Management of Hypoactive Sexual Desire Disorder (HSDD)

Abstract

Female sexual interest/arousal disorder (FSIAD), formerly known as hypoactive sexual desire disorder (HSDD), is characterized by reduced sexual interest, receptivity, pleasure, response, and sensation leading to personal distress and not related to a psychological disorder, medication, or medical condition. Low desire can be linked to situational circumstances, such as dysfunctional interpersonal relationships, or may have a physiologic cause related to chronic disease, certain medications, or hormonal factors. There is abundant research demonstrating that testosterone increases sexual desire and well-being in postmenopausal women with HSDD. Based upon this evidence, the transdermal testosterone patch is approved for treatment of women with HSDD in Europe and Australia. However, in the United States, the FDA has yet to approve a testosterone product for treating HSDD in women. There are many androgen and testosterone products under investigation, compounded preparations, and FDA-approved medications for men, which are commonly prescribed off label for women. This chapter will discuss medical management of HSDD, focusing on testosterone therapies in development.

Commentary: Management of Hypoactive Sexual Desire Disorder (HSDD)

• Marianne Brandon Ph.D. 

1. Wellminds Wellbodies, LLC, Annapolis, MD, USA

   Marianne Brandon Ph.D.

Hypoactive sexual desire disorder (HSDD), now part of the controversial new DSM-5 condition termed female sexual interest/arousal disorder (FSIAD), is one of the most common yet vexing female sexual dysfunctions to treat. This is due in part to the nuanced complexity of the interplay between physical and psychological factors that contribute to desire, as well as to our imperfect understanding of all etiologies of this condition. Given this complexity and multifactorial nature, HSDD/FSIAD represents a prototype condition benefiting from a biopsychosocial approach merging medical with psychotherapeutic treatments.

In the preceding chapter, Krapf, Goldstein, and Buster outline the known physiology of sexual desire, highlighting the excitatory and inhibitory neurotransmitters and brain regions essential in determining sexual desire. Discussing the known causes of low desire, including medications and medical conditions, the authors then segue into a discussion of the prominent role of androgens in sexual desire, providing a detailed discussion of current and upcoming treatment options for low desire. In the following complementary commentary, the broader approach to FSIAD is outlined, with a clear perspective on the rationale behind how and why obtaining a detailed sexual history is so critical to appropriate and complete treatment of this condition. How to merge medical and psychotherapies is then outlined, so that the reader develops a comprehensive overview of how to approach FSIAD.

1.1 Commentary

Drs. Kraph, Buster, and Goldstein offered an excellent and thorough review of the physiologic management of hypoactive sexual desire disorder in women. As they indicated, the assessment and treatment of psychosocial etiologies are equally important in the care of patients with desire concerns. Indeed, it was Dr. Goldstein himself who introduced the biopsychosocial model to me many years ago as I embarked on my specialization in sex therapy. This commentary will summarize an approach to assessing and treating the psychosocial aspects of desire disorders in women.

Most sexual medicine professionals would likely agree that desire disorders are among the most difficult to treat—largely due to the complex and often subtle psychological, relationship, and contextual dynamics that can interfere with libido. In spite of these challenges, surveys suggest that the majority of men and women consider sexual intimacy to be a vital aspect of a romantic relationship [1], and sexual satisfaction correlates with relationship satisfaction and life satisfaction [2]. As such, the experience of low desire can be extremely upsetting for a woman and/or her partner. In fact, fully one-third of women with low desire express distress about their lack of sexual interest [3]. Many of the women with low desire that I have worked with ruminate about this problem daily, feel tremendous guilt about depriving their partner of a critical aspect of intimacy, worry that their partner will leave or have an affair because of a lack of intimacy, and/or miss what was once a profound intimate experience making them feel vital, alive, and connected to their partner. However, it can also be the case that a woman’s distress about her low desire is the result of her partner’s negative reactions and she herself is not bothered by her lack of interest.

