Hypoactive Sexual Desire
Definitions and Diagnostic Criteria
The most frequently presenting sexual desire disorder is deficiency of sexual desire, which is termed hypoactive sexual drive. The essential feature is a deficiency or absence of sexual fantasy or desire for sexual activity that causes marked personal distress or interpersonal difficulty. It is interpersonal difficulty that usually prompts a person to seek help. This difficulty arises when the two people in a relationship have different intensities and frequencies of sexual desire. Regrettably, in such situations of desire discrepancy, it is usually the person with the lower level of sexual desire who is designated the “patient,” and attempts are made to enhance that person’s sexual desire. Another not uncommon interpersonal difficulty occurs when one particular partner never or only rarely initiates sexual activity but nonetheless happily participates and often experiences arousal and orgasm following sexual advances from the other partner. The perceived problem here is one of deficiency in proceptivity (i.e., seeking or initiating sexual activity).
Although various authors have attempted to define “normal” levels of sexual desire, there is no generally accepted criterion of normality. The intensity and frequency of sexual desire vary considerably, both in the population and over time within a particular individual. These dimensions, therefore, fall on a continuum extending from no desire at all to extremely frequent, highly intense sexual desire. Except where the higher levels of sexual desire disrupt life or lead to antisocial behavior, no point on this continuum can be considered abnormal. Hence, in the DSM-IV criteria for hypoactive sexual desire disorder, the judgment of deficiency or absence is left to the clinician, who must take into account factors that affect sexual functioning, such as age and the context of the person’s life.
The DSM-IV criteria require the clinician to specify whether the hypoactive sexual desire disorder is lifelong or acquired. Although we see people who have never experienced sexual drive and desire, in the majority of individuals presenting to sex therapy clinics the problem is acquired, developing after a period of adequate sexual desire. The DSM-IV criteria also require specification of whether the disorder is generalized (occurs in all sexual activities) or situational (occurs in one or some, but not all, sexual activities). Rather than applying such specifiers, we differentiate between situational and generalized by adopting different terminology. Our differentiation is based on the notion that sexual drive is omnipotent and can lead to all types of sexual activities. In contrast, sexual desire is a focused drive, the focus being on a particular sexual activity or a particular person. Hence, DSM-IV generalized-type hypoactive sexual desire disorder, in our terminology, is “sexual drive disorder,” and we restrict the DSM-IV term of hypoactive sexual desire disorder to situational-type hypoactive sexual desire disorder. This differentiation is helpful in the clinical situation, because it can influence both assessment and management of the disorder. Intact sexual drive implies that the neuroendocrine mechanisms on which sexual drive is based are functional. Hence, in sexual drive disorder, it is highly probable that the etiology involves organic or deep-rooted psychological factors. In contrast, in sexual desire disorder, the etiology is generally behavioral, a reflection of relationship difficulties or of a person’s not gaining satisfaction from a particular sexual activity.
A diagnostic feature not fully addressed by the current classification system is the well-recognized clinical presentation of “desire discrepancy” between partners. Although neither partner in such couples may be particularly excessive or deficient in sexual interest, there is nonetheless sufficient disparity to give rise to sexual frustration and conflict, leading to marital or partnership disharmony. It is usual in such cases for the partner with less sexual interest or motivation to be identified as the index patient, the one with the “problem.” Thus, therapeutic interventions tend to be focused on enhancement of libido rather than on working to diminish what could be seen as elevated levels in the higher-desire partner. Clinicians need to be aware of the consequent and real danger of pathologizing normal variations in sexual interest, particularly those at the lower end of the continuum, thereby unnecessarily stigmatizing individuals labeled as having low levels of desire or libido. Statistically, many more of these individuals will be women than men.
