Yonah Krakowsky1 and Ethan D. Grober2
(1)
Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
(2)
Division of Urology, Department of Surgery, Mount Sinai and Women’s College Hospital, University of Toronto, Toronto, ON, Canada
Ethan D. Grober
Email: egrober@mtsinai.on.ca
Keywords
HypoactiveSexual desireMalesLibido
16.1 Background
Low sexual desire is characterized by the absence or decrease in the frequency with which a person experiences desire for sexual activity [1]. Sexual desire can manifest as attempts to initiate sexual behavior, masturbation, erotic fantasies, sexual attraction to others, and spontaneous genital sensations of arousal [2]. The DSM V defines male hypoactive sexual desire disorder (HSDD) as persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity that causes significant distress. This deficiency or absence of sexual desire must occur more than 75 % of the time for more than 6 months [3].
Prevalence studies looking at “normal” couples have found that up to 16 % of men report a lack of interest in sex [4]. The National Health and Social Life Survey (NHSLS) reported 14–17 % of men aged 18–44 years have low sexual desire, a rate lower than that of erectile dysfunction (ED) in the cohort. In the survey, married men were less likely to have low desire, and no association between sexual desire and ethnicity was observed [5]. The National Survey of Sexual Attitudes and Lifestyles (NATSAL) , a population survey based in the United Kingdom, explored the sexual behaviors of 11,161 British men and women 16–44 years old. The most common complaint in this cohort was “lack of interest in sex” [6]. Similarly, a large Australian study investigating sexual behaviors in men ages 18–59 found 16 % of men reporting a lack of interest in sex [7]. The most commonly endorsed symptom in the Australian study was premature ejaculation, closely followed by low sexual interest. A related Swedish study revealed that of 1475 men 18–74 years old, 16 % reported low sexual desire [8]. Men 66–74 years old reported decreased interest in sex at similar rates as women, and those men with low sexual desire showed considerable comorbid sexual dysfunctions including premature ejaculation (26 %), insufficient partner lubrication (39 %), and orgasmic difficulties in the partner (24 %). An American survey using computer-assisted telephone interviews of 742 men 40–80 years old yielded “frequent lack of sexual interest” in 3.3 % of men and “periodic lack of sexual interest” in 4.8 % of men. Low sexual desire represented the third most common sexual complaint after premature ejaculation (4.7 % frequent, 7.0 % periodic) and ED (6.5 % frequent, 5.9 periodic) [9].
Clearly, large surveys of Western populations observe low sexual desire as a common symptom in adult men across a broad age spectrum. These men may present to primary care physicians, urologists, and mental health professionals or, as often occurs, remain unevaluated. Understanding the physiology, etiology, and evaluation of these patients can empower the clinician, regardless of specialty, to feel competent in addressing hypoactive sexual desire in the male.
16.2 Physiology of Hypoactive Sexual Desire
The physiology of sexual desire involves a complex network of biochemical and psychosocial factors. The biologic basis of sexual desire in humans is still largely unknown but appears to result from an interplay between internal processes (thoughts and fantasies), neurophysiological arousal, and emotional state [10]. Much more is known about arousal (the body’s anticipation of sexual activity) than the sexual desire that precedes it. Arousal leads to activation of the autonomic nervous system with parasympathetic stimulation resulting in increased blood flow to erectile tissue, as well as sympathetic nervous system activation, with a resultant increase in heart rate and muscle tone. Much less however is known about what drives sexual desire on a central level. Testosterone appears to be necessary for male sexual drive, although the relationships between testosterone and sexual desire may not be as linear as previously thought, as higher serum testosterone levels are not necessarily correlated with strong sexual desire [11]. However, studies have shown that loss of libido occurs at significant frequency in men with testosterone levels below 15 nmol/L [12].
Dopamine and prolactin both impact male sexual desire as well. Dopamine is thought to function in the mesolimbic dopaminergic pathway (the “reward pathway”) to increase desire. High prolactin levels can induce reversible hypogonadism, which may contribute to decreased sexual desire. Significant increases in prolactin, as seen in patients with prolactinomas, lead to a decrease in sexual desire and worsening of erectile function, both of which can be ameliorated by administration of a dopaminergic agonist [13]. It is thought that excess prolactin decreases pulsatile LH secretion centrally, leading to decreased libido secondary to depressed testosterone secretion [14]. Dopamine directly inhibits prolactin at the level of the pituitary. In a cohort of Parkinson’s patients, increasing dopamine pharmacologically was found to increase sexual desire [15], highlighting its role in low libido.