The diagnostic criteria for low desire in women have recently been modified from hypoactive sexual desire disorder (HSDD) as defined in the DSM-IV-TR [4] to the current DSM-5 classification of female sexual interest/arousal disorder (FSIAD) [5]. This recent modification is not without significant controversy. How to diagnosis low desire and even whether or not to regard low desire as a diagnosis in women [6] will likely remain contentious issues in the field of sexual medicine for some time. Indeed, female sexual medicine is a relatively new field, with still many unanswered questions. For example, recent research suggests that asexuality, or the absence of sexual attraction, may be normative for a subset of the population [7]. More research is clearly needed to clarify this hypothesis.

Currently, the diagnostic criteria for FSAID must include symptoms in at least three of the following categories: reduced interest in sexual activity, reduced fantasies or thoughts about sex, reduced initiation and/or non-receptivity to partner’s attempts to initiate, reduced sexual pleasure, reduced response to erotic cues, and reduced genital or nongenital sensations during sexual encounters. These symptoms must persist for a minimum of 6 months, cause a woman significant distress, and not be attributable to a mental disorder, medication, or substance abuse. Diagnosis also requires specification of whether the disorder is lifelong or acquired and generalized or specific to a situation and severity is rated as mild, moderate, or severe.

The assessment of low desire can be challenging for many reasons, not the least of which is a disturbing lack of training opportunities for physicians [8]. Time constraints, limitations on insurance reimbursement, and the potential awkwardness of discussing a patient’s intimacy concerns may also inhibit practitioners in assessing FSAID [9]. There are a variety of reliable and valid questionnaires that can assist in this process, including: the sexual interest and desire inventory-female (SIDI-F) [10], the decreased sexual desire screener (DSDS) [11], the female sexual distress scale-revised (FSDS-R) [12], and the female sexual function index (FSFI) [13].

Three principles may be considered the foundation for taking a sexual history: using a patient-centered approach, offering evidence-based diagnostic and treatment recommendations, and using a unified management approach for treatment [9]. Adherence to these basic principles ensures that the patient feels understood and receives state-of-the-art medical care. Desire concerns may cut to the core of her identity, as lovemaking is when she is most vulnerable and exposed. Thus, issues relating to her sexuality may be among the most difficult topics she will discuss with a medical professional in her lifetime.

In taking a sexual history, it is of course essential to maintain cultural and religious sensitivity, as well as to avoid an assumption of heterosexuality. It is also necessary to remain aware of your voice tone and other nonverbal cues that communicate information. As much as she is seeking relief for her symptoms, a patient may be acutely aware of your reactions and adjust her responses accordingly. A woman may thus not offer all necessary information during the initial assessment period, and instead, her story may unfold over multiple appointments. Indeed, she may not be ready to acknowledge to herself, or verbalize to another, information that is critical in understanding her low desire. For example, perhaps she is having an affair, or she is disgusted by the way her genitals changed following a traumatic childbirth, but she is too ashamed to admit this. Acute sensitivity when responding to her concerns is necessary.

A sexual history provides the practitioner with information to answer three critical questions: whether or not the patient has a disorder, what underlying organic and psychogenic factors contribute to the disorder, and whether or not the patient should be treated [14]. The sexual tipping point [15] is one comprehensive guide for evaluating the role that multiple biopsychosocial influences may have on the etiology of a woman’s low desire. This model conceptualizes low desire as being impacted by physiological, organic, psychosocial, and cultures issues. Thus, a woman’s psychological and medical health, the quality of her romantic and sexual relationship, and issues relating to the context of her life are all given consideration.