Hypoactive Sexual Desire - Gender IssuesDespite marked inconsistencies in the research, clinical as well as social observation suggests that there are differences in the felt experience of sexual desire between men and women. On the whole, it does appear that men have a more insistent, energized, and constant sexual appetite, and that access to awareness of this is facilitated for them through a wide range of environmental cues. Women, meanwhile, tend to express more sporadic sexual desires that are more heavily dependent on situational context. The progression from desire to the enactment of sexual behaviors seems to occur over a longer time span for women, thus creating more potential for disruption and distraction.
Many factors underpin these apparently significant behavioral differences. Women are socialized to be fearful of the negative consequences of unrestrained sexual expression and, if they adopt a conformist gender role, will tend to be uncomfortable about displaying sexual curiosity and interest. Men have clearly visible evidence of arousal in the erect penis, whereas women anatomically have less visual evidence of arousal. Often, women have had very little positive encouragement to interpret the range of signs and signals of arousal or may have been trained to repress, distrust, and dislike these physiological indicators. Moreover, the polarity that states and reinforces the view that men “get” and women “give” sex frames the experience of sexual interaction in such a way as to render sexual approaches to women from men “demanding,” and pressures may add to existing multiple demands drawing on low resources. Hence, socialization and sexual script imperatives, rather than constitutional or biological variables, may offer more to the understanding of observed differences in sexual interest levels between the genders.
Hypoactive Sexual Desire - Prevalence
The U.S. national probability sample of 1,749 women and 1,410 men aged 18-59 years provides useful prevalence data for sexual dysfunction, including hypoactive sexual desire ("lacked interest in sex"). Among women, the prevalence of this symptom changed little with age (18-29 years, 32%; 30-39 years, 32%; 40-49 years, 30%; 50-59 years, 27%). Among men, by contrast, the prevalence of “lacked interest in sex” increased with age (18-29 years, 14%; 30-39 years 13%; 40-49 years, 15%; 50-59 years, 17%).
The number of individuals with hypoactive sexual desire disorder presenting for treatment has increased substantially over the past 15-20 years. It is the commonest presentation among women with sexual dysfunction attending clinics for treatment, accounting for about 40% of cases. Among those presenting at sex therapy clinics with this problem, women outnumber men.
For example, at a psychosexual clinic in Oxford, UK, 37% of female patients had a primary diagnosis of hypoactive sexual desire disorder, compared with less than 5% of male patients. It may be that men who experience loss of sexual desire seek help from other types of clinics. For example, in the UK, whereas only 5.1% of male patients attending a psychosexual clinic presented with hypoactive sexual desire disorder, 34.2% of male patients seeking treatment for sexual dysfunction at a genitourinary medicine clinic presented with this problem, even though both clinics were run by the same clinician. Among patients seeking recruitment to a multicenter trial of a pharmacological treatment for sexual dysfunctions, 65% had a primary diagnosis of hypoactive sexual desire disorder.
Hypoactive Sexual Desire - Assessment
It is essential at the outset of the assessment process to define exactly what a patient means by his or her complaint of low or absent sexual desire. The process includes ascertaining the reference against which the patient judges him- or herself as having low sexual desire. The reference may be a within-subject change from a higher level; if so, can the patient identify the time point at which the change occurred and recall what happened, in terms of life events, at that time point? Alternatively, patients may judge themselves against the level of their partner’s sexual desire, a referent suggestive of a sexual desire discrepancy within the relationship. A frequent reference, however, is expectation (often unrealistically high) - the level of desire the patient expects to have.
The conceptual model proposed by S. Levine provides a helpful basis for the assessment and management of sexual desire disorders. Levine’s model consists of three principal components: 1) a biological drive component generated by neuroendocrine mechanisms, 2) a cognitive or attitudinal component ("sexual wish"), and 3) affective or interpersonal components ("sexual motive,” or willingness to engage in sexual behavior). All three components should be evaluated in patients presenting with hypoactive sexual desire disorder. It must be recognized, however, that the relative importance of these three components varies considerably. In particular, a person in whom the biological drive component is deficient can participate in - and may even initiate - sexual behavior if he or she has a desire and willingness to be sexual. Similarly, a person whose biological drive is strong may not wish to behave sexually or be willing to do so in a particular situation.