16.3 Etiology of Hypoactive Sexual Desire in Men
Many psychiatric diagnoses, medical conditions, and medications have a significant negative impact on sexual function, resulting in decreased sexual desire (Table 16.1 and Fig. 16.1). The relationship between these conditions and libido shapes the evaluation and treatment of the male patient complaining of low sexual desire. Major depression is associated with decreased sexual interest in 40 % of men [16]. Paradoxically, 9 % of men in the same study had an increase in sexual desire with the onset of depression. Due to high rates of comorbidity, evaluation of hypoactive sexual desire must include a focus on mood disorders [17]. Large studies have demonstrated a strong correlation between major depression, anxiety and somatization disorders, and hypoactive sexual desire in both men and women [18]. Both the psychiatric distress and often the pharmacological treatment can negatively impact libido. Early studies have shown loss of sexual interest in more than 70 % of patients with depressive disorders [19].
Table 16.1
Causes of low sex desire in men
|
Depression |
Androgen deficiency |
Stroke |
|
Antidepressant therapy |
Hyperprolactinemia |
HIV |
|
Anxiety |
Thyroid disease |
Heart failure |
|
Posttraumatic stress disorder |
Cushing’s disease |
Epilepsy |
|
Anger |
Relationship conflict |
Renal failure |
|
Aging |
Iatrogenic (medications) |
Coronary artery disease |
Fig. 16.1
Causes of low sex desire in men
Studies have linked numerous medical conditions with decreased male sexual desire. Hypothyroidism and natural aging have been associated with decreased sexual desire in men of all ages [20]. In a Swedish study of 500 men, all 51 years old, low levels of free testosterone were associated with low sexual interest [21]. High levels of prolactin can result in both hypogonadism and hypoactive sexual desire in men. Further, the neuroleptic activity of prolactin itself may lead to depression and anxiety, compounding the effects of low androgen levels [14]. Men with prostatitis or chronic pelvic pain report less frequent sexual thoughts and desires [22]. The Global Study of Sexual Attitudes and Behaviors [23] reported a number of risk factors for low sexual desire in men including divorce, poor overall health, vascular disease, financial problems, depression, and cigarette smoking. Aging itself contributes to decreased male sexual desire, but despite this, most men in self-reported surveys have persistent mild-to-moderate interest in sex later in life [24]. A large 2007 study reported that while sexual activity does decline with age, a significant portion of men and women remain sexually active well into their ninth decade of life [25].
A significant proportion of men with HIV who initiate treatment (71 %) report some degree of sexual dysfunction after beginning their treatment, with 89 % of this sample reporting a decrease or complete loss of sexual desire as part of their overall sexual dysfunction [26].
Psychiatric medications have been associated with both hypersexuality and hyposexuality although hypoactive sexual desire is much more common than hypersexuality [27]. Tricyclic antidepressants (e.g., amitriptyline) impact libido through their anticholinergic effects [28]. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), commonly used in treating depression, increase levels of serotonin, which may diminish sexual desire [29]. Bupropion , a non-SSRI antidepressant, causes significantly fewer sexual side effects due to its different mechanism of action [30]. Antipsychotics (e.g., haloperidol) increase prolactin levels and can cause profoundly diminished libido in many patients [31]. Atypical antipsychotics have less impact on prolactin than typical antipsychotics but may still impact sexual desire, often in a dose-dependent fashion [32]. Anticonvulsants have also been found to decrease DHEA levels, and to a lesser extent increase prolactin levels, thereby diminishing libido [33].
The interaction between partners can also strongly contribute to sexual desire. A perceived hypoactive sexual desire may be the result of different expectations between partners of a couple that is seeking counseling [34]. Anger and anxiety are two mechanisms that inhibit sexual desire and arousal [35]. Some suggest that anger and anxiety lead to performance fears, fear of pleasure, and “unconscious” fears of injury that may suppress sexual desire [36]. Many men have low sexual desire that is not clearly linked to an underlying medical or psychiatric condition. The DSM IV-TR lists hypoactive sexual desire disorder as a discrete diagnosis. The independent diagnosis of hypoactive sexual desire disorder in the DSM IV required two criteria to be met: criterion A, “persistently or recurrently deficient or absent sexual fantasies and desire for sexual activity,” and criterion B, the disturbance causes “marked distress or interpersonal difficulty.”
