Hypoactive sexual desire disorder

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Hypoactive sexual desire disorder
Specialty Psychiatry, gynaecology

Hypoactive sexual desire disorder (HSDD), hyposexuality or inhibited sexual desire (ISD) is considered a sexual dysfunction and is characterized as a lack or absence of sexual fantasies and desire for sexual activity, as judged by a clinician. For this to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug (legal or illegal), or some other medical condition. A person with ISD will not start, or respond to their partner's desire for, sexual activity. [1] HSDD affects approximately 10% of all pre-menopausal women in the United States, or about 6 million women. [2]


There are various subtypes. HSDD can be general (general lack of sexual desire) or situational (still has sexual desire, but lacks sexual desire for current partner), and it can be acquired (HSDD started after a period of normal sexual functioning) or lifelong (the person has always had no/low sexual desire.)

In the DSM-5, HSDD was split into male hypoactive sexual desire disorder [3] and female sexual interest/arousal disorder . [4] It was first included in the DSM-III under the name inhibited sexual desire disorder, [5] but the name was changed in the DSM-III-R. Other terms used to describe the phenomenon include sexual aversion and sexual apathy. [1] More informal or colloquial terms are frigidity and frigidness. [6]


Low sexual desire alone is not equivalent to HSDD because of the requirement in HSDD that the low sexual desire causes marked distress and interpersonal difficulty and because of the requirement that the low desire is not better accounted for by another disorder in the DSM or by a general medical problem. It is therefore difficult to say exactly what causes HSDD. It is easier to describe, instead, some of the causes of low sexual desire.

In men, though there are theoretically more types of HSDD/low sexual desire, typically men are only diagnosed with one of three subtypes.

Though it can sometimes be difficult to distinguish between these types, they do not necessarily have the same cause. The cause of lifelong/generalized HSDD is unknown. In the case of acquired/generalized low sexual desire, possible causes include various medical/health problems, psychiatric problems, low levels of testosterone or high levels of prolactin. One theory suggests that sexual desire is controlled by a balance between inhibitory and excitatory factors. [7] This is thought to be expressed via neurotransmitters in selective brain areas. A decrease in sexual desire may therefore be due to an imbalance between neurotransmitters with excitatory activity like dopamine and norepinephrine and neurotransmitters with inhibitory activity, like serotonin. [8] Low sexual desire can also be a side effect of various medications. In the case of acquired/situational HSDD, possible causes include intimacy difficulty, relationship problems, sexual addiction, and chronic illness of the man's partner. The evidence for these is somewhat in question. Some claimed causes of low sexual desire are based on empirical evidence. However, some are based merely on clinical observation. [9] In many cases, the cause of HSDD is simply unknown. [10]

There are some factors that are believed to be possible causes of HSDD in women. As with men, various medical problems, psychiatric problems (such as mood disorders), or increased amounts of prolactin can cause HSDD. Other hormones are believed to be involved as well.[ citation needed ] Additionally, factors such as relationship problems or stress are believed to be possible causes of reduced sexual desire in women. According to one recent study examining the affective responses and attentional capture of sexual stimuli in women with and without HSDD, women with HSDD do not appear to have a negative association to sexual stimuli, but rather a weaker positive association than women without HSDD. [11]


In the DSM-5, male hypoactive sexual desire disorder is characterized by "persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity", as judged by a clinician with consideration for the patient's age and cultural context. [3] Female sexual interest/arousal disorder is defined as a "lack of, or significantly reduced, sexual interest/arousal", manifesting as at least three of the following symptoms: no or little interest in sexual activity, no or few sexual thoughts, no or few attempts to initiate sexual activity or respond to partner's initiation, no or little sexual pleasure/excitement in 75–100% of sexual experiences, no or little sexual interest in internal or external erotic stimuli, and no or few genital/nongenital sensations in 75–100% of sexual experiences. [4]

For both diagnoses, symptoms must persist for at least six months, cause clinically significant distress, and not be better explained by another condition. Simply having lower desire than one's partner is not sufficient for a diagnosis. Self-identification of a lifelong lack of sexual desire as asexuality precludes diagnosis. [3] [4]



HSDD, like many sexual dysfunctions, is something that people are treated for in the context of a relationship. Theoretically, one could be diagnosed with, and treated for, HSDD without being in a relationship. However, relationship status is the most predictive factor accounting for distress in women with low desire and distress is required for a diagnosis of HSDD. [12] Therefore, it is common for both partners to be involved in therapy. Typically, the therapist tries to find a psychological or biological cause of the HSDD. If the HSDD is organically caused, the clinician may try to treat it. If the clinician believes it is rooted in a psychological problem, they may recommend therapy. If not, treatment generally focuses more on relationship and communication issues, improved communication (verbal and nonverbal), working on non-sexual intimacy, or education about sexuality may all be possible parts of treatment. Sometimes problems occur because people have unrealistic perceptions about what normal sexuality is and are concerned that they do not compare well to that, and this is one reason why education can be important. If the clinician thinks that part of the problem is a result of stress, techniques may be recommended to more effectively deal with that. Also, it can be important to understand why the low level of sexual desire is a problem for the relationship because the two partners may associate different meanings with sex but not know it. [13]