Hypoactive Sexual Desire - Biological Drive
In patients whose hypoactive sexual desire disorder is global, deficiency of sexual drive should be considered early in the assessment process, because an easily treatable condition, such as reduced serum testosterone, might be identified. Although assessment of sexual drive is difficult, answers to the following questions may help to ascertain whether the drive component is intact and, if so, its “strength”:
1. Do you have sexual thoughts (daydreams) that occur spontaneously without being triggered by seeing or hearing something sexually arousing? If so, how frequently do you have such thoughts?
2. Are you able to generate sexual fantasies or thoughts? If so, how frequently do you experience such fantasies?
3. Do you ever feel in need of sex? If so, how often? If the patient answers positively to this question, the clinician must probe further to ascertain whether the patient actually feels the need for sex or the need for intimacy. Asking the patient “what feelings do you get that tell you you need sex?” is often helpful in differentiating these two feelings. People who need sex to satisfy sexual drive usually describe genital feelings (see next question) or frequent sexual thoughts, whereas answers such as “feeling the need to be close to someone or to be held” point to need for intimacy rather than sex. Need for intimacy is probably not triggered by sexual drive.
4. Do you ever experience spontaneous feelings of sexual arousal without these being triggered by seeing or hearing something sexually arousing (e.g., in women, genital lubrication, genital warmth, clitoral tingling; in men, penile erection, tingling in penis, feeling of fullness in penis or pelvis)? If so, how often?
Hypoactive Sexual Desire - Treatment Approaches
Over the past 15 years, sex therapists have increasingly come to recognize and acknowledge the diversity of etiological factors implicated in sexual desire disorders. As a result, current psychological treatment approaches are varied, ranging from long-term, individual psychotherapy to short-term, problem-focused couples therapy. When working in this area, some therapists value a “toolbox” of eclectic interventions, including hypnosis, transactional analysis, systemic and feminist perspectives, Gestalt therapy, cognitive-behavior therapy, and other therapeutic techniques and frameworks.
There is increasing awareness of the possibility of organic etiologies for reduced sexual drive. Although our knowledge of how these operate has become more sophisticated, we continue to have only a rudimentary understanding of the ways in which psychological factors combine and interact to give rise to severe and long-standing difficulties with drive, desire, arousal, and orgasm in both men and women. We understand the power of these psychological forces, which extends to the capacity to overcome the action of drugs acting on sexual function, as we see them operating on a regular basis, but we have only a limited understanding as to how these forces function.
Relationship factors in absence of drive and desire are often played down by individuals, couples, and clinicians alike, because working with such factors is challenging, complex, and potentially “dangerous,” the threat of change being an extremely destabilizing force, especially in long-term partnerships.
Psychodynamically Oriented Sex Therapy
Before Masters and Johnson, such sex therapy as was available was dominated by the work of Freud and the psychoanalytic movement. Some tenets of these early approaches have now been seriously challenged and superseded. The fundamental concepts developed by early theorists, however, remain an enduring factor in therapeutic work for sexual difficulties. Kaplan’s contribution was the evolution of a sense of balance, in which the importance of psychodynamic aspects, alongside more practical behavioral programs, was highlighted. LoPiccolo reported successful outcomes for desire problems using a broad-spectrum approach.
A serious limitation in the understanding of sexual desire problems is the lack of a coherent and comprehensive theory concerning the nature of libido and the part it plays in the intrapsychic and interpersonal life of the individual. S. Levine’s model raises some critical questions regarding the distinctions between drive and desire and the importance of “self-regulation” and “partner regulation” as sources of sexual motivation.