The DSM V merged female arousal disorder and female hypoactive sexual disorder into one category—female sexual interest/arousal disorder—and relocated hypoactive sexual desire disorder in meninto its own diagnosis that has been renamed male hypoactive sexual desire disorder. The DSM V further updated its criteria to require the disorder to impact the patient 75 % of the time, to be 6 months or more in duration, and to be the cause of significant distress. Further, substance-induced sexual dysfunction and sexual disorder due to a general medical condition must be absent for the diagnosis of male hypoactive sexual desire disorder.
A recent study of 109 men diagnosed with hypoactive sexual desire disorder (according to DSM IV criteria) compared to 91 “normal” men showed no differences across age, testosterone levels, depressive symptoms, erectile function, illness, or medications. They did however differ significantly in several measures of sexual desire, supporting hypoactive sexual desire disorder as a valid, independent sexual disorder in men [37].
16.4 Evaluation
Assessing low sexual desire in an objective fashion is challenging. Clinicians must rely on the subjective reports of patients and couples in their initial evaluation and in assessing responses to treatment. Patients should be initially assessed with a thorough history and physical exam (Table 16.2). The history should focus on medical and sexual comorbidities, medications, and recreational drug and alcohol use. A sexual history and a concise psychiatric assessment focusing on depression/anxiety and the patient’s relationships are essential. Objective assessment of sexual desire can be achieved using The International Index of Erectile Function’s sexual desire domain [38]. The Sexual Desire Inventory was designed specifically to measure sexual desire and is used by some clinicians in both men and women [39]. Validated instruments exist for sexual desire assessment in women that are currently in use in clinical trials but have not been validated for men [40]. Objective assessment of sexual desire using either the IIEF or the SDI is recommended in the initial assessment of men with sexual dysfunction, as well as in assessing response to treatment.
Table 16.2
Initial workup of male with hypoactive sexual desire
|
History |
Including history of presenting complaint, medications, medical history, urologic history, relationship history, mood disorders, sexual history |
|
Physical |
Including genital exam with testicular size, DRE |
|
Laboratory |
TSH, prolactin, testosterone |
Physical exam should include a genital exam, including determination of testicular size and digital rectal exam (DRE) to assess for prostate tenderness. Signs of metabolic syndrome, liver disease, and thyroid disease should also be noted. Any abnormalities detected on history and physical should prompt the clinician to order the appropriate investigations or referrals to address the causes of low sexual desire.
Laboratory investigation should be directed toward suspected diagnoses. However, all patients should be investigated initially with evaluation of TSH, total testosterone, and prolactin levels to evaluate for the most common causes of HSD [41]. Clinicians should also obtain a baseline complete blood count (CBC), electrolytes, creatinine, and liver function tests. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels may also be appropriate to evaluate on a case-by-case basis.
16.5 Treatment
Patients that screen positive for depression or anxiety should receive appropriate treatment or referral. If significant relationship issues are discovered, couples’ therapy should be considered. Underlying medical conditions (e.g., endocrinopathies, hypogonadism) should be treated or referred to the appropriate specialist (Fig. 16.2). Patients with abnormal TSH levels should be referred to an appropriate specialist to determine treatment and follow-up. Patients with elevated prolactin should undergo appropriate head imaging, additional testing, and treatment by qualified healthcare providers, and appropriate follow-up with the referring physician after the specific underlying condition is addressed should assess improvement in sexual desire. The greatest challenge is treatment of the patient with no underlying cause for low libido. There are currently no FDA-approved medications targeted to hypoactive sexual desire, with current treatment options being limited to psychotherapy and off-label pharmacotherapy.
Fig. 16.2
Approach to men with low sexual desire
Masters and Johnson described therapy sessions that involved bringing the couple together to discuss sexuality as but one aspect within the larger framework of a relationship [42]. Cognitive behavioral therapy (CBT) is an effective approach to low sexual desire in women but less is known about its efficacy in men [43]. CBT involves identifying negative thoughts that lead to negative feelings and dysfunctional behaviors. In the context of HSDD, CBT focuses on unrealistic expectations, partner behaviors that decrease the patient’s desire in sex, and dysfunctional thoughts.
