Stephen B. Levine, MD

Every person possesses a complexity called sexuality that slowly manifests itself in variable ways from childhood to old age. Sexuality’s two major elements are sexual identity and sexual function, each of which has several components (

). The components evolve predictably over the life cycle, but also may abruptly change in response to personal, interpersonal, mental and physical difficulties, and cultural forces. The most central component is sexual desire, a complexity that represents the energy/motivation to socially express one’s gender identity, orientation, and intention as well as the force that shapes arousal, orgasm, and penetration experiences.

All of the components of sexuality except orientation are used to organize DSM-5 sexual dysfunction and sexual identity diagnoses. A working knowledge of all the components guides the sexual history. DSM-5 sexual diagnoses do not capture the actual sexual dramas of patients’ lives; they only characterize the seemingly negative outcomes of life processes.

As these processes become illuminated by the sexual history, a wide array of influential adversities become apparent. These include medical and psychiatric disorders, infidelity, infertility, preoccupation with commercial sex, childhood abuse and neglect, attachment problems, sexual identity struggles, sexual victimization, marital discord, divorce, grief, medication effects, ignorance, and the like. Sexual life is disrupted by many of the same forces that compromise mental health.

In discussing a patient’s sexual life, consider the following important cautions.

Do not consider sexual life separate from what you already understand about biopsychosocial processes during the life cycle.

 Because we experience our own sexuality as an intensely private subjective matter, we assume that patients do as well. We may not realize that they consider the psychiatrist as more knowledgeable than they are about this frequently problematic realm. They may welcome our inquiries and our attempts to understand and assist them. Clinical sexual expertise grows by the doctor’s interest and emerging personal comfort rather than the accumulation of esoteric knowledge.

Do not assume the process of taking a sexual history is a difficult personal process.

 Ask the patients if they have any sexual concerns that they would like to discuss. When they answer “yes” or when they spontaneously mention a sexual topic, invite them to tell you more: “Please say more about that” or “Tell me what you think it is important for me to know about that.” This shows the patient that you are interested and want to be helpful.

 While many men and women may prefer to discuss their concerns with a professional of the same gender, others prefer the opposite. Regardless of their preference, the patient’s discomfort quickly dissipates when the psychiatrist asks illuminating questions.

There is no such thing as a complete sexual history.

 The clinician’s responses follow from the patient’s’ concern: a 16-year-old who wants to change her social presentation; a 40-year-old who confesses his lifelong premature ejaculation; a 53-year-old woman who has new dyspareunia; a 24-year-old who has never had an orgasm; a 67-year-old gay man with faltering potency; a couple who has not had any sex for three years after the wife’s infidelity; a man caught in a sting operation for watching child pornography; a man in the midst of an affair with little desire for his wife, etc. All of these scenarios would elicit very different history taking.

 Clinicians should not burden themselves with the idea that each problem should generate a long list of items that must be covered during that session. Patients expect to have the conversation continue and will provide additional relevant information when the clinician mentions the previous sexual concern.

After the first session, the patient is either impressed or unimpressed with the doctor’s interest. It is not difficult to engage the patient in the topic during the next session. When the concern is the highly prevalent selective serotonin reuptake inhibitors-induced dysfunction, the patient will expect the doctor to follow up on any suggestions.

Of course, there are specific things that we want to know in each situation, but these questions naturally occur to clinicians after the patients tell their stories. If not, it is useful to consult a relevant article, readily found via PubMed by topic, or a book to augment the doctor’s knowledge of the patient’s concern. There are numerous comprehensive texts covering the broad range of sexual concerns, problems, and diagnoses.

 This distinction guides the search for the causal factors in symptom production (

). Without considering this fundamental distinction, the clinician’s work tends to be unfocused, inefficient, and confusing to both parties. Premature ejaculation and women’s anorgasmia typically tend to be lifelong, whereas erectile inconstancy and women’s desire/arousal problems tend to be acquired.

When problems are acquired, we zero in on what was occurring before the symptom appeared. We want to know if an acquired problem is specific to one partner or is true in all circumstances. Lifelong problems invite a focus on the patient’s family processes, relationship with parents, siblings, and experiences of abuse and neglect. We are interested in the patient’s sense of what historically has influenced the pattern. When “I don’t know” is the response, it is fine to say, “These patterns have multiple influences, but I presume you have considered certain ideas. Can you share them with me?”

Try to formulate the likely pathway to the problem.

