Hypoactive sexual desire disorder (HSDD) first appeared in DSM-III-R, and it has been argued that this diagnosis is largely founded on an androcentric view of sexuality with little basis in actual female sexual experience.1 DSM-III-R criteria included “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity.” DSM-IV added the requirement of “marked distress or interpersonal difficulty” as a result of this “disturbance” to make a diagnosis. Clinicians were to make the determination of “deficiency or absence” of sexual desire by “taking into account factors that affect sexual functioning, such as age and the context of the person’s life.” In the development of DSM-5, experts argued for changes to language and criteria; HSDD was replaced by female sexual interest/arousal disorder (FSIAD), which also absorbed and replaced female arousal disorder and sexual aversion.
The biggest change resulting from this polythetic approach was the combination of arousal and desire disorders, which recognized the interrelationship between desire and arousal.1 Changes to the criteria included the addition of a 6-month duration requirement and options for variability in the manifestation of the disorder (ie, 4 indicators out of a possible 6, lifelong or acquired, generalized or situational, level of distress). However, on October 1, 2015, DSM-5 diagnoses were replaced by ICD-10, which includes HSDD but not FSIAD.
Sally is a heterosexual woman in her mid-thirties. She has been married for 8 years and has no children. She and her husband, Joe, have sought treatment to “improve communication” and increase the frequency of sex in their marriage. When asked if she thinks about, wants, or looks forward to sex with her husband, she states matter-of-factly that “no sex ever again would be my dream.” Joe is understandably displeased to hear this assertion.
HSDD with distress
Despite the ongoing controversies surrounding the conceptualization of female sexual functioning and desire, research clearly demonstrates that low desire is common and that approximately 26% to 53% of women struggle with this issue.2,3 However, the prevalence of both low desire and distress is much smaller: approximately 7% to 16%, depending on age and menopausal status.3,4 The prevalence of low desire increases with age, although distress about low desire does not.1
CASE VIGNETTE CONT’D
Further assessment of Sally and Joe’s sexual relationship includes discussions of how sex is negotiated between them, how often each of them would prefer to have sex, and whether sex is enjoyable when it occurs. “I could take it or leave it,” she says and reports that she “never” feels a physical urge to engage in sexual behavior.
Sally also expresses frustration about her husband’s complaints of infrequent sexual activity and the arguments that result. She goes on to assert that “he doesn’t talk to me” and that she does not feel emotionally connected to her husband. As a result, she believes that it is “weird for him to expect me to want to have sex when we don’t even talk about how our day was.”
In clinical practice, low or absent desire is the most common sexual complaint among women of all ages, although their distress is often associated with a desire to be more emotionally connected to their partners rather than concern about the absence of a physical drive or urge.5 This difference highlights the importance of approaching problematic low desire as a biopsychosocial phenomenon and conducting a thorough mental health and relationship assessment before making a diagnosis and selecting a treatment.6,7
CASE VIGNETTE CONT’D
Joe says that he finds discussion of emotions to be “pointless” because they “aren’t actionable.” He grew up in a family that rarely displayed emotions openly, and he finds it difficult and uncomfortable to communicate with his wife in that way. He states matter-of-factly that he has “nothing to talk about” and does not understand the relationship between sharing his emotions and having sex with his wife. “She’s always been like this; isn’t there something she can take?”
Dr Cooper is a Psychologist at the Center for Marital and Sexual Health in Cleveland, OH. Dr McBride is a Fourth-Year Resident Physician in University Hospitals Case Medical Center’s Adult Psychiatry program in Cleveland. Dr Levine is Director of the Center for Marital and Sexual Health and is Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine in Cleveland. He was a site investigator for one of the phase III flibanserin trials. Dr Cooper and Dr McBride report no conflicts of interest concerning the subject matter of this article.
1. Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Arch Sex Behav. 2010;39:221-239.
2. Laumann EO, Nicolosi A, Glasser DB, et al. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified by the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res. 2005;17:39-57.
3. West SL, D’Aloiso AA, Agans RP, et al. Prevalence of low sexual desire and hypoactive sexual desire disorder in a nationally representative sample of US women. Arch Intern Med. 2008;168:1441-1449.
4. Dennerstein L, Koochaki P, Barton I, Graziottin A. Hypoactive sexual desire disorder in menopausal women: a survey of Western European women. J Sex Med. 2006;3:212-222.
5. Basson R. Women’s difficulties with low sexual desire, sexual avoidance, and sexual aversion. In: Levine SB, ed. Handbook of Clinical Sexuality for Mental Health Professionals. New York: Taylor and Francis; 2010:159-180.
6. Levine SB. What patients mean by love, intimacy, and sexual desire. In: Levine SB, ed. Handbook of Clinical Sexuality for Mental Health Professionals. New York: Taylor and Francis; 2010:41-56.
7. Kingsberg SA, Rezaee RL. Hypoactive sexual desire in women. Menopause. 2013;20:1284-1300.
8. Davis SR, Moreau M, Kroll R, et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med. 2008;359:2005-2017.
9. Stahl SM, Sommer B, Allers KA. Multifunctional pharmacology of flibanserin: possible mechanism of therapeutic action in hypoactive sexual desire disorder. J Sex Med. 2011;8:15-27.
10. Stahl SM. Stahl’s Essential Psychopharmacology. 3rd ed. Cambridge, UK: Cambridge University Press; 2008:447, 341-355, 651-654.
11. Borsini F, Evans K, Jason K, et al. Pharmacology of flibanserin. CNS Drug Rev. 2002;8:117-142.
12. Reviriego C. Flibanserin for female sexual dysfunction. Drugs Today. 2014;50:549-556.
13. DeRogatis LR, Komer L, Katz M, et al. Treatment of hypoactive sexual desire disorder in premenopausal women: efficacy of flibanserin in the VIOLET Study. J Sex Med. 2012;9:1074-1085.
14. Thorp J, Simon J, Dattani D, et al. Treatment of hypoactive sexual desire disorder in premenopausal women: efficacy of flibanserin in the DAISY Study. J Sex Med. 2012;9:793-804.
15. Katz M, DeRogatis LR, Ackerman R, et al. Efficacy of flibanserin in women with hypoactive sexual desire disorder: results from the BEGONIA Trial. J Sex Med. 2013;10:1807-1815.
16. Goldfischer ER, Breaux J, Katz M, et al. Continued efficacy and safety of flibanserin in premenopausal women with hypoactive sexual desire disorder (HSDD): results from a randomized withdrawal trial. J Sex Med. 2011;8:3160-3172.
17. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26:191-208.