Hypoactive Sexual Desire

Definitions and Diagnostic Criteria

The most frequently presenting sexual desire disorder is deficiency of sexual desire, which is termed hypoactive sexual drive. The DSM-IV (American Psychiatric Association 1994) criteria for hypoactive sexual desire disorder are presented in

Table 63-1. The essential feature is a deficiency or absence of sexual fantasy or desire for sexual activity that causes marked personal distress or interpersonal difficulty. It is interpersonal difficulty that usually prompts a person to seek help. This difficulty arises when the two people in a relationship have different intensities and frequencies of sexual desire. Regrettably, in such situations of desire discrepancy, it is usually the person with the lower level of sexual desire who is designated the “patient,” and attempts are made to enhance that person’s sexual desire. Another not uncommon interpersonal difficulty occurs when one particular partner never or only rarely initiates sexual activity but nonetheless happily participates and often experiences arousal and orgasm following sexual advances from the other partner. The perceived problem here is one of deficiency in proceptivity (i.e., seeking or initiating sexual activity).

Although various authors have attempted to define “normal” levels of sexual desire, there is no generally accepted criterion of normality. The intensity and frequency of sexual desire vary considerably, both in the population and over time within a particular individual. These dimensions, therefore, fall on a continuum extending from no desire at all to extremely frequent, highly intense sexual desire. Except where the higher levels of sexual desire disrupt life or lead to antisocial behavior, no point on this continuum can be considered abnormal. Hence, in the DSM-IV criteria for hypoactive sexual desire disorder, the judgment of deficiency or absence is left to the clinician, who must take into account factors that affect sexual functioning, such as age and the context of the person’s life.

The DSM-IV criteria require the clinician to specify whether the hypoactive sexual desire disorder is lifelong or acquired. Although we see people who have never experienced sexual drive and desire, in the majority of individuals presenting to sex therapy clinics the problem is acquired, developing after a period of adequate sexual desire. The DSM-IV criteria also require specification of whether the disorder is generalized (occurs in all sexual activities) or situational (occurs in one or some, but not all, sexual activities). Rather than applying such specifiers, we differentiate between situational and generalized by adopting different terminology. Our differentiation is based on the notion that sexual drive is omnipotent and can lead to all types of sexual activities. In contrast, sexual desire is a focused drive, the focus being on a particular sexual activity or a particular person. Hence, DSM-IV generalized-type hypoactive sexual desire disorder, in our terminology, is “sexual drive disorder,” and we restrict the DSM-IV term of hypoactive sexual desire disorder to situational-type hypoactive sexual desire disorder. This differentiation is helpful in the clinical situation, because it can influence both assessment and management of the disorder. Intact sexual drive implies that the neuroendocrine mechanisms on which sexual drive is based are functional. Hence, in sexual drive disorder, it is highly probable that the etiology involves organic or deep-rooted psychological factors. In contrast, in sexual desire disorder, the etiology is generally behavioral, a reflection of relationship difficulties or of a person’s not gaining satisfaction from a particular sexual activity.

A diagnostic feature not fully addressed by the current classification system is the well-recognized clinical presentation of “desire discrepancy”  between partners. Although neither partner in such couples may be particularly excessive or deficient in sexual interest, there is nonetheless sufficient disparity to give rise to sexual frustration and conflict, leading to marital or partnership disharmony. It is usual in such cases for the partner with less sexual interest or motivation to be identified as the index patient, the one with the “problem.” Thus, therapeutic interventions tend to be focused on enhancement of libido rather than on working to diminish what could be seen as elevated levels in the higher-desire partner. Clinicians need to be aware of the consequent and real danger of pathologizing normal variations in sexual interest, particularly those at the lower end of the continuum, thereby unnecessarily stigmatizing individuals labeled as having low levels of desire or libido. Statistically, many more of these individuals will be women than men.

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Provided by ArmMed Media
Revision date: June 14, 2011
Last revised: by David A. Scott, M.D.