 Understanding the pathways to these problems is often necessary to improving patients’ lives. Psychiatrists can intervene with a phosphodiesterase-5 inhibitor, flibanserin, bremelanotide, and an SSRI to address erectile dysfunction, sexual interest/arousal disorder, and premature ejaculation. These prosexual prescriptions are best provided after careful listening and questioning, which is essential in establishling a trusting therapeutic alliance.

The understanding of pathogenesis can become more complete with each session as we learn more about the patient’s experiences, capacities, and thinking. Such understanding that derives from learning about the person’s sexual struggles does not mean that every psychiatric patient requires a sexual history. But do not be shocked when a patient brings up the topic in the context of a nonsexual problem.

When sexuality is relevant to understanding the patient’s problem, some psychiatrists deflect the topic with comments such as “I am not a sexual specialist;” “We don’t have time for that subject;” or “Share that with your psychotherapist.” Such rejecting responses often indicate one or more of the following private concerns of the psychiatrist.

“My personal sexual life is problematic. What do I have to offer patients if I can’t solve my own sexual issues?”

 The more you know about the universality of sexual concerns, the frequency of sexual problems, and the prevalence of DSM-5 sexual diagnoses, the better you will feel about taking a sexual history. Our difficulties can generate interest as well as empathy. A doctor can feel addicted to pornography, not have sex with her husband, have difficulty ejaculating, or have dyspareunia-yet still be helpful to patients. Helping others exposes you to considerations that can illuminate an avenue of your own concerns.

“I do not know enough about the subject to help.”

 Often the clinician knows more than they originally thought and can readily acquire more knowledge. Few psychiatrists have in-depth knowledge of all disorders (eg, depression, anxiety, psychosis), and yet we calmly provide care.

“I am afraid of what I may feel while hearing about sexual fantasies and behavior.”

 Transient arousal, envy, attraction, and disgust may indeed occur during a session. These brief feelings are not disclosed to the patient; however, they are often not discussed with the supervisor either. Each of these feared affects have a different personal meaning that needs to be considered. Envy, for example, teaches the psychiatrist what they might like to personally experience, while disgust informs the doctor what they considers abnormal. No psychiatrist can possibly experience the full range of human sexual behaviors; we should expect a private affective response. These transient internal experiences are stimuli for our professional growth.

“My values preclude my dealing with sexual minority patients in any depth.”

 The subtle privilege of being a psychiatrist is the opportunity for life-long learning. In-depth patient experience is a powerful source of learning. Your personal values, whatever their sources, create a priori negative judgments that you fear will become evident to the patient. Getting to know the actual person who has a variation in gender identity, orientation, or intention is the best way to overcome such prejudice.

Each new sexual minority patient can be your personal continuing medical education course, if only you allow yourself to be with the patient over time. At one point or another, every psychiatrist wants to run away from patients whose behavior is socially offensive, but it is a developmental task for clinicians to grow comfortable separating themselves from the differing lives of patients and to counter our morally censorious impulses to live up to our time-honored professionalism.

The power of these four rationalizations help psychiatry residents, fellows, and practicing psychiatrists to avoid inquiring or responding to sexual issues and creates a hesitance to use words involving sexuality. In basic seminars, I invite the group to speak a series of sexual words out loud: penis, vagina, clitoris, scrotum, breast, labia minora, labia majora, and nipple. This produces mirth. Then: menstruation, sexual intercourse, ejaculation, orgasm, cunnilingus, anal intercourse, and fellatio. I usually notice some people are skipping some words. It is initially difficult for both patients and doctors to transfer one’s private sexual language into professional language. Then I ask them to repeat words that some patients will use: blow job, eating her, going down, dick, snatch. I end the desensitization by asking the group to call out as many words as possible for the penis and then the breast. This short anxiety-provoking icebreaker precedes a presentation about the sexual history.

The sexual history is undertaken under a variety of circumstances; for instance, the patient’s sexual complaint, report of an individual’s or a couple’s relationship disappointment, a general review of psychiatric symptoms, a joke told to the doctor, a casual “by the way” remark, medication nonadherence, or a lack of mention of this vital aspect of life. Any professional delay of the sexual inquiry should be temporary.

Sexual life is not just about sexual identity and sexual behavior. Sex serves other functions such as the illumination of the relational self, the ability to love, the ability to remain loveable, and the ability to manage one’s emotional life.

