfunctions, though these included only dysfunctions dealing with the function of genitals such as premature ejaculation and impotence for men, and anorgasmia and vaginismus for women. Prior to Masters and Johnson's research, female orgasm was assumed by some to originate primarily from vaginal, rather than clitoral, stimulation. Consequently, feminists have argued that "frigidity" was "defined by men as the failure of women to have vaginal orgasms".
Following this book, sex therapy increased throughout the 1970s. Reports from sex-therapists about people with low sexual desire are reported from at least 1972, but labeling this as a specific disorder did not occur until 1977. In that year, sex therapists Helen Singer Kaplan and Harold Lief independently of each other proposed creating a specific category for people with low or no sexual desire. Lief named it "Inhibited Sexual Desire," and Kaplan named it "Hypoactive Sexual Desire." The primary motivation for this was that previous models for sex therapy assumed certain levels of sexual interest in one’s partner and that problems were only caused by abnormal functioning/non-functioning of the genitals or performance anxiety but that therapies based on those problems were ineffective for people who did not sexually desire their partner. The following year, 1978, Lief and Kaplan together made a proposal to the APA’s taskforce for sexual disorders for the DSM III, of which Kaplan and Lief were both members. The diagnosis of Inhibited Sexual Desire (ISD) was added to the DSM when the 3rd edition was published in 1980.
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. For example, sexual desire may be lower in East Asian populations than Euro-Canadian/American populations. In other cultures, 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.
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). 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 psychosexual disorders for the DSM-III-R thought that term "inhibited" suggests psychodynamic etiology (i.e. that the conditions for sexual desire are present, but the person is, for some reason, inhibiting their own sexual interest.) The term "hypoactive sexual desire" is more awkward, but more neutral with respect to the cause. The DSM-III-R estimated that about 20% of the population had HSDD. In the DSM-IV (1994), the criterion that the diagnosis requires "marked distress or interpersonal difficulty" was added.
Low sexual desire alone is not equivalent to HSDD because of the requirement in HSDD that the low sexual desire causes marked distress and interpersonal difficulty and because of the requirement that the low desire is not better accounted for by another disorder in the DSM or by a general medical problem. It is therefore difficult to say exactly what causes HSDD. It is easier to describe, instead, some of the causes of low sexual desire.
In men, though there are theoretically more types of HSDD/low sexual desire, typically men are only diagnosed with one of three subtypes.
- Lifelong/generalized: The man has little or no desire for sexual stimulation (with a partner or alone) and never had.
- Acquired/situational: The man was previously sexually interested in his present partner but now lacks sexual interest in them but has desire for sexual stimulation (i.e. alone or with someone other than his present partner.)
- Acquired/generalized: The man previously had sexual interest in his present partner, but lacks interest in sexual activity, partnered or solitary.
Though it can sometimes be difficult to distinguish between these types, they do not necessarily have the same etiology. The cause of lifelong/generalized HSDD is unknown. In the case of acquired/generalized low sexual desire, possible causes include various medical/health problems, psychiatric problems, low levels of testosterone or high levels of prolactin. One theory suggests that sexual desire is controlled by a balance between inhibitory and excitatory factors. This is thought to be expressed via neurotransmitters in selective brain areas. A decrease in sexual desire may therefore be due to an imbalance between neurotransmitters with excitatory activity like dopamine and norepinephrine and neurotransmitters with inhibitory activity, like serotonin. The, New York-based, "New View Campaign" organization has expressed skepticism about too much emphasis on explanations based on neurotransmitters because emphasis on such explanations have been made largely by "educational" efforts funded by Boehringer-Ingelheim while it was attempting to get the FDA to approve a drug affecting neurotransmitters for treatment for HSDD. 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. In many cases, the cause of HSDD is simply unknown.
