Hypoactive Sexual Desire Disorder
Hypoactive Sexual Desire Disorder
Hypoactive sexual desire disorder (HSDD) is defined as the persistent or recurrent extreme aversion to, absence of, and avoidance of all, or almost all, genital sexual contact with a sexual partner. Synonyms for HSDD include sexual aversion, inhibited sexual desire, sexual apathy , and sexual anorexia. HSDD is not rare, occurring in both sexes. It is the most common of all female sexual disorders, occurring in at least 20% of women in the United States.
The affected person has a low level of sexual interest and desire that is manifested by a failure to initiate or be responsive to a partner’s initiation of sexual activity. HSD becomes a diagnosable disorder when it causes marked distress or interpersonal instability, according to the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (also known as the DSM-IV-TR), the handbook used by mental health professionals to diagnose mental disorders. HSDD may be either situational (solely oriented against one partner), or it may be general, in which case there is a lack of sexual interest in anyone. In the extreme form of HSDD, the patient not only lacks sexual desire, but may also find sex to be repulsive, revolting and distasteful. Phobic or panic responses may be present in extreme cases of HSD. HSDD may be the result of either physical or emotional factors.
HSDD may be a primary condition in which the patient has never felt much sexual desire or interest, or it may have occurred secondarily when the patient formerly had sexual desire, but no longer has interest. If lifelong or primary, HSDD may be the consequence of sexual trauma such as incest, sexual abuse, or rape. In the absence of sexual trauma, there is often a repressive family attitude concerning sex that is sometimes enhanced by rigid religious training. A third possibility is that initial attempts at sexual intercourse resulted in pain or sexual failure. Rarely, HSDD in both males and females may result from insufficient levels of the male sex hormone, testosterone.
Acquired, situational HSDD in the adult is commonly associated with boredom in the relationship with the sexual partner. Depression , the use of psychoactive or antihypertensive medications, and hormonal deficiencies may contribute to the problem. HSDD may also result from impairment of sexual function, particularly erectile dysfunction on the part of the male, or vaginismus on the part of the female. Vaginismus is defined as a conditioned voluntary contraction or spasm of the lower vaginal muscles resulting from an unconscious desire to prevent vaginal penetration. An incompatibility in sexual interest between the sexual partners may result in relative HSDD in the less sexually active member. This usually occurs in the presence of a sexually demanding partner.
Painful intercourse (dyspareunia ) is more common in women than in men, but may be a deterrent to genital sexual activity in both sexes. The causes are usually physical in nature and related to an infection of the prostate gland, urethra, or testes. Occasionally, an allergic reaction to a spermicidal preparation or condom may interfere with sexual intercourse. Painful erections may be a consequence of Peyronie’s disease, which is characterized by fibrotic changes in the shaft of the penis that prevent attainment of a normal erection. In the female, dyspareunia may be caused by vaginismus or local urogenital trauma or inflammatory conditions such as hymenal tears, labial lacerations, urethral bruising, or inflammatory conditions of the labial or vaginal glands.
Priapism is the occurrence of any persistent erection of more than four hours duration occurring in the absence of sexual stimulation. It is not associated with sexual excitement and the erection does not subside after ejaculation. Priapism can occur at any age, but clusters of occurrence are common between the ages of five and 10 years and between the ages of 20 and 50. In children, priapism is commonly associated with leukemia and sickle cell disease, or occurs secondary to trauma. The most common cause in adults is the intrapenile injection of agents to correct erectile dysfunction. Priapism may also occur secondary to the use of psychotropic drugs, such as chlorpromazine and prazosin. The pain accompanying priapism may be a cause of HSDD.
A rare but important cause of HSDD is a functioning prolactin-secreting tumor of the pituitary gland, a prolactinoma. Men with this condition typically state that they can achieve an erection, but that they have no interest in sexual relations. In the female, prolactinomas are associated with galactorrhea (lactation in the absence of pregnancy), amenorrhea, symptoms of estrogen deficiency and dyspareunia. Although prolactinomas are benign tumors, they can cause visual disturbances by enlarging and causing pressure on the optic nerves within the confines of the sella turcica, the location of the pituitary gland at the base of the brain. Headaches and enlargement of the male breasts are fairly common in this condition. The diagnosis is confirmed by the finding of high levels of circulating prolactin in the blood. Enlargement of the pituitary gland area may be detected by the use of magnetic resonance imaging (MRI) or computerized axial tomography (CAT) scanning, also called computed tomography.
DELAYED SEXUAL MATURATION
Delayed sexual maturation is a potential cause of HSDD. It is present in boys if there is no testicular enlargement by age 13-and-a-half or if there are more than five years between the initial and complete growth of the genitalia. In girls, delayed sexual maturation is characterized by a lack of breast enlargement by age 13, or by a period greater than five years between the beginning of breast growth and the onset of menstruation. Delayed puberty may be the result of familial constitutional disorders, genetic defects such as Turner’s syndrome in females and Klinefelter’s syndrome in males, central nervous system disorders such as pituitary conditions that interfere with the secretion of gonadotropic hormones, and chronic illnesses such as diabetes mellitus, chronic renal failure, and cystic fibrosis.