 Over time, focusing on sexual life enables doctors to converse with patients about these larger matters. Patients better understand themselves as a result and deeply appreciate their psychiatrist or psychotherapist. Doctors’ growing comfort with the sexual history enables them to understand their patients’ sexual lives and psychiatric diagnoses in a deeper, more individualistic way.

Welcome to the world of clinical sexuality; it all begins with a willingness to be interested!

Dr Levine is Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine where he served as director for the Center for Marital and Sexual Health. He is the author of five books including recently published 

Psychotherapeutic Approaches to Sexual Problems: An Essential Guide for Mental Health Professionals

The Handbook of Clinical Sexuality for Mental Health Professionals

. In March 2005, he and two colleagues received a lifetime achievement Masters and Johnson’s Award from the Society for Sex Therapy and Research. He reports no conflicts of interest concerning the subject matter of this article.

, 5th ed. New York: Guildford Press; 2014.

Handbook of Clinical Sexuality for Mental Health Professionals

Psychotherapeutic Approaches to Sexual Problems: An Essential Guide for the Mental Health Professional

. Washington, DC: American Psychiatric Association Publishing; 2019.

Articles

Sexual life is not just about sexual identity and sexual behavior. 

Illuminate Life Processes by Taking a Sexual History

Slideshows

These simple tips may help take the mystery out of the process of psychotherapy and put us in a better position to understand our patients-and ourselves.

8 Core Components of Psychotherapy

This activity offers CE credits for:
1. Physicians (CME)
2. Other

To understand the various sexual disorders that can present during a person’s lifespan and the psychiatrist’s role in helping relieve such problems.

At the end of this CE activity, participants should be able to:

• Discuss the 3 basic clinical concepts of sexual dysfunction

• Understand the reasons for limitations in prevalence data

• Describe the pathogenesis of the dysfunction

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

 This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 

 ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants:

 AANPCP and AAPA accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit ™.

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Stephen B. Levine, MD, has no disclosures to report.

Katherine Hall, PhD, (peer/content reviewer) has no disclosures to report.

 staff and CME Outfitters staff have no disclosures to report.

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

 became part of the vocabulary of clinical medicine in 1970 with the publication of Masters and Johnson’s 

 Before this book appeared, male sexual problems were conceived of as either premature ejaculation or impotence, and most female sexual function problems were categorized under frigidity. The terms for the specific sexual dysfunctions, which generally reference sexual behavior with partners, have been evolving ever since.

DSM-5 has separate vocabularies for men and women (

). The current labels refer to complaints of low sexual desire, poor sexual arousal, difficult orgasmic attainment, and painful intercourse. DSM-5 categorizes these well-known symptom presentations but omits several problems.

The patterns that are not well characterized in DSM-5 include the so-called male sexual addictions or hypersexuality and 4 infrequently encountered patterns: persistent genital arousal syndrome, post-orgasmic illness syndrome, pleasureless orgasm, and highly restricted patterns of orgasmic attainment. The topic of sexual dysfunction, which is distinct from sexual identity issues, is too broad to be tersely summarized. To understand in detail the specific dysfunctions, readers can consult Binik and Hall

The sources of dysfunctional patterns are scientifically not well established. Yet, for practical purposes, clinicians offer a variety of therapeutic interventions based on their history taking and their preferred understanding of pathogenesis. Although many mysteries of sexual pathophysiology await illumination, patients sometimes expect mental health professionals to provide guidance about their persistent sexual disappointments.

When looking at the sexual dysfunctions as a group, it is useful to consider several basic ideas.

The first is to categorize the specific problem as seemingly always present (lifelong) or acquired after a period of normal sexual function (acquired) and as specific to a partner or a type of sexual activity (situational) or present with all partners and sexual circumstances (generalized). These distinctions help clinicians focus on the relevant history of the presenting problem-that is, to focus on the situation before the symptoms began or, if lifelong, to focus on past important developmental experiences.

The second is to keep in mind that all sexual behavior-solitary and partnered, normal and dysfunctional, morally acceptable or socially disapproved of-is constructed with biological, psychological, interpersonal, and cultural contributions. This concept helps clinicians to put generalizations about sexual dysfunction into perspective, to remain humble, and to bring an intelligent skepticism to pronouncements about causality and treatment claims. It is also why the need for clinical judgment in this arena is stressed so heavily within DSM-5. As psychiatry’s interest in the sexual dysfunctions has lessened over the past several decades, sexual medicine has become more prominent.