Psychotherapy has also been proposed to address men with low sexual desire and involves looking at sexual dysfunction from the perspective of unresolved, unconscious conflicts within the patient. Clinicians should familiarize themselves with therapy providers in their vicinity if they themselves aren’t trained in sex therapy.
Hormone replacement is ) a viable option in some men with HSDD. In hypogonadal men, exogenous testosterone can increase the frequency of fantasies, arousal, desire, ejaculation, spontaneous erections, and orgasms through coitus or masturbation [11]. In eugonadal men, however, exogenous testosterone has demonstrated no clinical benefit [44]. Testosterone supplementation using injectable formulations improved sexual interest in one study of eugonadal men but did not translate into improvement in sexual relationships [45]. Supraphysiological doses of testosterone administered to healthy volunteers as a potential male contraceptive resulted in a significant increase in psychosexual stimulation and arousal, but without changes in sexual activity or spontaneous erections [46]. Dehydroepiandrosterone (DHEA) , a testosterone precursor, may benefit women with HSDD, but no benefit has been demonstrated in men using any parameter of sexual function [47].
Other options for the treatment of HSDD include neuroleptic medications. Bupropion, traditionally used for depression, anxiety, and smoking cessation, can increase desire in women via an increase in dopamine levels [48], but its effects in men with HSD are unknown. Flibanserin, a serotonin receptor agonist/antagonist, has shown some efficacy in treating HSDD in premenopausal women, but data supporting its use in men are lacking as well [49]. Gepirone is a selective serotonin receptor partial agonist that has also shown promise in treating HSDD in premenopausal women as well as men [50]. Recent reports suggest gepirone is effective in increasing sexual function in depressed men, although sexual desire didn’t show the same statistically significant improvements as the other sexual domains [51].
16.6 Conclusion
Hypoactive sexual desire is a common complaint for men of all ages. By recognizing different etiologies that contribute to low libido in men, clinicians can initiate a patient-centered evaluation for men complaining of low sexual desire. A thorough history, physical exam, and appropriate laboratory investigations can identify those men with underlying medical and/or psychiatric conditions that can be addressed to improve sexual desire. Those without modifiable comorbid conditions represent a challenge to all clinicians, as male hypoactive sexual desire as a discrete diagnosis remains without targeted therapies. As the understanding of male hypoactive sexual desire evolves, more tools will become available in both assessment and treatment.
Commentary: Hypoactive Sexual Desire in Men
Eusebio Rubio-Aurioles3
(3)
Departamento de Psiquiatrí a y Salud Mental, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
Hypoactive sexual desire disorder in males represents a diagnostic and therapeutic challenge to both clinicians and mental health specialists. The number of affected men is striking and highlights the need for a better understanding of decreased sexual desire in men. Diagnostically, the subjective nature of sexual desire and the absence of validated instruments to aid diagnosis specifically in men can limit accurate identification of affected men, particularly in the presence of other confounding conditions such as depression or anxiety. Thus, it is imperative that the workup thoroughly assess for conditions that can result in the patient’s symptoms. The preceding chapter discusses the physiology of low sexual interest in men, as well as conditions that may predispose to decreased sexual interest. Segueing then into evaluation and treatment, Krakowsky and Grober acknowledge the diagnostic challenge inherent in identifying low sexual desire in men and discuss the role of psychotherapy, as well as limited pharmacotherapy, in the treatment of this condition.
Expanding on the discussion of the role of psychotherapy in low sexual desire in men, the following commentary focuses on the role of dual-control models in sexual function. Such models incorporate both excitatory and inhibitory factors in explaining sexual dysfunctions, providing a basis for understanding the impact of various factors and interventions. Diving more deeply into the psychological underpinnings of low sexual desire and using case vignettes, Rubio-Aurioles highlights an integrated approach to men with decreased sexual desire, marrying psycho- and pharmacotherapy.
The Editors
Commentary
Sexual problems in general and sexual dysfunctions in particular present a challenge to the clinician who still operates with the duality of mind-body imposed in medicine some years ago. The intertwining of factors that originated in the biological processes of the body with factors of a so-called “mental” nature is so pervasive in the reality of clinical practice that the ideal of an integral approach is an imperative when the assessment of a specific sexual problem is in order.
In the case of sexual desire, the above consideration is even more critical. Sexual desire is an elusive and mysterious experience for many people, yet it is considered one of the main motivators in life. The elusive nature of sexual desire is fairly evident for the man, who after having decided to marry the “perfect candidate” loses his desire for sexual interaction with her with absolutely no clue as to why his desire remains vivid, but not for his wife.
