Hypoactive Sexual Desire Disorder

Hypoactive Sexual Desire Disorder
Cindy Meston, Ph.D. & Amelia M. Stanton

Male Hypoactive Sexual Desire Disorder

Definition, Diagnosis, and Prevalence

Male Hypoactive Sexual Desire Disorder (MHSDD) is defined in the DSM-5 as persistent or recurrently deficient sexual or erotic thoughts, fantasies, and desire for sexual activity. These symptoms must have persisted for a minimum of six months, and they must cause clinically significant distress. The disorder is specified by severity level and subtyped into lifelong versus acquired, generalized versus situational.

In past editions of the DSM, hypoactive sexual desire disorder was gender non-specific and could therefore apply to either men or women. As sexual desire and arousal problems have been combined into a single disorder for women in DSM-5, MHSDD now accounts only for men. Other than the change from a gender non-specific disorder to a gender-specific disorder, there have not been any substantive alterations in the diagnostic criteria from DSM-IV-TR to DSM-5. One small change is worth noting. In DSM-IV-TR, hypoactive sexual desire disorder required “persistent” low interest in sex. The DSM-5 now specifies requires that the symptoms be present for at least six months before a diagnosis can be conferred.

Low desire is less commonly the presenting clinical sexual complaint for men, who are more likely to present with erectile dysfunction. Cultural norms that often portray men as being ever desirous of sex may make it difficult for men to report low sexual desire to their physicians or their psychologists.

Most epidemiological studies have not inquired about the full set of diagnostic criteria for HSDD, making it difficult for researchers to determine accurate prevalence rates for the disorder. Research studies have asked men if they have a lack of interest in sex, but not whether the problem was consistent over a period of 6 months and distressing. One study did examine the prevalence of distressingly low sexual interest in men over at least a two-month period. In this study, 14.4% of men in Portugal, Croatia, and Norway reported a distressing lack of sexual desire lasting at least 2 months (Carvalheira, Traeen, & Štulhofer, 2014). Men between the ages of 30 and 39 were most likely to report low sexual interest.

 

Self-reported prevalence rates of problems with desire range from 4.8% in the U.S. (Laumann, Glasser, Neves, & Moreira, 2009) to 17% in the U.K. (Mercer et al., 2003). Desire problems appear to increase with age. In a sample of Swedish men between the ages of 66 and 74, 41% experienced low sexual desire (A. Fugl-Meyer & Sjogren, 1999). Prevalence rates typically decrease when studies examine persistent lack of interest in sexual activity. In a sample of 40 to 80 year-old men in the U.S., 4.8% reported an occasional lack of sexual desire, while only 3.3% reported a frequent lack of sexual desire (Laumann, Glasser, Neves, & Moreira, 2009).

Men in community samples are more likely to report desire problems than men in clinical samples. In community samples, reports of desire concerns exceed reports of erectile problems (Fugl-Meyer & Sjogren, 1999; Mercer et al., 2003). Men in clinical settings may feel more comfortable talking about erectile problems than desire problems, especially if they consider their problems to be biological rather than psychological in nature (Kedde, Donker, Leusink, & Kruijer, 2011).

Factors Associated With Male Hypoactive Sexual Desire Disorder

Given that research has not yet examined factors associated with MHSDD as defined in DSM-5, our review will focus on the causes and consequences of low sexual interest (formerly HSDD). Historically, hormones have been the focus of biological research on low sexual desire in men. Recent studies have also investigated the relationship between neurological disorders and poor sex drive. Psychological causes of decreased interest in sexual activity seem to include relationship difficulties and certain mental health problems.

Biological Factors

Hormonal factors are often implicated in low sexual desire. In men for whom androgen levels have been suppressed, low testosterone levels have been associated with low levels of sexual interest (Bancroft, 2005). For these men, testosterone replacement has been shown to increase sexual desire; this is not the case for men with normal androgen levels (Giovanni Corona, Rastrelli, & Maggi, 2011; Isidori et al., 2005; Khera et al., 2011). Hypogonadism, diminished functional activity of the gonads, has been observed in 3-7% of men between the ages of 30 and 69 and in 18% of men aged 70 and older (Araujo et al., 2007). This condition may account for the relationship between aging and low sexual interest. Hyperprolactinema, defined as high levels of prolactin, and hypothyroidism have also been associated with low sexual desire in men (Carani et al., 2005; G Corona et al., 2004; Giovanni Corona et al., 2011; Maggi, Buvat, Corona, Guay, & Torres, 2013).