The latter is dominated by research and clinical interventions in urology and gynecology, and pharmaceutical research into prosexual agents. Nonetheless, a broad array of clinicians encounter patients’ sexual concerns. These include psychiatrists, psychologists, relationship therapists, sex therapists, counselors, infectious disease specialists, physical therapists, and primary care physicians. Each stakes out a narrow band of sexual concerns and dysfunctions. Each tends to have a biologic or psychological bias when it comes to explaining the problem and recommending treatment. A urologist, for instance, is more likely to prescribe a phosphodiesterase-5 inhibitor (PDE-5i) than to refer a man with erectile dysfunction to a mental health professional. A psychologist who confronts new lower desire and difficulty with ejaculation is less likely to consider a prolactinoma than would a primary care physician.

The sexual lives of patients, however, are rarely as simple as various professionals’ interventions suggest. Care is frequently optimized when medical and nonmedical professionals collaborate to bring their different skills and knowledge to patients.

The third basic concept is to keep in mind that sexual function, while very important to general well-being, is merely one aspect of a person’s life. While specialists tend to focus on the sexual problem, the process of determining the specific psychological, interpersonal, biological, and cultural determinants of a presenting problem often leads mental health professionals to realize that almost any sexual dysfunction can be a symptom of other DSM-5 diagnoses. MDD, for example, can lead to insufficient or excess sexual desire and impairment of arousal or orgasm. The clinician is called upon to separate:

• Sexual dysfunction that is the product of a psychiatric disorder from

• Reactive symptoms that stem from having the sexual dysfunction from

• Current life dilemmas beyond a DSM-5 diagnosis that impair sexual function or satisfaction from

• Remote adversities during childhood or adolescence that undermined the person’s ability to feel safe during the recurring intimate life experience

The skillful treatment of sexual dysfunction begins with a careful history to reveal the psychological, interpersonal, and biological health of the patient and his or her partner. An analogy may help. When learning histology, students are taught to look first at the tissue slice with the naked eye before they look under a microscope to correctly identify the organ they are examining. The following case illustrates the patient’s and the physician’s joint realization that focusing merely on the sexual problem can be usefully avoided.

A regimen of 60 mg of paroxetine and 5 mg of aripiprazole for several years has enabled a 37-year-old married father of 2 to stop watching pornography, to stop following women on the street who have shapely buttocks, and to quiet the strange noises in his head. At a follow-up visit, he complains that he ejaculates only about 50% of the time with his wife. He no longer masturbates and when he notices an attractive stranger, he turns away.

His ejaculatory difficulty began when the SSRI was prescribed. He and his wife were grateful for the drug because it enabled him to concentrate at work and to be more attentive at home. “Life is good now; before I thought I was losing my mind and my family!” After discussing his wife’s casual attitude toward his delayed ejaculation, he shares that the rear entry into the vagina position during intercourse is his preferred position for reaching orgasm.

When the risks and costs of the treatment options are reviewed, the patient and physician agree to keep his medicines as is. Periodic inability to ejaculate is viewed as the price he is paying for a much improved life.

The prevalence of sexual dysfunction is greater among psychiatric and medical patients than in the general population. Results from a well-designed study of frequency in the latter group showed that the point prevalence of sexual dysfunction for those aged between 19 and 59 years was 35%.

 This fact has stirred prosexual medication research. The higher prevalence among psychiatric patients has been demonstrated for a variety of psychiatric disorders.

Epidemiological data, however, cannot be translated into DSM-5 sexual dysfunction diagnoses because they do not measure distress. While men’s sexual life may be dysfunctional in terms of rapid ejaculation, unreliable erections, or undependable ejaculation during intercourse, and women’s sexual function impaired by painful intercourse, low interest in partner sexual expression, inefficient arousal, or low rates of orgasm with partner sex, prevalence estimates do not translate into help seeking.

Many people do not seek psychiatric attention for their sexual dysfunctions.

 They may know that the source of the problem is partner alienation and are distressed about their situation but not the dysfunction per se. Some are too embarrassed to discuss their situation, particularly their earlier childhood/adolescent experience with sexual molestation or intrafamilial abuse. Some are simply overwhelmed by all the demands on them, making their dysfunction low on their priority list. Some have already spoken to a medical doctor and have failed to improve with the recommendation made. Some realize that their partner has no interest in having sex after the discovery of infidelity. Some cannot afford the cost of treatment because many insurance plans do not pay for these diagnoses. Some do not think that their problem can be helped, and others do not know where to go for help. Finally, some simply do not value sexual expression.