In the work of Kaplan and others we see acknowledgement of the power of unconscious processes and defense mechanisms - along with the analysis of resistances - to diminish anxiety. Emphasis tends to be on understanding the attitudes and conflicts that impede the progress of personal relationships and on ways in which the processes of psychotherapy can remove the blocks that prevent the achievement of personal and sexual fulfillment. Psychodynamic approaches recognize and work with the influence of past and present transferential relationships as well as with current relationship conflicts and issues. The extent to which such issues underpin motivation for sexual contact, the central role of these in treatment, and the relevance of the patient’s object relations history to his or her inhibitions are topics addressed by psychodynamic perspectives.
Cognitive and Behavioral Perspectives
Management of problems of sexual desire with cognitive and behavioral techniques has become increasingly comprehensive in its approach to both assessment and treatment. LoPiccolo and Friedman postulated that the etiologies of sexual desire problems are broad and suggested that many factors may operate simultaneously to determine the relative severity of the difficulty. They and others assert that because of the complexity of these disorders, the treatment approach must be thorough and must operate from a wide base. This perspective recognizes the assessment challenge presented by disorders of desire. Reports of frequency of sexual activity can be very misleading, since, for example, some low-desire people may engage in sex more often than they wish in response to partner pressure. Additionally, acquisition of information about levels of sexual desire is problematic, given the strong social and relationship pressure to state that one does desire sexual activity. Use of questionnaires and standardized self-report inventories is one way of attempting to resolve or minimize these assessment difficulties.
The efficacy of hypnosis as a potential behavior modifier in low desire has not been fully evaluated. Although hypnosis is often regarded with suspicion by therapists and patients alike, there are those who argue strongly for its inclusion in the “treatment toolbox” for desire disorders and who believe that it may do much (in the right patients) to increase preparedness to engage sexually. Hypnosis may thus be a useful adjunct to standard sex therapy techniques, with successful outcomes depending on the therapist’s ability to carefully select and individually tailor hypnotic interventions rather than relying on more general application.
Treatment programs that help patients focus on bodily cues associated with feelings that result in avoidance of sex may also be of practical use. These programs incorporate remedial work to raise awareness of first sensual and then sexual pleasure. Building on such awareness, therapists then introduce cognitive interventions designed to generate alternative responses and behavioral exercises intended to provide opportunities for rehearsing these alternative responses. In this way, the restructuring of sexual behaviors helps individuals with desire disorders to learn or relearn how to be comfortably sexual and characterizes this particular approach. The multimodal emphasis of these programs is in keeping with current general psychiatric practice, in that it enhances affective experiencing and improves cognitive mastery and behavioral regulation while aiming toward specific goals and allowing for systematic evaluation.
Work with sexual scripts is an explicitly interactional approach to treatment and may be especially useful in highlighting salient features of desire discrepancy disorders in couples. Sexual behaviors can be seen as “scripted” to fit the roles, expectations, and mores of social life. Sexual scripts provide the cognitive organization of sexual interchange and focus attention on the contextual character of sexual conduct. Lack of congruence of sexual-script parameters between partners may contribute to the development of either specific dysfunctions or loss of desire. Script negotiation, with therapist support, encourages exploration of the complex motives underlying sexual behavior and allows recognition of the power and importance of context. A consideration of scripts can be useful in the assessment of desire disorders; working to modify such scripts in the treatment process allows movement away from a focus on both frequency and individual blame. Script adaptation can be usefully incorporated into both broad-spectrum cognitive-behavioral approaches and systems-interactional approaches to therapy.
Systems and Interactional Perspectives
Systemic and interactional perspectives examine the “fit” of a couple, with special emphasis on sexual communication and its rhythmicity. Three types of interaction may be particularly important with regard to desire: sensate exchange, affect-regulated interaction, and symbolic interaction. Low sexual desire, along with many other complaints that seem to fall outside the classical medical model, is a condition with different meanings. The systemic approach suggests that hypoactive sexual desire is a subjective experience of dissatisfaction, reflecting imbalance of interactions rather than any kind of “disease” process.