In the case of men, the therapy may depend on the subtype of HSDD. Increasing the level of sexual desire of a man with lifelong/generalized HSDD is unlikely. Instead the focus may be on helping the couple to adapt. In the case of acquired/generalized, it is likely that there is some biological reason for it and the clinician may attempt to deal with that. In the case of acquired/situational, some form of psychotherapy may be used, possibly with the man alone and possibly together with his partner. [9]



Flibanserin was the first medication approved by FDA for the treatment of HSDD in pre-menopausal women. Its approval was controversial and a systematic review found its benefits to be marginal. [14] The only other medication approved in the US for HSDD in pre-menopausal women is bremelanotide, in 2019. [2]


A few studies suggest that the antidepressant, bupropion, can improve sexual function in women who are not depressed, if they have HSDD. [15] The same is true for the anxiolytic, buspirone, which is a 5-HT1A receptor agonist similarly to flibanserin. [16]

Testosterone supplementation is effective in the short term. [17] However, its long-term safety is unclear. [17]


The term "frigid" to describe sexual dysfunction derives from medieval and early modern canonical texts about witchcraft. It was thought that witches could put spells on men to make them incapable of erections. [18] Only in the early nineteenth century were women first described as "frigid", and a vast literature exists on what was considered a serious problem if a woman did not desire sex with her husband. Many medical texts between 1800 and 1930 focused on women's frigidity, considering it a sexual pathology. [19]

The French psychoanalyst, Princess Marie Bonaparte, theorized about frigidity and considered herself to suffer from it. [20] In the early versions of the DSM, there were only two sexual dysfunctions listed: frigidity (for women) and impotence (for men).

In 1970, Masters and Johnson published their book Human Sexual Inadequacy [21] describing sexual dysfunctions, though these included only dysfunctions dealing with the function of genitals such as premature ejaculation and impotence for men, and anorgasmia and vaginismus for women. Prior to Masters and Johnson's research, female orgasm was assumed by some to originate primarily from vaginal, rather than clitoral, stimulation. Consequently, feminists have argued that "frigidity" was "defined by men as the failure of women to have vaginal orgasms". [22]

Following this book, sex therapy increased throughout the 1970s. Reports from sex-therapists about people with low sexual desire are reported from at least 1972, but labeling this as a specific disorder did not occur until 1977. [23] In that year, sex therapists Helen Singer Kaplan and Harold Lief independently of each other proposed creating a specific category for people with low or no sexual desire. Lief named it "inhibited sexual desire", and Kaplan named it "hypoactive sexual desire". The primary motivation for this was that previous models for sex therapy assumed certain levels of sexual interest in one's partner and that problems were only caused by abnormal functioning/non-functioning of the genitals or performance anxiety but that therapies based on those problems were ineffective for people who did not sexually desire their partner. [24] The following year, 1978, Lief and Kaplan together made a proposal to the APA's taskforce for sexual disorders for the DSM III, of which Kaplan and Lief were both members. The diagnosis of Inhibited Sexual Desire (ISD) was added to the DSM when the 3rd edition was published in 1980. [25]

For understanding this diagnosis, it is important to recognize the social context in which it was created. In some cultures, low sexual desire may be considered normal and high sexual desire is problematic. For example, sexual desire may be lower in East Asian populations than Euro-Canadian/American populations. [26] In other cultures, this may be reversed. Some cultures try hard to restrain sexual desire. Others try to excite it. Concepts of "normal" levels of sexual desire are culturally dependent and rarely value-neutral. In the 1970s, there were strong cultural messages that sex is good for you and "the more the better". Within this context, people who were habitually uninterested in sex, who in previous times may not have seen this as a problem, were more likely to feel that this was a situation that needed to be fixed. They may have felt alienated by dominant messages about sexuality and increasingly people went to sex-therapists complaining of low sexual desire. It was within this context that the diagnosis of ISD was created. [27]

In the revision of the DSM-III, published in 1987 (DSM-III-R), ISD was subdivided into two categories: Hypoactive Sexual Desire Disorder and Sexual Aversion Disorder (SAD). [28] The former is a lack of interest in sex and the latter is a phobic aversion to sex. In addition to this subdivision, one reason for the change is that the committee involved in revising the psychosexual disorders for the DSM-III-R thought that term "inhibited" suggests psychodynamic cause (i.e., that the conditions for sexual desire are present, but the person is, for some reason, inhibiting their own sexual interest). The term "hypoactive sexual desire" is more awkward, but more neutral with respect to the cause. [29] The DSM-III-R estimated that about 20% of the population had HSDD. [30] In the DSM-IV (1994), the criterion that the diagnosis requires "marked distress or interpersonal difficulty" was added.