The problems surrounding sexual desire for clinicians begin with the diagnosis of the condition. “Low libido,” “hypoactive sexual desire disorder,” and “lack of interest in sex” are terms used to describe this clinical problem [1]. Libido refers to the Freudian construct of drive, and its use, although generalized, does not give honor to the original ideas of what libido [2] was supposed to be.1 Hypoactive sexual desire makes reference to the inclusion in the 1980s [2] of the condition initially called inhibited sexual desire and then modified to hypoactive sexual desire disorder in the classification of mental disorders. The problem with these terms is that they refer to a condition that actually excludes most of the patients presenting with the complaint of low or absent sexual desire due to depression, hormonal problems, and relationship issues that should not be present for a diagnosis of hypoactive sexual desire disorder to be made. Another problem is that the term “desire” is not always understood or interpreted uniformly; the term “sexual interest” has been suggested in its stead [3]. In my opinion, the use of the term “low sexual desire/interest” facilitates the frame of mind needed in the clinical setting to address this condition [4].
The Psychological Factors in Low Sexual Desire
In the last several years, a number of models have been proposed to explain variations in sexual desire/interest. Several of these models can be grouped under the term “dual-control models,” which serve to synthesize activating and inhibiting components involved in sexual desire.
Helen Kaplan [5], who devoted considerable time and effort to conceptualize sexual desire problems as a distinct sexual dysfunction, organized factors that produce the experience of lust as sexual incentives and sexual suppressors or inhibitors, both of a physiological and a psychological nature. Among the psychological inhibitors of desire Kaplan enumerates are partner unattractive, negative thoughts, anti-fantasies, negative emotions, and stress and anger. Some time later, John Bancroft [6] proposed a model named the dual-control model that is supported by psychosocial research where inhibitory processes are considered “active processes.” These inhibitory processes serve either functional purposes, such as the inhibition of sexual activity when there is real danger or threat, or dysfunctional ones, such as situations in which there is only perceived danger or when the individual has a “high inhibitory tone.” Michael Perelman organized these ideas in a model called the Sexual Tipping Point (TM) Model [7]. The model proposes that a balance between pro and con factors results in activation or deactivation of the sexual experience; the lack or deficit in desire/interest would be the result of the predominance of inhibitory processes over excitatory ones (Fig. 16.3).
Fig. 16.3
Representation of two models that consider factor pro-desire and anti-desire to the left after Helen Kaplan and to the right the Sexual Tipping Point from Michael Perelman [1, 2]
Several of these ideas have been tested empirically. Bozman and Beck [8, 9] studied the effects of anger and anxiety on sexual desire and sexual arousal and found that these emotional states reduce sexual desire. More recently, Carvalho and Nobre [10] tested an integrative model of biopsychosocial determinants of men’s sexual desire using sophisticated statistical techniques (path analysis) to assess the relationships between several psychological variables and the level of sexual desire. Their investigation supports the previous elaborations offered by clinicians and researchers but shows that for some of the variables traditionally related to low sexual desire, such as dyadic adjustment, the effect is not as important as, for instance, the lack of erotic thoughts and erectile concerns (Fig. 16.4).
Fig. 16.4
Path analysis of causal directions between predictors and sexual desire in men (standardized regression coefficient β), N = 205 [10]
Psychological Etiologies in Low Sexual Desire of Men
Krakowsky and Grober have presented the array of possible etiological processes in detail in the preceding chapter. Psychological or mental processes are often involved when a man complains of low sexual desire. Figure 16.5presents an algorithm for diagnosis and shows the processes where psychological considerations are critical, although the psychological impact of the condition is almost always present, regardless of the etiological process (Fig. 16.5).
Fig. 16.5
Diagnostic algorithm for men with low sexual desire/interest. Highlighted in gray are processes identified with mental health MHSDD = male hypoactive sexual desire disorder. Modified from [4]
Case Examples
The following clinical vignettes present typical situations where the psychological factors are predominant in men seeking consultation for low sexual desire/interest.