When individuals or couples seek help for sexual dysfunction, it is often because their relationship is at a crisis point. This is why clinicians emphasize that residents try to determine why patients are seeking help at this juncture in their lives. A woman’s chief complaint may be lifelong anorgasmia, but she is seeking help now because she fears losing her husband to another woman via an affair or divorce because their sexual life is mutually unsatisfying.

, many patients appeared at new sexual dysfunction clinics across the US and Europe because of the hope generated by the positive results of Masters and Johnson. A decade later, therapists were lamenting that the cases readily cured by sex therapy had disappeared; they were primarily seeing men, women, and couples with complaints of multidetermined complexity.

By 1980, the enigmatic problems with low sexual desire had been defined. When SSRIs were noted to delay ejaculation in the early 1990s, a wave of men requested treatment. When sildenafil was brought to market, a tsunami of patients sought this wondrous panacea, although as many as 50% of those who were given a prescription did not continue to use the drug.

In stark contrast, in 2015 when flibanserin was approved by the FDA for sexual interest arousal disorder (SIAD) in women, there was only a trickle of interest in the drug.

 Given the purported high prevalence of SIAD, many are wondering about the reasons for the drug’s poor reception. Explanations include the contraindication of alcohol use, the lengthy time to a positive effect, controversy about its approval, the need for physician special education before prescribing, and marketing mismanagement.

Be sophisticated about drug-induced sexual dysfunction. Four phases of sexual function can be efficiently covered in taking a history of this complaint. These help to illuminate the pathogenesis of the dysfunction:

• What was sexual function like before the psychiatric problem (depression, psychosis, addiction) was established?

• What was the effect of the condition on sexual function? (Often it is impaired)

• What was the effect of improvement of the condition on the patient’s sexual function? (Sometimes no improvement in sexual function has occurred)

• What was the effect of the medication when the condition was treated initially and after several months? (A highly unusual new sexual symptom-penile or vaginal anesthesia, burning during or after orgasm, clitoral priapism-suggests a medication adverse effect)

By asking the first 2 questions before prescribing a psychotropic, not only does it prepare the patient to think clearly about medication effects, it can also strengthen the patient’s trust about the psychiatrist’s concern for his or her welfare.

Drug-induced sexual dysfunction depends on the degree of excitement and stimulation in a person’s life. Thus, one episode of sex with one’s partner may be quite arousing because of special circumstances, yet most of the time the level of arousal is low enough that the medication limits what is physiologically possible. Psychiatrists must recognize that not all sexual activity among the married occurs within marriage. Here is an example.

A 40-year-old chronically depressed mother of 3, who was living in an asexual marriage with a man without sexual interest in her, stopped her infrequent masturbation once an SNRI was prescribed. “What good is my sexual interest? I’m glad it is gone.” A year later, while taking 300 mg/d of the SNRI, she began an affair during which she was multiorgasmic with almost any sexual behavior the couple engaged in. “I guess it was not just the Effexor!” she remarked.

Provide a follow-up appointment when prescribing a drug for sexual dysfunction. An SSRI for premature ejaculation or a PDE-5i for erectile disorder may or may not be immediately effective. Not only might the dose need to be modified, but the patient may need to better understand what the medications can and cannot do. Despite the availability of flibanserin for women, many clinicians prescribe other medications, such as testosterone and bupropion. The follow-up appointment is also for the physician so that he or she can continue to learn about the patient’s life and the efficacy of the previous intervention. Many patients consider their gradual revelation of their lives to be therapeutic.

Appreciate the gynecological changes of menopause. Perimenopause is often associated with reduced vaginal lubrication, diminished sexual drive, and decreased vulvar and nipple sensitivity.

 As many women age beyond the menopause, a high percentage lose interest in sex because of pain during intercourse. This pain often signals the beginning of vulvar-vaginal atrophy.

 While early in its course the discomfort may be significantly relieved by moisturizers and lubricants, a surprising number of male partners and women do not understand these physiological changes. Instead, unfortunate couples needlessly consider the problem to be a manifestation of the loss of love.