It is useful to ask a woman her understanding of her low libido and what, if any, treatment she has previously attempted. However, be prepared to probe her responses further. For example, it is not unusual for a patient to initially state, “Everything is perfect in my relationship except for my lack of desire,” only to verbalize upon further exploration that significant challenges involving such essential dynamics as power, trust, physical attraction, sexual technique, communication, or respect do exist but are difficult for her to articulate. The context of her current life is also relevant, including her stress level, sexual dysfunction in her partner, and parenting or eldercare responsibilities that can all interfere with her desire to make love. Historical issues relating to her sexual debut [16] or past trauma [17] can also impact her current experience of desire. In sum, sex drive can be a sensitive barometer of balance in just about any aspect of a woman’s life.

A thorough assessment enables a practitioner to determine whether or not treatment is indicated and, relatedly, which treatments to recommend. The biopsychosocial model of care necessitates that a woman’s psychological and biological treatment needs are all attended to. This is essential regardless of the etiology of a patient’s low desire. Ultimately, physiological etiologies have psychological ramifications, just as psychological issues eventually impact a woman’s biology [9, 18].

The initial phase of treatment may include education about FSAID, including a conversation about the differences between spontaneous and responsive sexual desire [19]. Specifically, it is considered non-dysfunctional for some women to feel open and responsive to a partner’s advances without ever feeling the spontaneous desire for sex. Prepare the patient that she will function as an active member of her treatment team, which will likely include a medical professional and sex therapist. Discussing the relatively high rates of sexual dysfunction and dissatisfaction in the general population [20] may help her feel less alone.

It will be helpful to have a list of qualified therapists as referral sources that you can offer your patient at this time. Even if your patient does not meet the diagnostic criteria for a sexual dysfunction, she may be struggling with her own or her partner’s expectations about her sexual function, and thus it is likely that a psychotherapy referral will be helpful. On this list you can include the organizations offering sex therapist referrals: the American Association of Sex Educators, Counselors, and Therapists (www.AASECT.org), the Society for Sex Therapy and Research (www.SSTARnet.org), and the International Society for the Study of Women’s Sexual Health (www.ISSWSH.org). You may also identify local therapist referral sources by contacting your state psychological association.

Therapists approach the treatment of low desire in women from a variety of perspectives. A focus on the development and cultivation of sexual excitatory mechanisms to support libido is generally more beneficial than attempting to decrease the inhibitory mechanisms making sex less appealing for her [21]. Evidence-based practice includes the development of mindfulness skills [22], therapy groups that focus on communication skills training, sensate focus, fantasy training, intimacy exercises and education [23, 24], and/or an intersystems model addressing familiar and intergenerational influences to low desire [25, 26]. Therapists will make decisions regarding whether individual therapy, couple therapy, or both are necessary. Patients may report that their progress in reaching their treatment goals is variable, in part because the desire disorders exhibit a strong placebo response [27] and in part because, as previously described, the etiologies of desire disorders can be so complex and multi-determined.

In sum, low desire concerns in women are classic mind-body phenomenon, requiring an integrated biopsychosocial treatment approach [28]. Communication among members of the treatment team is strongly encouraged, as it will help to ensure that the patient’s unique needs are being addressed. For further training opportunities in female sexual medicine, please see the International Society for the Study of Women’s Sexual Health (www.ISSWSH.org).

References

• 1. Leiblum SR. Clinical perspectives on and treatment for sexual desire disorders. In: Leiblum SR, editor. Treating sexual desire disorders. New York: The Guilford Press; 2010.

• 2. Davison SL, Bell RJ, LaChina, M. The relationship between self-reported sexual satisfaction and general well-being in women. J Sex Med. 2009;6:2690–7.

• 3. Rosen RC, Shifren JL, Monz BU, Odom DM, Russo PA, Johannes CB. Correlates of sexually related personal distress in women with low sexual desire. J Sex Med. 2009;6:1549–60.

• 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.

• 5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

• 6. Teifer L, Hall M. A skeptical view of desire norms and disorders promotes clinical success. In: Leiblum SR, editor. Treating sexual desire disorders: a clinical casebook. New York: The Guilford Press; 2010.