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 prolactin 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. According to one recent study examining the affective responses and attentional capture of sexual stimuli in women with and without HSDD, women with HSDD do not appear to have a negative association to sexual stimuli, but rather a weaker positive association than women without HSDD 
HSDD, like many sexual dysfunctions, is something that people are treated for in the context of a relationship. Theoretically, one could be diagnosed with, and treated for, HSDD without being in a relationship. However, relationship status is the most predictive factor accounting for distress in women with low desire and distress is required for a diagnosis of HSDD. Therefore, 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.
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.
As neurotransmitters and sex hormones have modulatory function on sexual desire, treatment intervention has been evaluated in multiple clinical trials. Intrinsa is a testosterone patch that works by releasing the hormone testosterone through the skin into the bloodstream. It is licensed by Procter & Gamble for the use in post-menopausal women with surgical menopause who are also receiving estrogen replacement therapy. Flibanserin, a 5-HT1A receptor agonist and 5-HT2A receptor antagonist, has been investigated by Boehringer Ingelheim as a novel, non-hormonal treatment for pre-menopausal women with Hypoactive Sexual Desire Disorder (HSDD). Development on this medication has since been discontinued by the company. Preclinical evidence suggested that flibanserin targets these receptors preferentially in selective brain areas and helps to restore a balance between inhibitory and excitatory effects.
Bremelanotide is a cyclic hepta-peptide lactam analog of alpha-melanocyte-stimulating hormone (alpha-MSH) that activates themelanocortin receptors MC3-R and MC4-R in the central nervous system. It is a metabolite of Melanotan II that lacks the C-terminal amide function.In studies, bremelanotide was shown to be effective in treating sexual dysfunction in both men (erectile dysfunction or impotence) and women (sexual arousal disorder). Unlike Viagra and other related medications, it does not act upon the vascular system, but directly increases sexual desire via the nervous system thus can be considered as True Aphrodisiac. A Phase III clinical trial was scheduled to begin in the first half of 2007, but was delayed until August 2007. On August 30, 2007 Palatin (Pharmacological Company) announced that the U.S. Food and Drug Administration had expressed serious concerns regarding the risk/benefit ratio of bremelanotide with regards to the side effect of increased blood pressure. The FDA stated that it would consider alternate uses for bremelanotide, including as a treatment for individuals who do not respond to more established ED treatments. However, On May 13, 2008, Palatin Technologies announced it had "discontinued development of Bremelanotide for the treatment of male and female sexual dysfunction" while concurrently announcing plans to develop it as a treatment for hemorrhagic shock instead.On August 12, 2009, the company announced that in a double-blind study of 54 volunteers bremelanotide failed to evoke the hypertensive side effects seen with the nasal delivery system used in prior studies, concluding that "variability of uptake" inherent in intranasal administration of the drug resulted in "increases in blood pressure and gastrointestinal events...primarily related to high plasma levels in [only] a subset of patients" and that subcutaneous administration of the drug circumvented the potential for this side effect. Palatin has completed a human Phase 2B study utilizing subcutaneous administration and is expecting to release its Phase 2B report in the Early half of Q4 2012.
Off-label treatments allow therapists to propose other molecules such as the antidepressant bupropion A few studies suggest that bupropion can improve sexual function in women who are not depressed, if they have hypoactive sexual desire disorder. Other molecules such as Dopamine D2 receptor agonists (cabergoline, pramipexole, ropinirole...) can increase the sexual desire (and orgasmic capacity), but can also lead to a hypersexuality condition.
HSDD, as currently defined by the DSM has come under criticism of the social function of the diagnosis.
- HSDD could be seen a part of a history of the medicalization of sexuality by the medical profession to define normal sexuality. It may also over pathologize normal variation in sexuality because the parameters of normality are unclear. This lack of clarity is partly due to the fact that the terms "persistent" and "recurrent" do not have clear operational definitions.
- HSDD may function to pathologize asexuals, though their lack of sexual desire may not be maladaptive. Because of this, some members of the asexual community lobbied the mental health community working on the DSM-5 to regard asexuality as a legitimate sexual orientation rather than a mental disorder.
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.
- Research indicates a high degree of comorbidity between HSDD and female sexual arousal disorder. Therefore, a diagnosis combining the two might be more appropriate.