A woman with a long history of regular satisfying sex with her husband developed “a spare tire” around her abdomen and voiced concern over not feeling attractive in her mid-50s. In addition, intercourse began to be painful, and she began to minimize their sexual encounters. Sex was something they did; it was not discussed. Her husband-a craftsman who fished, hunted, taught wrestling, and drank heavily in his spare time-never talked much about anything. To her, he seemed indifferent when she complained about the changes in her body. He suddenly decided to leave her, saying only that they never had sex anymore. By the time he returned apologetically 2 months later because he was unhappy apart from her, she had learned that he had a younger girlfriend. They sought help for their marriage when she could not get over her anger for being abandoned and being lied to about the younger woman.

While there is much more to these lives, it is startling how little they appreciated these physiological events. I casually educate patients and their partners about the expected sexual impact of menopause for the majority of women.

Be aware that any sexual dysfunction in any era of adult life can lead to the demise of a couple’s sexual life. There are 2 main sources of couples’ nurturance: psychological intimacy and sexual behavior.

 Without sex, individuals often feel disconnected, alone, and without the reassurance that comes from a pleasurable sexual intimacy.

The prevalence of rapid ejaculation and anorgasmia is highest among young adults, whether single or partnered. When paired together, such couples have a difficult time outgrowing their youthful problems. Sex tends to become devalued and may end because the partners lose interest in experiencing their individual and joint disappointments. As years go by and life gets complicated by work and children, many women begin to lose their desire for partner sex. Sometimes this is compounded by a subtle loss of respect for the partner as they more clearly realize the partner’s limitations. Middle-aged men do not complain of low desire as frequently as middle-aged women; they complain of erection problems. Long-standing couples, aged approximately 60 years and older, often share sexual arousal complaints. Each is no longer as spontaneously interested in sex; each may be less sexually arousable and may find regular orgasmic attainment more difficult.

These common age-related patterns are not inevitable! The sexual dysfunctions raise the vital question of what accounts for individuals who are able to sustain a vital, nurturing, pleasurable, nondysfunctional sexual life despite the expected physiological challenges of aging.

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Dr. Levine is Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine in Cleveland, OH. He has written several books, including 

 Demystifying Love: Plain Talk for the Mental Health Professional

Barriers to Loving: A Clinician’s Perspective

. He is co-director of the Center for Marital and Sexual Health in Beachwood, OH.

. 5th ed. New York: Guilford Press; 2014.

 Laumann E, Paik A, Rosen R. Sexual dysfunction in the United States: prevalence and predictors. 

 Dunn KM, Croft PR, Hackett GI. Association of sexual problems with social, psychological, and physical problems in men and women: a cross-sectional population survey. 

 Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. 

 Brotto LA. Flibanserin. Arch Sex Behav. 2015;44:2103-2105.

 Hayes R, Dennerstein L. The impact of aging on sexual function and sexual dysfunction in women: a review of population-based studies. 

 Palma F, Volpe A, Villa P, et al. Vaginal atrophy of women in postmenopause: results from a multicentric observational study: the AGATA study. 

Although many mysteries of sexual pathophysiology await illumination, patients may expect mental health professionals to provide guidance about their persistent sexual disappointments. Insights here.

Sexual Dysfunction: The Role of Clinical Psychiatry

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.

 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.

 resulting from this polythetic approach was the combination of arousal and desire disorders, which recognized the interrelationship between desire and arousal.

 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.

Despite the ongoing controversies surrounding the conceptualization of female sexual functioning and desire, 

 clearly demonstrates that low desire is common and that approximately 26% to 53% of women struggle with this issue.

 However, the prevalence of both low desire 

 distress is much smaller: approximately 7% to 16%, depending on age and menopausal status.

The prevalence of low desire increases with age, although distress about low desire does not.

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 

 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 

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?”

Psychotherapy has been used for decades to treat low sexual desire, although few outcome studies have evaluated its efficacy. Sex therapy (eg, sensate focus) has been found to be modestly effective for the treatment of HSDD, and mindfulness-based cognitive-behavioral therapy has been 

 in improving sexual desire and arousal in cancer survivors.

 Psychotherapy (individual and/or couples) is likely to produce more positive outcomes when HSDD is acquired or situational, as opposed to a lifelong problem. When psychological factors (eg, relationship conflict, poor body image, abuse history, depression, anxiety) are the cause of low desire, psychotherapy should focus on these difficulties prior to or in conjunction with addressing low desire.