The more two people differ in experience, in language skills, in cultural and religious heritage, and generally in the ways they “make meaning,” the more their cognitive constructs will fail to meet. This mismatch leads to a situation in which interactional “fit” is effortful and challenging, the deficits in cognitive “kinship” raising problems for communication on all levels, including, and sometimes especially, the sexual.
When couples bond, they form implicit and explicit contracts. If these are questioned or broken, disrupting the relationship system, hypoactive sexual desire may well result. “Understandings” about the division of labor and power in the partnership are particularly prone to such disintegration and the ensuing loss of desire of one or both partners. Loss of desire may also result from confusion about the fulfillment of roles or the inability of one or both partners to express hurt, frustration, or anger. These are all systemic, transactional issues. Successful treatment may require adjustment of various aspects of the interactive system that exists between the partners. A systemic perspective allows for a movement away from “norms” and blaming of one partner; its focus is the relationship, and it is well suited to complex, multifactorial presentations.
Medical Treatments
At present, medical treatments play only a small part in the management of sexual desire disorders, except where certain treatable, organic etiological factors are confirmed. It is our concern that medical treatments designed specifically to treat hypoactive sexual desire will lead to misdiagnosis and inappropriate prescribing. Segraves and Segraves warn that the major danger of pharmacotherapy without concomitant psychotherapy is that a case will be left with incomplete resolution.
Endocrine treatment In both men and women, sexual drive appears to be androgen dependent. Biochemical evidence of androgen deficiency in patients presenting with hypoactive sexual desire requires appropriate hormone replacement, provided that contraindications are not present. Although a substantial literature exists demonstrating androgen-dose-related enhancement of sexual drive in hypogonadal men, there are few data relating to women. Kaplan and Owett reported that testosterone induced increased sexual desire in women whose pretreatment serum testosterone levels had been iatrogenically reduced. Data also support the beneficial effects on sexual desire of testosterone or androgenic progestogens in postmenopausal women. Although some clinicians prescribe androgen treatment empirically to premenopausal women with hypoactive sexual desire and claim good results, the role of such treatment has yet to be established by means of carefully controlled, well-powered clinical trials.
Pharmacological treatment Although clinicians may use drugs empirically when psychological approaches to the management of hypoactive sexual desire fail, at present there are no drugs licensed for the treatment of this condition. Individual case reports and small-scale studies have described successful outcomes, in terms of enhancement of sexual desire, with pharmacotherapy. Antidepressants and dopamine agonists are probably the classes of drugs most frequently used for this purpose. In particular, there is suggestive evidence that bupropion may enhance sexual drive.
Management of Hypoactive Sexual Desire
The presentations of clients with drive/desire disorders are divisible into those with primary and those with secondary problems. Primary desire disorders represent a significant challenge to psychological approaches, given that patients with these disorders lack the ability to recognize alternative states of desire due to the general absence habitually experienced. This problem of recognition can make it very difficult to find or establish a starting point from which to work. A pattern in which novelty facilitates higher levels of felt desire for a relatively brief period (possibly up to 2 years), followed by recurrence of the desire problem, leading to compensatory behavior and pretence, which then gives way to resentment and weariness, is common. Such a pattern tends to lead, ultimately, to a situation in which the relationship is threatened by conflict, thus prompting one or both partners to seek help.
Primary Hypoactive Sexual Desire
Psychological interventions for primary presentations of hypoactive sexual desire tend to commence with pathologization of an individual by a referral agent, a partner, and/or frequently the individual him- or herself. Such individuals usually report that their motivation to engage in sexual behaviors is very low and has always been so. In other words, the hypoactive sexual desire represents the individual’s “norm,” and the impetus to change the status quo is largely externally driven. The type of management originally advocated for sexual dysfunctions by Masters and Johnson was not designed to deal specifically with low sexual desire. Although many of the behavioral exercises may enhance arousal and orgasm, they often fail to increase sexual desire or motivation. Additionally, presentations are diverse in both apparent etiology and maintenance patterns. Zilbergeld and Ellison argued that each case of low desire should be assessed individually and management tailored to specific needs.