Depression, Anxiety, and Chronic Stress
David, 44 years of age, was an executive from a big accounting firm. He recently lost his job after a large illegal transaction was discovered; he has been looking for a new position for 10 months unsuccessfully. He explains that his wife, who is a successful public relations manager in a big pharma company, told him that the situation in their intimacy is no longer acceptable and that either he finds a solution for his lack of interest in sexual intimacy or they were going to divorce. He accepts that his desire and interest in sexual activity has disappeared and indicates that no other sexual partners exist and that he has been faithful during the 10 years of marriage which he considers otherwise very good. David considers himself to be in good health, with no medical history of relevance. His erectile function is normal according to the SHIM questionnaire. Basic laboratory studies including testosterone, prolactin, and TSH are normal.
Depression can impair sexual desire, as it is one of the frequent symptoms that accompany this medical condition. Depressive illness can be easily identified with two questions [11]; a “no” response to these two questions makes it highly unlikely for the man to have a depression:
· During the past month, have you often been bothered by feeling down, depressed, or helpless?
· During the past month, have you often been bothered by little interest or pleasure in doing things?
If the initial clinical impression of depressive illness is confirmed, proper treatment and consideration of referral to a mental health specialist is in order.
The impact of depression in the health of the relationship is clear in this example. The partner of a man with low desire feels rejection, and this can be the beginning of a new problem as the relationship deteriorates. Usually, healthy partners are direct in their communication and frequently request their male partners with low desire to address the issue directly.
Treatment of depression represents still another challenge, as most antidepressants have a negative impact on sexual desire. However, to treat the depressive illness is critical for the recovery of health; a clear explanation of the next steps during treatment is helpful and much better if the partner is present in the consultation.
Relationship Conflict
Jose, 50 years of age, is a successful entrepreneur that runs a construction company that was started by him 20 years ago. His first marriage lasted 15 years and ended because of multiple disagreements regarding the time Jose devoted to family and work. Three years ago he initiated a new relationship with a young and attractive woman who treated him very well and after a year moved in with Jose, who lived alone before that. As the couple stared their cohabitation, his desire for sexual interaction started to diminish. As the relationship progressed, her economic demands increased. In addition, significant arguments revolving the amount of money allotted to the first wife by the divorce agreement and requests to help her family have been pervasive. Jose recognizes the beauty and initial attraction and would like to find ways to repair his current relationship as he considers a second failure impossible to bear. There has been no sexual interaction during the last 6 months. Jose masturbates when she is not around with no problems and with fantasies of different women. Basic laboratory studies, including testosterone, prolactin, and TSH levels, are normal.
Many men experience difficulties with their sexual desire when the environment in the relationship turns hostile. Identifying the conflict in a relationship is easy when this is explicit, but sometimes this is not the case.
Conflict with the sexual partner is a long recognized etiology of secondary and selective (specific to the partner) low sexual desire [12]. Conflict in relationships is easy to identify if the right questions are asked. Sometimes asking directly about the quality of the relationship will provide enough information. The questions presented below can provide good clinical information about the quality of the relationship. Although they were developed in a research setting, these questions provide good guidance on what to investigate when a couple is being evaluated [13]:
· Do you and your partner agree or disagree on displays of affection?
· Do you often think about getting a divorce or separation or ending your current relationship?
· In general, would you say that everything is fine between you and your partner?
· Do you confide in your partner?
· Do you ever regret getting married (or living together)?
· How many times do you and your partner calmly discuss something?
· How many times do you and your partner work together in something?
· Circle the number that best corresponds to your level of happiness as a couple (rate between 1 and 7, 7 being perfectly happy).
Male Hypoactive Sexual Desire Disorder
Victor is a 35-year-old professor at a recognized university. He has been dedicated to his career and academic advance, and his efforts have culminated in international recognition and a good number of publications. Three years ago he decided to start a formal relationship with a former student, who is now a promising professor at the same university. They decided to marry 2 years ago. He and his partner, who presents herself to the consultation, consider their marriage as very good with the exception of the almost nonexistent sexual life. Victor had a depressive episode when he was 17 years old after the passing of his mother; he recognizes the depressive illness and gives assurance during the consultation that he is not depressed now. When sexual interaction occurs, it is highly pleasurable for both, with no problems with the erection, lubrication, and easiness of orgasm and ejaculation control. Basic laboratory studies, including testosterone, prolactin, and TSH, are normal.
Low sexual desire, in the absence of medical and psychosocial factors that could otherwise explain it, is referred to as male hypoactive sexual desire disorder. A recent report characterized these men [14], who have been shown to have differences in the pattern of activation in response to sexual stimuli [15].