A history of each partner’s sexual experience reveals that this is one of the few sexual relationships Sally has ever had. Attempts to explore her thoughts and feelings about sexual behavior and her views of herself as a sexual being lead to acknowledgments that she has “never felt comfortable” discussing, thinking about, or engaging in sexual behavior. She has never enjoyed sex. She has never masturbated and does not know how to communicate what feels good. Her discomfort is visible. Later, she says that she feels “dirty” and “guilty” when engaging in sexual behavior and connects this to her religious upbringing. She asks, “Isn’t there something I can take?”

Before flibanserin, there were no FDA-approved treatments for HSDD. In the past, low desire was treated with a variety of investigational therapies: bupropion, testosterone, and dehydroepiandrosterone. Bupropion, a norepinephrine and dopamine reuptake inhibitor, has been used off-label on the hypothesis that increasing the concentration of these neurotransmitters promotes libido. Among hormone therapies, 

 has the strongest evidence base, but it has adverse effects of masculinization. The FDA did not approve its use in women for this purpose based on the lack of efficacy in its final controlled trials and the unknown long-term effects on the breast.

 Three monoamine neurotransmitters are of particular interest in considering the action of 

: serotonin, norepinephrine, and dopamine. In general, each monoamine is produced by discrete brainstem nuclei, which then project diffusely across the whole cortex. Serotonin activity in the prefrontal cortex has been associated with a 

, while norepinephrine and dopamine are associated with an increase.

 Understanding these circuits is critical to the current understanding of the mechanism of action of flibanserin.

For each of these 3 monoamine neurotransmitters, a circuit exists between the brainstem nuclei and the cortex. For example, neurons using serotonin as their neurotransmitter project onto and excite cortical neurons. These cortical neurons project back to the brainstem and use glutamate as their neurotransmitter, which excites the serotonin brainstem nuclei. The cortical glutamatergic neurons and the brainstem serotonergic neurons are mutually excitatory, forming a positive feedback loop.

Those nuclei containing dopamine and norepinephrine release neurons that project to the prefrontal cortex in a similar fashion, with one key difference. Rather than projecting directly on these brainstem nuclei to excite them, some glutamatergic cortical neurons synapse on an inhibitory inter-neuron first. This inter-neuron serves to flip the signal, turning a mutually excitatory network into an inhibitory one. Thus, glutamatergic cortical input inhibits, rather than promotes, norepinephrine and dopamine release.

Most antidepressants act directly on monoamine transporters and 

 the availability of these neurotransmitters

; flibanserin has more in common with atypical antipsychotics and buspirone than with classic antidepressants. The proposed mechanism of flibanserin differs from that of other antidepressants in that it acts by indirectly modulating the release of neurotransmitters via its actions on cortical glutamate neurons.

Flibanserin predominantly binds 2 subtypes of serotonin receptor. The serotonin-1A receptor is a postsynaptic receptor on the cortical glutamate neuron, which in theory serves to inhibit its firing.

 The serotonin-2A receptor is its opposite, a postsynaptic receptor on the cortical glutamate neuron that promotes its firing. As an agonist of the former and an antagonist of the latter, flibanserin should reduce the firing of these neurons at both receptors.

In the reciprocally exciting serotonin-glutamate circuit, serotonin brainstem nuclei are no longer stimulated by the glutamatergic cortical neurons, which decreases the libido-dampening effects of serotonin.

 In the reciprocally inhibiting circuits between norepinephrine and dopamine brainstem nuclei and cortical neurons, norepinephrine and dopamine output to the cortex is enhanced as the inhibiting GABAergic neuron’s activity decreases. This, in theory, potentiates the libido-enhancing effects of these neurotransmitters.

 Flibanserin is rapidly absorbed: half of the compound is absorbed in 25 minutes, and a 

 Steady state is achieved in 3 days, and the drug must be taken daily. It can be taken with or without food, although fatty meals increase its absorption slightly. Flibanserin is metabolized in the liver, mostly by cytochrome P-450 (CYP) 3A4, and its use is contraindicated in those with liver disease. The 

 flibanserin dosage-and the lowest dosage found to be effective-is 100 mg daily, at night.

 that women who take flibanserin experience one additional “satisfying sexual event” (ie, intercourse, oral sex, masturbation, or genital stimulation by a partner) every 28 days.

 The studies were conducted in women with 

 HSDD and those with Beck Depression Scores above 14 (ie, minimal symptoms of depression). The efficacy of flibanserin in women with lifelong HSDD or significant mood symptoms remains to be seen. Like all new pharmacotherapies, it has been studied in a highly selective group of women. Because it will likely be prescribed to women who have comorbid diagnoses, the effectiveness of flibanserin may be diminished.