The DSM-5, published in 2013, split HSDD into male hypoactive sexual desire disorder and female sexual interest/arousal disorder. The distinction was made because men report more intense and frequent sexual desire than women. [3] According to Lori Brotto, this classification is desirable compared to the DSM-IV classification system because: (1) it reflects the finding that desire and arousal tend to overlap (2) it differentiates between women who lack desire before the onset of activity, but who are receptive to initiation and or initiate sexual activity for reasons other than desire, and women who never experience sexual arousal (3) it takes the variability in sexual desire into account. Furthermore, the criterion that 6 symptoms be present for a diagnosis helps safeguard against pathologizing adaptive decreases in desire. [31] [32]



HSDD, as currently defined by the DSM has come under criticism of the social function of the diagnosis.

Other criticisms focus more on scientific and clinical issues.

DSM-IV criteria

Prior to the publication of the DSM-5, the DSM-IV criteria were criticized on several grounds. It was suggested that a duration criterion should be added because lack of interest in sex over the past month is significantly more common than lack of interest lasting six months. [41] Similarly, a frequency criterion (i.e., the symptoms of low desire be present in 75% or more of sexual encounters) has been suggested. [42] [43]

The current framework for HSDD is based on a linear model of human sexual response, developed by Masters and Johnson and modified by Kaplan consisting of desire, arousal, orgasm. The sexual dysfunctions in the DSM are based around problems at any one or more of these stages. [13] Many of the criticisms of the DSM-IV framework for sexual dysfunction in general, and HSDD in particular, claimed that this model ignored the differences between male and female sexuality. Several criticisms were based on inadequacy of the DSM-IV framework for dealing with females' sexual problems.

See also

Related Research Articles

Libido is a person's overall sexual drive or desire for sexual activity. Libido is influenced by biological, psychological, and social factors. Biologically, the sex hormones and associated neurotransmitters that act upon the nucleus accumbens regulate libido in humans. Social factors, such as work and family, and internal psychological factors, such as personality and stress, can affect libido. Libido can also be affected by medical conditions, medications, lifestyle and relationship issues, and age. A person who has extremely frequent or a suddenly increased sex drive may be experiencing hypersexuality, while the opposite condition is hyposexuality.

Paraphilia is the experience of intense sexual arousal to atypical objects, situations, fantasies, behaviors, or individuals.

Gender dysphoria (GD) is the distress a person feels due to a mismatch between their gender identity and their sex assigned at birth. People with gender dysphoria are typically transgender. The diagnostic label gender identity disorder (GID) was used until 2013 with the release of the DSM-5. The condition was renamed to remove the stigma associated with the term disorder.

Sexual fetishism or erotic fetishism is a sexual fixation on a nonliving object or nongenital body part. The object of interest is called the fetish; the person who has a fetish for that object is a fetishist. A sexual fetish may be regarded as a non-pathological aid to sexual excitement, or as a mental disorder if it causes significant psychosocial distress for the person or has detrimental effects on important areas of their life. Sexual arousal from a particular body part can be further classified as partialism.

Sexual desire is a motivational state and an interest in sexual objects or activities, or as a wish, or drive to seek out sexual objects or to engage in sexual activities. Synonyms for sexual desire are libido, sexual attraction and lust. Sexual desire is an aspect of a person's sexuality, which varies significantly from one person to another, and also varies depending on circumstances at a particular time. Not every person experiences sexual desire; those who do not experience it may be labelled asexual.

Persistent genital arousal disorder (PGAD), previously called persistent sexual arousal syndrome, is spontaneous, persistent, unwanted and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and is typically not relieved by orgasm. Instead, multiple orgasms over hours or days may be required for relief.

Sexual dysfunction is difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including physical pleasure, desire, preference, arousal or orgasm. According to the DSM-5, sexual dysfunction requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunctions can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

Human sexual response cycle

The human sexual response cycle is a four-stage model of physiological responses to sexual stimulation, which, in order of their occurrence, are the excitement-, plateau-, orgasmic-, and resolution phases. This physiological response model was first formulated by William H. Masters and Virginia E. Johnson, in their 1966 book Human Sexual Response. Since then, other human sexual response models have been formulated.

Sexual arousal disorder is characterized by a lack or absence of sexual fantasies and desire for sexual activity in a situation that would normally produce sexual arousal, or the inability to attain or maintain typical responses to sexual arousal. The disorder is found in the DSM-IV. The condition should not be confused with a sexual desire disorder.