Certain medications, like SSRIs and SNRIs, have been linked to low sexual interest in men (Clayton, Croft, & Handiwala, 2014; Clayton, Kennedy, Edwards, Gallipoli, & Reed, 2013). Atypical antidepressants may have lower incidence of reduced sexual desire (Clayton, Croft, et al., 2014; Clayton et al., 2013).

Neurological disorders and other medical conditions are associated with low sexual desire. In a recent study, one quarter of men with multiple sclerosis reported low sexual interest (Michal Lew-Starowicz & Rola, 2014). Men with inflammatory bowel disease (IBD), Crohn’s disease, and ulcerative colitis have also reported low sexual desire. However, decreased desire may result from the medications used to treat conditions like IBD, which have been shown to lower testosterone. Furthermore, IBD is highly comorbid with depression, which may or may not be the underlying cause of decreased sexual interest (O’Toole, Winter, & Friedman, 2014). Coronary disease, heart failure, renal failure, and HIV have also been associated with low sexual interest in men (Bernardo, 2001; Lallemand, Salhi, Linard, Giami, & Rozenbaum, 2002; Meuleman & Van Lankveld, 2005; Toorians et al., 1997). It remains unclear if decreases in desire are due to the conditions themselves, the medications used to treat the conditions, or the psychosocial stressors that often accompany the conditions. Further research in this area is warranted.

Psychological Factors

There are many psychological factors that have been associated with low sexual desire in men. These factors may include relationship problems, concerns about one’s own sexual performance, and comorbid psychological conditions, such as depression and anxiety. In a sample of male outpatients seeking treatment for sexual dysfunction, psychosocial symptoms were more predictive of low sexual interest than hormonal and other biological factors (Corona et al., 2004).

Relationship problems and interpersonal factors have been strongly associated with the male sex drive. Men who have partners with low sexual desire are more likely to have sexual desire concerns than men who have partners without desire problems (McCabe & Connaughton, 2014). Desire problems have also been linked to not finding one’s partner attractive and to long-term (more than 5 years) relationships (Carvalheira et al., 2014).

Individual factors, particularly mental health problems, have also been related to sexual desire problems in men. In a survey of male outpatients who sought treatment for sexual dysfunction, 43% of the men with a history of psychiatric symptoms reported moderate to severe loss of sexual desire (Corona et al., 2004). Many studies have highlighted the correlation between depression and low sexual desire (Carvalheira et al., 2014; McCabe & Connaughton, 2014; Pastuszak, Badhiwala, Lipshultz, & Khera, 2013).

Assessment and Treatment of Male Hypoactive Sexual Desire Disorder

Given that MHSDD is new to DSM-5, there are no assessment tools or treatment studies based on the new diagnostic criteria. However, there are many studies that focus independently on the assessment and treatment of low sexual desire in men. Treatment for MHSDD differs based on the etiology of the disorder, but the most common biological treatment centers on increasing testosterone levels. Though treatments targeting testosterone have been efficacious, they have recently been overprescribed and overused by men with normal testosterone levels. Psychosocial treatment for MHSDD includes cognitive and behavioral components, as well as attention to building strong communication between partners.

Assessment

Assessment for MHSDD should include private meetings with each member of the couple, as well as a couples meeting. Individual meetings with the male partner may reveal a number of diagnostic factors, including atypical arousal patterns that are not being met by his current partner, decreased attraction to his current partner, or a sexual affair that is satisfying his sexual needs outside of his current relationship.

In addition to having individual and group? Do you mean couple meetings, clinicians should also assess for changes in health status, life stressors, and relationship factors around the time that the male partner started to experience a lack of sexual interest. These factors may become the target of the clinician’s treatment plan.

Clinicians should also consider the possibility that male patients presenting with complaints of low sexual desire may actually be suppressing their desires. This often occurs in men who are in long-standing heterosexual relationships who either have had sexual relations with men or who have fantasized about sexual relations with men during masturbation (Meana & Steiner, 2014b). The re is also a small possibility that men who report low sexual desire may be asexual, meaning that they may not be sexually attracted to anyone or anything also needs to be explored.