Primary hypoactive sexual desire can be managed by engaging with an individual or couple and therapeutic work done either with a single therapist or in cotherapy.Many patients presenting with primary hypoactive sexual desire are relatively unaware of their affective responses to situations involving sexual stimulation. Their feeling responses to sexual situations may incorporate anxiety, anger, resentment, and bewilderment, but such reactions may only be vaguely accessible to them. This lack of insight into emotional responses tends to lead to the experience of sex as somewhat neutral, when, in fact, strong negative feelings lead to active avoidance and, thus, a type of “canceling out” process. One goal of therapy in such cases is to facilitate and increase awareness of the links between physical responses and affective experiences, so as to encourage more proactive and conscious choices.
Work with individuals The existence of negative attributions to specifically sexual body parts and experiences associated with them, combined with a degree of ignorance as to what kind of sexual behaviors may be pleasurable, is an indication for the use of individually tailored sexual growth programs. One-on-one sex education, liberally scattered with permission-giving statements and encouragement, is also important in reducing the sense of sexual naivete and gaucheness common in many men and women with primary hypoactive sexual desire. Such education should also extend to building robust sexual confidence and instilling the notion that each individual is the expert in his or her own sexuality.
Explicit instruction and encouragement in the use of a variety of relaxation techniques to minimize sexual anxiety, combined with exploration of libido-enhancing strategies for increasing sexual desire in anticipation of and in preparation for lovemaking, may be used to compensate for the absence of sexual curiosity and experimentation during adolescence often reported by patients with primary hypoactive sexual desire. Depending on the treatment approach used, this may or may not be accompanied by work to promote insight into underlying personal or relationship conflicts. Reformulation of attributions about the cause of the problems in ways that are conducive to therapeutic change and resolution of interpersonal difficulties is often a key component of adapting behaviors.
Behavioral assignments used in individual programs focus on facilitating an increased familiarity and ease with sensual and sexual responses, sexual skills enhancement to empower and raise sexual confidence levels, and encouragement to learn how to use the knowledge and awareness gained from self-stimulation to enrich sexual partnerships. Also useful in both primary and secondary hypoactive sexual desire are interventions designed to induce drive, or “prime the pump.” The conscious decision to engage in sensual/sexual daydreaming, to actively use fantasy to raise levels of desire, and to generally take an active role in the anticipation of sexual contact instead of waiting to be aroused by a partner can redistribute responsibility in a way that may ultimately increase levels of desire for both partners.
Work with couples When primary hypoactive sexual desire is a component of a couple’s presentation for psychosexual therapy, a central consideration is usually to help the couple understand how low levels of desire in one partner might respond to improvement of their communication in general and of their sexual communication in particular. Learning to register the early stages of anger and anxiety in themselves by focusing on bodily sensations, and being able to alert their partner to these signs, may help prevent the partners from getting caught up in a volatile and vicious circle of action/reaction from which there seems to be no escape. Couples may additionally need very clear and specific guidance in improvement of the techniques they use for physical erotic stimulation (
see Table 63-2), especially as it is not unusual to find partnerships in which one individual has primary hypoactive sexual desire and the other is sexually inexperienced and underconfident. Such guidance must be framed in a sensitive manner by the therapist to prevent defensiveness from becoming resistance and avoidance. We all tend to be somewhat sensitive to any suggestion that we might be inadequate as lovers.
Sensate focus programs can be used both to explore and to improve communication patterns. Such programs also have diagnostic value, facilitating access to the nature of intimate interchange in the couple relationship. Isolating and pinpointing particular behaviors that carry negative significance for one or both partners and focusing on these is often the way in which blocks can be overcome. Getting couples to identify “good quality” time in relationships that have adapted to the existence of sexual difficulties and potential or real conflict by developing elaborate avoidance rituals can be problematic. Managing the demands of a multiplicity of roles may contribute to this challenge.
