Inhibited Sexual Desire; Causes, Diagnosis, Treatment

Inhibited Sexual Desire








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Inhibited Sexual Desire (ISD) is one of the most common sexual dysfunctions, especially in women. Family physicians have an opportunity to recognize ISD before the associated problems become entrenched, and to guide couples toward a satisfactory resolution. A summary is presented of current thinking on ISD and its causes. Case reports and observations about the frequency of and treatment for ISD are included. Much less has been written about sexual avoidance in the presence of desire. A definition is offered of simple sexual avoidance in the absence of genital dysfunction. Frequency, treatment response, and specific cases are described. A newly identified entity—mutual unwillingness to importune for sex—is discussed briefly. Counseling which focuses on communication, self-responsibility, and sex education is very helpful to patients with sexual problems.

Hypoactive sexual desire disorder (HSDD) is a common multifactorial condition which is characterized by a decrease in sexual desire that causes marked personal distress and/or interpersonal difficulty. The general idea that HSDD is a sexual dysfunction difficult to treat is due to a large number of potential causes and contributing factors. Indeed, a balanced approach comprising both biological and psycho-relational factors is mandatory for accurate diagnosis and tailored management in clinical practice. There are currently no approved pharmacological treatments for premenopausal women with HSDD, while transdermal testosterone is approved in Europe for postmenopausal women who experience HSDD as a result of bilateral oophorectomy.

Causes of Hyposexual Desire Disorder

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/generalized – The man previously had a sexual interest in his present partner, but lacks interest in sexual activity, partnered or solitary.
  • Acquired/situational – The man was previously sexually interested in his present partner but now lacks sexual interest in this partner but has a desire for sexual stimulation (i.e. alone or with someone other than his present partner.)
  • Negative attitudes toward sexuality
  • Relationship difficulties (poor communication, abuse)
  • Partner sexual functioning
  • Childhood stressors
  • Medical conditions (diabetes mellitus, thyroid dysfunction)
  • Endocrine disorders (hyperprolactinemia)
  • Erectile dysfunction
  • History of emotional or physical abuse
  • Another psychiatric diagnosis (depression, anxiety)
  • Medication side effects
  • Stressors (job loss, bereavement)
  • Alcohol use

Symptoms of Hyposexual Desire Disorder 

Symptoms for Female Sexual Interest/Arousal Disorder include the following:

  • Absent or reduced interest in sexual activity
  • Absent or reduced sexual thoughts or fantasies
  • Reduced or no initiation of sexual activity
  • Absent or reduced sexual excitement or pleasure during most sexual activity
  • Absent or reduced sexual interest or arousal in response to internal or external cues, such as a partner’s attempts to initiate sexual activity
  • Absent or reduced genital or nonessential sensations during sexual activity

To meet criteria for Female Sexual Interest/Arousal Disorder, the symptoms must be present for at least six months and cause significant distress to the individual.

Symptoms of Male Hypoactive Sexual Desire Disorder include the following:

  • Reduced or absent sexual thoughts or fantasies
  • Reduced or absent desire for sexual activity

Similar to Female Sexual Interest/Arousal Disorder, the symptoms must also be present for at least six months and cause significant distress to the individual.

Diagnosis of Hyposexual desire disorder

In the DSM-5, male hypoactive sexual desire disorder is characterized by “persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity”, as judged by a clinician with consideration for the patient’s age and cultural context. Female sexual interest/arousal disorder is defined as a “lack of, or significantly reduced, sexual interest/arousal”, manifesting as at least three of the following symptoms: no or little interest in sexual activity, no or few sexual thoughts, no or few attempts to initiate sexual activity or respond to partner’s initiation, no or little sexual pleasure/excitement in 75–100% of sexual experiences, no or little sexual interest in internal or external erotic stimuli, and no or few genital/nongenital sensations in 75–100% of sexual experiences.

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For both diagnoses, symptoms must persist for at least six months, cause clinically significant distress, and not be better explained by another condition. Simply having a lower desire than one’s partner is not sufficient for a diagnosis. Self-identification of a lifelong lack of sexual desire as asexuality precludes the diagnosis.