Treatment

Treatment for low sexual desire in men should be etiologically oriented. If low testosterone level is determined to be the likely cause of MHSDD, biological treatment focuses primarily on increasing testosterone levels. As mentioned earlier, hypogonadism in males typically leads to low testosterone production, decreased sexual interest, and difficulties sustaining an erection. Testosterone replacement therapy can be delivered through the skin via an over the counter gel or patch, by injections, or by slow release pellets (Testopel) implanted under the skin. In a couple of studies, increasing testosterone levels has been shown to have beneficial effects on sexual motivations and sexual thoughts (Allan, Forbes, Strauss, & McLachlan, 2008; Wang et al., 2000).

There has been some concern about the overuse of testosterone gels, especially by men who have normal testosterone levels. According to Handelsman (2013), the prescribing of off-label testosterone, particularly transdermal testosterone, has increased in most countries between 2000 and 2011, and the rising trend accelerated over the last half decade of the survey period. One of the likely causes of this increase may be the permissive US and European guidelines for the prescription of testosterone, which promote the use of the drug for age-related functional androgen deficiency (Handelsman, 2013). In some countries, total testosterone prescribing exceeds the maximum amount that could be attributed to pathological androgen deficiency, which is known to occur in about 0.5% of men (Handelsman, 2010). In a study of older men randomly assigned to either daily application of testosterone gel or daily application of a placebo gel, men in the active condition had a greater frequency of cardiovascular, respiratory, and dermatologic events compared to men in the control condition (Basaria et al., 2010). The incidence of adverse cardiovascular events in the testosterone group was significant enough to stop the trial before the completion of enrollment.

If low sexual desire is determined to be caused by elevated prolactin, another endocrinologic disorder, or by depression, or anxiety, there are different biological treatment approaches to consider. Although organic hyperprolactinemia more frequently affects women than men, many psychotropic medications can cause increased prolactin in men (Rubio-Aurioles & Bivalacqua, 2013). Treatment of other endocrinolgic disorders, such as hypothyroidism and hyperthyroidism, can increase sexual desire, as it is often compromised by these conditions. Depression and anxiety may also lead to decreased sexual desire in men. Treatment for depression often entails the use of antidepressants, which have been shown to impact sexual function in both men and women. If a depressed patient is already experiencing decreases in sexual desire before starting an antidepressant regimen, then his doctor should consider prescribing an antidepressant that has more mild effects on sexual function, such as mirtazapine, buproprion, and SNRI’s like duloxetine (Clayton, Croft, et al., 2014).

It is also noteworthy that men with metabolic syndrome commonly report low sexual interest. If low sexual desire appears to be secondary to metabolic syndrome, then clinicians may recommend a combination of lifestyle changes, exercise, healthy diet, and testosterone replacement therapy (Glina, Sharlip, & Hellstrom, 2013).

Psychosocial treatment for MHSDD mirrors psychological treatment for FSIAD, as MHSDD and FSIAD share many causal psychological factors. Meana and Steiner (2014a) provide a thorough overview of efficacious psychosocial treatments for MHSDD. Cognitive-affective-behavioral therapy is a treatment approach that combines cognitive, emotion-centered, and behavioral strategies. The cognitive component of the treatment includes identifying and challenging maladaptive thoughts and sexual scripts that interfere with sexual desire (Meana & Steiner, 2014a). Therapists may encourage patients with low desire to refocus on sexual stimuli, either before or during sexual activity. The emotional regulation aspect may help men decrease or control emotional reactivity with acceptance techniques like mindfulness. Acceptance techniques come into play in situations when patients may not be able to achieve the sexual function or level of desire that they wish. In these cases, learning to accept certain realities may have as positive an impact as changing what can be modified (Meana & Steiner, 2014a). Effective psychosocial treatment for MHSDD also includes different behavioral activation strategies, such as sensate focus and optimizing the timing of sexual interactions, which help couples refocus on sensuality and encourage them to prioritize sexual activity.

Cognitive-affective-behavioral therapy for MHSDD also includes relationship skills-building and communication training, which are important for men who are having trouble talking about sexual preferences with their partners. Johnson and Zuccarini (2010) hypothesizeconclude that intimate connection between partners is the basis of sexual desire, so their treatment approach highlights the importance of communication. Conflict resolution is an important part of communication training, as therapists may help their male patients with desire concerns by teaching them strategies to minimize blaming and encourage self-soothing (Meana & Steiner, 2014a). Another relational approach to treating sexual desire is the adoption of the Good Enough Sex (GES) model, which embraces the acceptance of individual and couple differences in the meaning and importance of sexual desire within the context of the relationship (McCarthy & Metz, 2008; Metz & McCarthy, 2012).

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