Adverse drug reactions include those typical of centrally acting agents as well as a few unique to this compound. Adverse effects such as headache, fatigue, nausea, and dizziness occur at rates comparable to other psychoactive medications. Respiration rate, blood pressure, and temperature remain unchanged with flibanserin administration, and no electrocardiographic changes are observed. Somnolence is the most serious adverse effect and affects more than 

 The median onset of this symptom is 2 days, and it lasts for a median duration of 35 days.

 Alcohol increases sedation, and its use is strongly contraindicated for women who take flibanserin.

Hypotension and syncope are not generally observed but occur when this compound is co-administered with a CYP 3A4 inhibitor (eg, fluoxetine, grapefruit juice, certain antibiotics) or when alcohol is consumed. Providers must take great care to educate and remind patients about the dangers of ignoring this potentially catastrophic adverse effect.

Patients are accustomed to hearing warnings about mixing alcohol and prescription drugs; however, many view these guidelines as suggestions rather than requirements. Women who take flibanserin must be willing and able to commit to forgoing alcohol consumption, potentially for 

, depending on how long they receive this medication. Ultimately, some women may be unwilling to make this sacrifice in return for one additional positive sexual experience each month.

Joe admits that he puts little effort into “seducing” his wife. “I just ask her if ‘tonight is the night’ and usually she says no.” Joe also acknowledges that his wife does “pretty much all” of the housework but argues that he does not “see dirt the way she does.” Joe is unable to connect his behavior to his wife’s lack of desire for him.

Selecting the most appropriate intervention.

 Mental health and medical providers should consider evaluating and discussing every patient’s sexual history, functioning, and related thoughts and feelings. In evaluating for HSDD and the appropriateness of a pharmacological intervention such as flibanserin, a complete and detailed personal and relationship history is necessary to rule out individual, partner, or relationship variables that may contribute to a lack of interest in sex. Developing this level of understanding is best achieved by meeting with both partners individually and as a couple over several sessions. The 

 provides a list of potential factors that influence desire and can be a helpful reference for providers. It is, however, incomplete owing to the myriad of circumstances that accompany and may contribute to low desire in women.

The American Psychiatric Association and the American Foundation for Urologic Disease require the presence of both low sexual desire and sexually related personal distress to make the diagnosis of HSDD. Once low desire has been determined, evaluating distress can be a more complex task. It is useful to determine whether a woman experiences 

 distress about her lack of sexual desire or whether 

 (eg, repeated sexual requests, expressions of anger, frequent conflict about lack of sexual activity) about her disinterest in sex is the main cause for concern. This distinction can help clinicians select the most appropriate intervention (ie, individual or couples; medical or psychotherapeutic).

Sally rolls her eyes as Joe states his desire to have sex “at least twice a week.” However, when he shares feelings of rejection and sadness when rebuffed by his wife, she begins to tear up. “I want to want to have sex with my husband,” she says. “I don’t want to hurt him.”

Although increased media attention and an impressive advertising strategy will likely result in some women contacting their primary care physician for this issue, it is important to remember that many people-men and women alike-have difficulty discussing sexual concerns with others. 

 offer strategies for encouraging discussion and incorporating office-based counseling (eg, the PLISSIT model). Primary care physicians may also consider the use of self-report assessment tools such as the 

 In addition, consultation with local mental health and medical professionals who have expertise in this area may be helpful.

To date, a safe and effective pharmacotherapy for HSDD has been elusive. As a result, care has been centered on the treatment of psychiatric and medical comorbidities, re-evaluation of medications that may contribute to decreased libido (eg, SSRIs, oral contraceptives), and individual and/or couples psychotherapy. Undoubtedly, the FDA’s approval of a medication specifically for improving female sexual desire is a watershed moment.

Is flibanserin, erroneously referred to in the media as the “pink Viagra,” the answer to a lack of sexual interest? For some women, possibly. But for others, like Sally, psychotherapy will probably be necessary to help address personal and relationship issues that affect her lifelong lack of desire. More important, with the approval of flibanserin will come renewed attention to understanding the complexities of female sexual functioning and to helping women improve their sexual experiences.

This article was originally posted on 12/01/2015 and has since been updated.

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.

 Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. 

Before flibanserin, there were no FDA-approved treatments for hypoactive sexual desire disorder. The authors clarify the intricacies of an HSDD diagnosis and discuss implications for treatment.

Stephen B. Levine, MD

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