• 7. Brotto LA, Yule MA, Gorzalka BB. Asexuality: an extreme variant of sexual desire disorder? J Sex Med. 2015;13(3):646–60.

• 8. Parish S, Clayton A. Sexual medicine education: review and commentary. J Sex Med. 2007;4:259–67.

• 9. Althof SA, Rosen RC, Perelman MA, Rubio-Aurioles E. Standard operating procedures for taking a sexual history. J Sex Med. 2013;10:26–35.

• 10. Clayton A, Seagraves RT, Leublum S, Basson R, Pyke R, Cotton D, Lewis-D’Asostino D, Evans KR, Sills TL, Wunderlich GR. Reliability and validity of the sexual interest and desire inventory-female (SIDI-F), a scale designed to measure severity of female hypoactive sexual desire disorder. J Sex Marital Ther. 2006;32:115–35.

• 11. Clayton A, Goldfischer E, Goldstein I, Derogatis L, Lewis-D’Agostino D, Pyke R. Validation of the decreased sexual desire screener (DSDS): a brief diagnostic instrument for generalized acquired female hypoactive sexual desire disorder (HSDD). J Sex Med. 2009;6:730–8.

• 12. Derogatis L, Clayton A, Lewis-D’Agostino D, Wunderlich G, Fu Y. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008;5:357–64.

• 13. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, D’Agostino R Jr. 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.

• 14. Perelman M. Psychosocial history. Women’s sexual function and dysfunction: study, diagnosis, and treatment. London: CRC Press; 2005.

• 15. Perelman M. The sexual tipping point: a mind/body model for sexual medicine. J Sex Med. 2009;6(3):629–32.

• 16. Rapsey CM. Age, quality, and context of first sex: associations with sexual difficulties. J Sex Med. 2014;11(12):2873–81.

• 17. Yehuda R, Lehrner A, Rosenbaum TY. PTSD and sexual dysfunction in men and women. J Sex Med. 2015;12:1107–19.

• 18. Perelman M. Female sexual dysfunction and the central nervous system. J Sex Med. 2007;4(4):257–9.

• 19. Basson R, Brotto LA, Laan E, Redmond G, Utian WH. Assessment and management of women’s sexual dysfunctions: problematic desire and arousal. J Sex Med. 2005;2(3):291–300.

• 20. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States. J Am Med Assoc. 1999;281:537–44.

• 21. Janssen E, Bancroft J. The dual control model: the role of sexual inhibition and excitation in arousal and behavior. In: Janssen E, editor. The psychophysiology of sex. Bloomington, IN: Indiana University Press; 2007.

• 22. Brotto L, Woo JT. Cognitive-behavioral and mindfulness-based therapy for low sexual desire. In: Leiblum SR, editor. Treating sexual desire disorders. New York: The Guilford Press; 2010.

• 23. ter Kuile MM, Both S, van Lankveld JJDM. Cognitive behavioral therapy for sexual dysfunctions in women. Psychiatr Clin N Am. 2010;33:595–610.

• 24. Trudel G, Marchand A, Ravart M, Aubin, S Turgeon L, Fortier P. The effect of a cognitive-behavioral group treatment program on hypoactive sexual desire in women. Sex Relat Ther. 2010;16(2):145–64.

• 25. Weeks GR, Hertlein KM, Gamdescia N. The treatment of hypoactive sexual desire disorder. J Fam Psychother 2009;20:129–49.

• 26. Weeks G, Gamdescia N. Definition, etiology, and treatment of absent/low desire in women. In: Hertlein KM, Weeks GR, Gambescia N, editors. Systemic sex therapy. New York: Routledge; 2015.

• 27. Bradford A, Meston C. Placebo response in the treatment of women’s sexual dysfunctions. J Sex Marital Ther. 2009;35:164–81.

• 28. Perelman M. Clinical application of CNS-acting agents in FSD. J Sex Med. 2007;4(4):280–90.