Bremelanotide, sold under the brand name Vyleesi, is a medication used to treat low sexual desire in women. Specifically it is used for low sexual desire which occurs before menopause and is not due to medical problems, psychiatric problems, or problems within the relationship. It is given by an injection just under the skin of the thigh or abdomen.

Sex therapy is a strategy for the improvement of sexual function and treatment of sexual dysfunction. This includes sexual dysfunctions such as premature ejaculation or delayed ejaculation, erectile dysfunction, lack of sexual interest or arousal, and painful sex. It includes dealing with problems imposed by atypical sexual interests (paraphilias), gender dysphoria and being transgender; highly overactive libido or hypersexuality, a lack of sexual confidence, recovering from sexual abuse, such as rape, sexual assault, and sexual issues related to aging, illness, or disability.

Sexual medicine is a branch of medicine concerning the diagnosis, treatment, and prevention of disorders of sexual function. Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.

Female sexual arousal disorder (FSAD) is a disorder characterized by a persistent or recurrent inability to attain sexual arousal or to maintain arousal until the completion of a sexual activity. The diagnosis can also refer to an inadequate lubrication-swelling response normally present during arousal and sexual activity. The condition should be distinguished from a general loss of interest in sexual activity and from other sexual dysfunctions, such as the orgasmic disorder (anorgasmia) and hypoactive sexual desire disorder, which is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time.

Blanchard's transsexualism typology is a proposed psychological typology of gender dysphoria, transsexualism, and fetishistic transvestism, created by Ray Blanchard through the 1980s and 1990s, building on the work of prior researchers, including his colleague Kurt Freund. Blanchard categorized trans women into two groups: homosexual transsexuals who are attracted exclusively to men, and who seek sex reassignment surgery because they are feminine in both behavior and appearance; and autogynephilic transsexuals who are sexually aroused at the idea of having a female body. According to Anne Lawrence, Blanchard's typology broke from earlier ones which "excluded the diagnosis of transsexualism" for arousal in response to cross-dressing. Lawrence stated that, before Blanchard, the idea that arousal in response to cross-dressing or cross-gender fantasy meant that one was not transsexual was a recurring theme in scholarly literature. Alice Dreger stated that Blanchard, Bailey, and Lawrence all agree that any trans woman who would benefit from sex reassignment surgery should receive it.

Historically, studies assumed that transgender sexuality might be distinct from traditional human sexuality. For much of the 20th century, what was described as "transsexualism" was believed to be sexual in nature, and so was defined along these terms.


Flibanserin, sold under the brand name Addyi, is a medication approved for the treatment of pre-menopausal women with hypoactive sexual desire disorder (HSDD). The medication increases the number of satisfying sexual events per month by about one half over placebo from a starting point of about two to three. The certainty of the estimate is low. The side effects of dizziness, sleepiness, and nausea occur about three to four times more often.

Sexual desire discrepancy (SDD) is the difference between one's desired frequency of sexual intercourse and the actual frequency of sexual intercourse within a relationship. Among couples seeking sex therapy, problems of sexual desire are the most commonly reported dysfunctions, yet have historically been the most difficult to treat successfully. Sexual satisfaction in a relationship has a direct relationship with overall relationship satisfaction and relationship well-being. Sexual desire and sexual frequency do not stem from the same domains, sexual desire characterizes an underlying aspect of sexual motivation and is associated with romantic feelings while actual sexual activity and intercourse is associated with the development and advancement of a given relationship. Thus together, sexual desire and sexual frequency can successfully predict the stability of a relationship. While higher individual sexual desire discrepancies among married individuals may undermine overall relationship well-being, higher SDD scores for females may be beneficial for romantic relationships, because those females have high levels of passionate love and attachment to their partner. Studies suggest that women with higher levels of desire relative to that of their partners' may experience fewer relationship adjustment problems than women with lower levels of desire relative to their partners'. Empirical evidence has shown that sexual desire is a factor that heavily influences couple satisfaction and relationship continuity which has been one of the main reasons for the interest in this research domain of human sexuality.

Robert Taylor Segraves is an American psychiatrist best known for his work on sexual dysfunction and its pharmacologic causes and treatments.

Lori Brotto Canadian psychologist

Lori Anne Brotto is a Canadian psychologist best known for her work on female sexual arousal disorder (FSAD).

Sexual arousal Arousal of sexual desire, during or in anticipation of sexual activity

Sexual arousal is typically the arousal of sexual desire during or in anticipation of sexual activity. A number of physiological responses occur in the body and mind as preparation for sexual intercourse and continue during it. Male arousal will lead to an erection, and in female arousal the body's response is engorged sexual tissues such as nipples, vulva, clitoris, vaginal walls, and vaginal lubrication. Mental stimuli and physical stimuli such as touch, and the internal fluctuation of hormones, can influence sexual arousal.


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