- 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. One could claim that this criterion (for all of the sexual dysfunctions, including HSDD) decreases the scientific validity of the diagnoses or is a cover-up for a lack of data on what constitutes normal sexual function.
- The distress requirement is also criticized because the term "distress" lacks a clear definition.
- It is suggested that a duration criterion should be added because lack of interest in sex over the past month is significantly more common than lack of interest lasting six months. Similarly, a frequency criterion (i.e., the symptoms of low desire be present in 75% or more of sexual encounters) has been suggested.
The current framework for HSDD is based on a linear model of human sexual response, developed by Masters and Johnson and modified by Kaplan consisting of desire, arousal, orgasm. The sexual dysfunctions in the DSM are based around problems at any one or more of these stages. 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.
- The focus on merely the physiological ignores the social, economic and political factors including sexual violence and lack of access to sexual medicine or education throughout the world affecting women and their sexual health.
- The focus on the physiological ignores the relationship context of sexuality despite the fact that these are often the cause of sexual problems.
- The focus on discrepancy in desire between two partners may result in the partner with the lower level of desire being labeled as "dysfunctional," but the problem really sits with difference between the two partners. However, within couples the assessment of desire tends to be relative. That is, individuals make judgments by comparing their levels of desire to that of their partner.
- The sexual problems that women complain of often do not fit well into the current DSM framework for sexual dysfunctions.
- The current system of sub-typing may be more applicable to one gender than the other.
Given criticisms of the current DSM classification, a new disorder combining the characteristics of HSDD and sexual arousal disorder has been proposed for the next version of the DSM (the DSM-V, due to be published in 2013). The name proposed for this disorder is Sexual Interest/Arousal Disorder. See Sexual Interest/Arousal Disorder for a more extensive review. The criteria proposed for diagnosing this disorder in women are:
1. Lack of sexual interest/arousal of a least 6 months duration as manifest by at least four of the following indicators:
- Absent/reduced interest in sexual activity
- Absent/reduced sexual/erotic thoughts or fantasies
- No initiation of sexual activity and is not receptive to a partner’s attempts to initiate
- Absent/reduced sexual excitement/pleasure during sexual activity (on at least 75% or more of sexual encounters)
- Desire is not triggered by any sexual/erotic stimulus (e.g., written, verbal, visual, etc.)
- Absent/reduced genital and/or nongenital physical changes during sexual activity (on at least 75% or more of sexual encounters)
2. The disturbance causes clinically significant distress or impairment Specifier:
- Lifelong or acquired
- Generalized or situational
- Partner factors (partner’s sexual problems, partner’s health status)
- Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
- Individual vulnerability factors (e.g., depression or anxiety, poor body image, history of abuse experience)
- Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity)
- Medical factors (e.g., illness/medications)
3. The sexual dysfunction is not better accounted for by another Axis 1 disorder (except for another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
This classification is desirable compared to the current DSM – IV classification system because: (1) it reflects the finding that desire and arousal tend to overlap (2) it differentiates between women who lack desire before the onset of activity, but who are receptive to initiation and or initiate sexual activity for reasons other than desire, and women who never experience sexual arousal (3) it takes the variability in sexual desire into account. Furthermore, the criterion of 4/6 symptoms be present for a diagnosis helps safeguard against pathologizing adaptive decreases in desire.
The limited research in male sexual desire has revealed that it may differ from female sexual arousal in some respects (e.g., tend to have higher masturbation frequency and often continue to masturbate despite low sexual desire), but that there are likely more within-gender than between-gender differences, there are three options under consideration for the diagnosis of low sexual desire in men:
- The DSM-IV-TR name and criteria be preserved for men in the DSM-V
- Proposed criteria for Sexual Interest/Arousal Disorder in women be adopted for men (one gender neutral category)
- The proposed criteria for Sexual Interest/Arousal Disorder be adopted for men with the modification that absence or reduced genital and/or non-genital physical changes not be included as criterion
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