Sexual anhedonia is a rare variant of HSDD seen in the male, in which the patient experiences erection and ejaculation, but no pleasure from orgasm. The cause is attributed to penile anesthesia, due to psychogenic factors occurring in an hysterical or obsessive person. Psychiatric referral is indicated unless there is evidence of spinal cord injury or peripheral neuropathy. Loss of tactile sensation of the penis is unlikely to be organic in cause unless there is associated anesthetic areas in the vicinity of the anus or scrotum.
The HSDD patient complains of a lack of interest in sex even under circumstances that are ordinarily erotic in nature, such as pornography. Sexual activity is infrequent and eventually is absent, often resulting in serious marital discord. HSDD may be selective and focused against a specific sexual partner. When boredom with the usual sexual partner is the cause and frequency of sex with the usual partner decreases, real or fantasized sexual desire toward others may be normal or even increased.
If the cause of HSD falls into a detectable category such as abnormalities of the genitalia, or is due to a related condition such as a prolactinoma, chronic renal disease, diabetes mellitus, genetic disorder, or is familial in nature, the patient will manifest the signs and symptoms of the comorbid (co-occurring) condition. It is important to identify such causes, as their presence will usually dictate appropriate therapy.
Currently, there is no approved drug or pharmacological treatment for HSDD and psychotherapy has proved to be only minimally effective. A primary goal of therapy is aimed at removal of the underlying cause of HSDD. The choice of medical therapy or behavioral or dynamic psychotherapy depends on the cause. If the cause is related to a medical condition, therapy is directed toward the cure or amelioration of that condition. Examples include cure or amelioration of underlying comorbid conditions such as genitourinary infections, improvement in diabetic control, avoidance of substance abuse and of medications that may be potentially responsible.
Therapy should also be directed towards other accompanying sexual disorders such as erectile dysfunction, which may be contributory. In cases where insufficient testosterone is suspected as a possible cause, serum androgen levels should be tested. A testosterone level less than 300 ng/dl in males and less than 10 ng/dl in females indicates a need for supplemental replacement therapy. If the cause is deemed to be of an interpersonal nature, couples therapy may be beneficial, in which case the support and understanding of the sexual partner is essential. Tricyclic antidepressants (TCAs) or monoamine oxidase inhibitors (MAOIs) may help in the treatment of accompanying depression or panic symptoms.
A recent study has reported that almost a third of nondepressed women with HSDD responded favorably to therapy with sustained release tablets of bupropion hydrochloride. The responders noted significant increases in the number of sexual arousals, sexual fantasies, and in the desire to engage in sexual activities. Bupropion hydrochloride (Wellbutrin) is currently approved by the FDA for the treatment of depression. Its favorable action on HSDD may be attributable to its enhancement of certain neurotransmitters that affect sexual desire, principally norepinephrine and dopamine.
Comorbid — Having another disorder or condition simultaneously.
Dyspareunia — Painful sexual intercourse.
Galactorrhea —Lactation occurring in the absence of pregnancy
Hypogonadism — Abnormally decreased gonad function with retardation of sexual development.
Priapism — Painful involuntary penile erection persisting in excess of four hours.
Prolactin — A hormone that stimulates milk production and breast development.
Vaginismus — An involuntary tightening of the vaginal muscles that makes sexual intercourse painful, difficult, or impossible.
The prognosis for HSDD depends primarily on the underlying cause or causes. In certain medical conditions, the prognosis for development, or recovery of sexual interest, is good. Examples include therapy of hypogonadism with testosterone, or the appropriate treatment of a prolactin-secreting pituitary tumor. On the other hand, in certain genetic defects such as Turner’s syndrome and Klinefelter’s syndrome, attainment of sexual function is impossible. By far, however, the vast majority of HSDD cases are situational in nature, usually relating to dissatisfaction or loss of interest in the sexual partner. In cases of marital discord, significant assistance may be obtained by counseling given by a health professional trained in the field. Cases of dissatisfaction by both partners often do not respond to such therapy, and frequently culminate in separation, finding a new sexual partner, and divorce.
Unfortunately, it is difficult or impossible to predict the occurrence of HSDD in situational cases that comprise the majority of patients. The patience, understanding and support of the sexual partner is essential in those cases of HSDD in which the cause is temporary or transient. Some therapists recommend a period of abstinence from genital sex and have emphasized the value of a period of concentration on non-genital sex in the treatment of HSD.
Borkow F., and A. J. Fletcher, eds. The Merck Manual of Diagnosis and Therapy. 16th edition. Rahway, NJ: Merck Research Laboratories, 1992.
Carnes, Patrick, Ph.D. Sexual Anorexia. Center City, MN: Hazelden Press, 1997.
Lue, Tom F., F. Goldstein. “Impotence and Infertility.” In Atlas of Clinical Urology. Volume 1. New York: Current Medicine, 1999.
Segraves R.T., Croft H., Kavoussi R., and others. “Bupropion sustained release (SR) for the treatment of Hypoactive Sexual Desire Disorder (HSDD) in nondepressed women.” Journal of Sex and Marital Therapy 27 (May-June 2001): 303–16.
Ralph Myerson, MD