Medications associated with low sexual desire

Drug classMedications
  • Antiepileptic drugs
  • Carbamazepine, phenytoin, primidone
  • Cardiovascular and antihypertensive agents
  • ACE inhibitors, amiodarone, β-blockers (atenolol, metoprolol, propranolol), calcium channel blockers, clonidine, digoxin, diuretics (hydrochlorothiazide, spironolactone), lipid-lowering agents
  • Hormonal medications
  • Antiandrogens (flutamide), GnRH agonists, oral contraceptive pills
  • Pain relievers
  • Psychotropic medications
  • Prolactin-inducing antipsychotics, anxiolytics (alprazolam, diazepam), lithium, SNRIs, SSRIs, tricyclic antidepressants
OtherChemotherapeutic agents, histamine receptor blockers, indomethacin, ketoconazole
  • Drugs of abuse
Alcohol, amphetamines, cocaine, heroin, marijuana

ACE = angiotensin-converting enzyme; GnRH = gonadotropin-releasing hormone; NSAID = non-steroidal anti-inflammatory drug; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.

Adapted with permission from Kingsberg SA, Woodard T. Obstet Gynecol 2015;125:477–486, with additional data from Buster JE. Fertil Steril 2013;100:905–15. Permission granted by Wolters Kluwer.

Treatment of Hyposexual desire disorder

Medication

  • Flibanserin is the first and only medication approved for women for the treatment of HSDD. It is only slightly effective over placebo, having been found to increase the average number of satisfying sexual events per month by 0.5 to 1. The side effects of dizziness, sleepiness, and nausea occur about three to four times more often. Overall improvement is slight to none.

Off-label

  • A few studies suggest that the antidepressantbupropion, can improve sexual function in women who are not depressed if they have HSDD. The same is true for the anxiolytic, buspirone, which is a 5-HT1A receptor agonist similarly to flibanserin. Testosterone supplementation is effective in the short-term. However, its long-term safety is unclear.

 

Investigational

  • Bremelanotide (tentative brand name Rekynda), a melanocortin receptor agonist, has successfully completed phase III clinical trials for the treatment of HSDD. A New Drug Application is expected to be filed in the latter half of 2017.

Agents under investigation for treatment of HSDD

AgentStudyStudy designKey findings
  • Bremelanotide
Clayton et al, 2016R, DB, PC study; 12 wk; premenopausal women with HSDD (n = 92), FSAD (n = 12), or mixed (n = 290); subcutaneous bremelanotide (0.75, 1.25, or 1.75 mg) ∼45 min before anticipated sexual activitySignificant improvement in number of SSEs, FSFI total score, and FSDS-DAO score for bremelanotide (1.25 and 1.75 mg, doses pooled) vs placebo; most common AEs with bremelanotide 1.25 and 1.75 mg: nausea (22% and 24%, respectively) flushing (14% and 17%), headache (9% and 14%); discontinuation due to AEs: 5.1% and 6.1% for bremelanotide 1.25 and 1.75 mg, respectively
Clayton et al, 2017; Derogatis et al, 20172 R, DB, PC studies; 24 wk; premenopausal women with HSDD (N = 1,202); subcutaneous bremelanotide 1.75 mg before anticipated sexual activityIn both studies, significant improvement in FSFI-d and FSDS-DAO Desire scores (primary endpoints) for bremelanotide vs placebo; no significant between-treatment difference in change in the number of SSEs
Clayton et al, 2017R, DB, PC, single-dose, crossover, alcohol interaction study; healthy volunteers (n = 12 men, n = 12 women); intranasal bremelanotide 20 mg, ethanol 0.6 g/kgNo significant increase in the incidence of AEs, no clinically relevant changes in blood pressure, and no PK interactions when bremelanotide was coadministered with alcohol
  • Bupropion + trazodone
Pyke et al, 2015OL crossover study; 4 wk per treatment; premenopausal women with HSDD (N = 30); low- or moderate-dose bupropion + trazodone or bupropion 300 mg/dSignificantly more treatment responders with moderate-dose bupropion + trazodone vs bupropion 300 mg/d on FSFI-d (76% vs 38%) and FSDS-R-13 (88% vs 45%); most common AEs with moderate-dose bupropion + trazodone: dry mouth (53.8%), somnolence (34.6%), constipation (23.1%), insomnia (23.1%); discontinuation due to AEs: 3.8% for moderate-dose bupropion + trazodone, 0% for bupropion 300 mg/d
  • Testosterone + sildenafil