Identifying these patients is essential in directing therapeutic interventions more efficiently.
Treatment Approaches for the Psychological Factors in Low Sexual Desire
Treatment of Low Sexual Desire Secondary to Depressive Illness and/or Anxiety Disorder
Major depression is associated with decreased sexual interest in >40 % of men [16]. Treatment of depression should include the use of pharmacotherapy. While many of the medications used to treat depression impact sexual function, antidepressants that have less impact on sexual function include mirtazapine, bupropion, and the serotonin-norepinephrine reuptake inhibitors venlafaxine and duloxetine [17, 18]. There is ample evidence that the combination of pharmaco- and psychotherapy improves the efficacy of the treatment of depression [19]; therefore, such combinations should be provided whenever possible.
Several anxiety disorders might be related to low sexual desire, among them: posttraumatic stress disorder, acute stress disorder, and generalized anxiety disorder. Identification and proper treatment of these conditions might be critical for the management of low sexual desire [20].
Treatment of Low Sexual Desire Secondary to Relationship Conflict
Conflict and relationship distress may cause low sexual desire; when this factor is encountered, the patient and his partner should be referred to couple/relationship therapy (sometimes called marital therapy), a specialized form of psychotherapy that has proven efficacy in addressing couple distress [21]. Although reports on the application of couple therapy to low sexual desire are still anecdotal [22], clinical experience suggests this approach is sensible and effective. Sometimes, troubled relationships benefit from relatively simple interventions. Straightforward, small changes in couple dynamics can improve partner interaction for some couples, and such “treatment” can be performed in the primary care setting. Examples include the use of open communication on sexual issues with an open and honest approach, more time dedicated to physical intimacy and to talking about intimacy issues and sharing of feelings [23]. Severe conflict should be referred to a specialized professional.
Treatment of Male Hypoactive Sexual Desire Disorder
There are two possible approaches to the treatment of male hypoactive sexual desire disorder: pharmacological approaches and psychotherapeutic approaches. Regarding pharmacological approaches, there are no effective symptomatic treatments as there are for other sexual dysfunctions such as erectile dysfunction (i.e., phosphodiesterase type 5 inhibitors). Bupropion, an antidepressant that affects reuptake of dopamine and norepinephrine [24], has been studied and has shown a modest effect on women [25, 26]. Flibanserin, an agonist/antagonist of serotonin receptors, has shown efficacy in treating hypoactive sexual desire disorder (HSDD) in premenopausal women in several studies [27]. Although no reports of its efficacy in men with HSDD exist, flibanserin has the potential for possible benefit. Current experience is only in research settings as flibanserin has not yet been approved in any country.
Specific psychotherapeutic interventions for hypoactive sexual desire disorder have the following components [17]: affectual awareness that strives to identify positive and negative emotions related to sexual interaction and desire; insight and understanding, where a framework to understand the problem is offered to the patient; cognitive and systemic therapy, when individual psychological causes are addressed and interaction factors are addressed and corrected; and, finally, behavioral intervention, where a number of strategies are utilized to gradually overcome obstacles to sexual interaction.
Psychosexual therapy has developed approaches to treat hypoactive sexual desire in men, combining the classical interventions designed by Masters and Johnson [28] with more integrated psychodynamic and systemic interventions developed by Helen Kaplan in her classical approach to psychosexual therapy [6]. In short, these procedures involve the use of prescribed sequences of progressively more integrated and complex sexual behaviors for the patient to engage with his partner (or during self-stimulation with structured fantasies) and a variety of psychotherapeutic interventions including interpretation, confrontation, and restructuring of the couple interaction to address the more unconscious processes that are considered to block the experience of sexual desire.
Conclusion
Low sexual desire is a common complaint that has several etiologies. Investigating all levels of possible causality is critical for success in clinical management of this condition. The psychological factors are highly prevalent, and the clinician addressing this important area of health with patients should include an integrated and holistic approach to adequately evaluate and treat men with low sexual desire.
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Footnotes
1
Just as an example, see the definition of libido in a psychoanalytical online resource: Libido: the psychosexual energy originating in the id. Libido is the electric current of the mechanism of personality. It powers all psychological operations, invests desires, and undergoes ready displacement. It is the basic fuel of the self. Because it is of a relatively fixed quantity, like gasoline in a tank, it obeys laws of psychical “economy” in that a surplus in one system means a loss somewhere else. It can be either free or bound.