Poels et al, 2013R, DB, PC, crossover study; 4 wk each of active treatment and placebo; premenopausal or postmenopausal women with HSDD (n = 24) or FSAD (n = 5) and relative insensitivity for sexual cues; sublingual testosterone 0.5 mg with sildenafil 50 mg (gelatin capsule)Significant increases in subjective indices of sexual function (sexual desire, arousal) for testosterone + sildenafil vs placebo; most common AEs with testosterone + sildenafil: flushing (23.0%), headache (15.9%)
  • Testosterone + buspirone

van Rooij et al, 2013R, DB, PC, crossover study; 4 wk each of active treatment and placebo; premenopausal or postmenopausal women with HSDD (n = 23) or FSAD (n = 5) and over-activation of sexual inhibitory mechanisms; sublingual testosterone 0.5 mg with buspirone 10 mg (gelatin capsule)Significant increases in subjective indices of sexual function (sexual desire, arousal) for testosterone + buspirone vs placebo; most common AEs with testosterone + buspirone: dizziness (11.3%), lightheadedness (10.3%)
  • Tribulus Terrestris
de Souza et al, 2016R, DB, PC study; 120 d; postmenopausal women with HSDD (N = 36); T terrestris750 mg (3 250-mg tablets)No significant differences between T terrestrisand placebo on FSFI domain or total scores; improvement on QS-F domains of desire, arousal/lubrication, pain, and anorgasmia with T Terrestris; no improvement with placebo; increase in bioavailable testosterone with T terrestris but not placebo; 3 patients in each treatment discontinued due to AE of nausea

To Keep Your Husband’s /Wife Interest In You

Boobs and cleavage are the most attractive part for any man’s eyes. If you are married for long and if you think that boredom is setting in your sexual relationship with your husband, then occasional cleavage show is a good idea. It helps to revamp your sexual life. 

Cleavage: ever attractive point in a woman

  • Though your husband has seen you naked umpteen number of times, your cleavage will still be an attractive part of you to him. Because it creates secrecy, it creates longing, it makes him see more.
  • Cleavage show is often more attractive than full boob show, because of the shape that it holds and because of secrecy factor.

It should be occasional 

  • If you show cleavage daily, he may get used to seeing them regularly, which will take away the secrecy and ‘surprise’ factor.

It should be non- intentional, accidental

  • You should never give a hint to him that you are showing cleavage intentionally. It should be like, natural, without your effort, while you are doing something, it just happened. If he gets to know that you are intentional, it will take away the hidden fun. It will slightly affect the attraction that it generates in his mind.

Show it from a distance

  • Better if he is not very close to you when you expose cleavage. Better that he is at a distance. If he is very near to you and starts love making immediately, it is good. But it will take away that long-lasting attraction that you want to create in his mind.

Timing is very important –

  • It should not be for a too short a time, that he never notices it. It should not be too long that he gets bored seeing it. That perfect timing is very important.

Take care to avoid third parties

  • Make sure that there is nobody else in the room or house when you try it. Your aim is to attract your husband only. 

Be ready for sex, or be patient

  • Even if there is no immediate success, the positive sex appeal that you create will have accumulated effects over a period of time. So, if he starts lovemaking it is fine. If he doesn’t then also there is nothing to worry. You are winning.

A few ideas for cleavage show 

  • You both are getting ready to go shopping, you are getting dressed, and forgot closing the door. (Can be dangerous, if someone else is in the home).
  • Your cleaning the floor, while he is reading the newspaper on a chair, right in front of you and you just flaunt cleavage while you concentrate on cleaning the floor.

Just take any chance when you can bend a little in front of him, say serving food in dinner.

Hyposexual desire disorder
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Avoid-

Scratching your chest, squeezing your boobs, yawning, or making ugly faces while you attempt this. He will definitely look away.

Criticism of Hyposexual desire disorder

General

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

  • HSDD could be seen as part of a history of the medicalization of sexuality by the medical profession to define normal sexuality. It has also been examined within a “broader frame of historical interest in the problematization of sexual appetite”.
  • HSDD has been criticized over pathologizing normal variations 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 of conditions with many causes that it functions as little more than a starting place for clinicians to assess people.
  • 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.

DSM-IV criteria of Hyposexual desire disorder

  • Prior to the publication of the DSM-5, the DSM-IV criteria were criticized on several grounds. It was 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 DSM-IV framework for sexual dysfunction in general, and HSDD, in particular, claimed that this model ignored the differences between male and female sexuality. Several criticisms were based on the inadequacy of the DSM-IV framework for dealing with female’s sexual problems.
  • Increasingly, evidence shows that there are significant differences between male and female sexuality. Level of desire is highly variable from female to female and there are some females 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 females 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 the 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 the 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 females complain of often do not fit well into the DSM-IV framework for sexual dysfunctions.
  • The DSM-IV system of sub-typing may be more applicable to one sex than the other.
  • Research indicates a high degree of comorbidity between HSDD and female sexual arousal disorder. Therefore, a diagnosis combining the two (as the DSM-5 eventually did) might be more appropriate.

References

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