Different life stages involve the adoption, prioritization, and re-prioritization of different roles. Men and women may have a professional/worker role, a domestic role, and a parental, filial, friendship, and community role in addition to the role of lover. The lover role tends to be the one that most often and easily falls off the agenda as the demands of others increase or as stress levels rise and fatigue sets in. Early partnerships and the sexual relationships accompanying them tend to involve only two or three of these roles, whereas during a couple’s 30s and 40s, the number of roles and demands of juggling them are often at their peak. The introduction of timetables can be revealing in providing a structured process that encourages couples to reflect upon their individual and joint distribution of time among the variety of roles and activities that make up their lives. This process almost always reveals deficits in personal and relationship time that tend to be clarified through juxtaposition with periods in the couple’s life when they were more physically intimate and more mutually attentive.
The following case example illustrates the management of a couple in which the female partner experienced primary sexual desire disorder.
Mrs. P was referred to the clinic with a presenting problem of loss of desire. She and her husband, both in their 30s, had relatively demanding careers. They had been married for over 10 years and had one son, age 6. Mrs. P had a recent history of depression, which was currently being controlled through medication. She reported that her depression first started after the birth of their child. Neither spouse expressed much emotion, although they were comfortable and forthcoming in talking about their difficulties. Mrs. P’s level of desire seemed to have become further inhibited since the birth of their son; however, it had never been very high, and neither partner could remember a time when she had initiated sexual contact.
Currently the frequency of sexual activity between the couple was once every 4-6 months. Mr. P described his sexual desire as “normal,” but he had reached the stage where he very rarely tried to initiate anything, as he felt that refusal and rejection were inevitable. The couple had discussed Mrs. P’s generally low level of desire, and it was reported that both her sister and her brother experienced very similar levels of desire.
A cotherapy team consisting of a male and a female therapist worked with the couple. In initial sessions, Mr. and Mrs. P were split up and given individual time to explore their own separate issues. Mrs. P looked at her attitudes toward sex and experiences of sexual contact, trying to identify what factors made things better or worse. Mr. P discussed the frustration and rejection that he experienced within the relationship and his feelings of impotence regarding his ability to change the situation. The couple was instructed to carry out sensate focus, stage 1. There was a ban on intercourse, and they were advised to try to incorporate considerable buildup to when they were going to carry out the program. Mrs. P felt that when there was a long buildup, she was more able to respond. Strategies for her self-management of this process were introduced. The couple reported some limited success at both tasks, although initiation had been mostly from Mr. P, who felt that if he had not mentioned doing the tasks, Mrs. P would have avoided them.
During sessions, further factors were identified that optimized Mrs. P’s level of desire. These included choosing the time of week or day that they could carry out tasks and monitoring her level of desire in relation to her menstrual cycle. Mrs. P felt that she was most likely to be interested in sexual activity during the time leading up to ovulation. Some individual work was suggested for Mrs. P around fantasy, and it was suggested that she find herself some acceptable erotic fiction to read to help her frame her fantasy. Mr. P found the ban on intercourse quite frustrating, especially since there had been an increase in nonsexual physical contact. Various coping strategies were discussed with Mr. P and the couple together, such as the acceptability of his engaging in self-stimulation. This discussion resulted in his decision not to use self-stimulation for the time being and to reassure Mrs. P more about his support of the program, as he felt that, long term, this combination of abstinence and reassurance would help the situation more. Individual work was commenced with Mr. P on how he might be able to enhance physical erotic stimulation for his partner in the most “romantic,” least-threatening/demanding way possible, as Mrs. P had identified waning romance in the relationship as a compounding factor for her.
The ban on intercourse was broken on a few occasions during the treatment. On one particular occasion, Mrs. P had actively wanted to be sexual after a meal out together to celebrate a friend’s wedding. This experience of desire had been characterized by considerable anticipation of the event for a number of days beforehand, coupled with the increased contact and communication they had been working on. Both partners had enjoyed intercourse on this occasion, and there was an associated increase in confidence for the couple. The behavioral program was amended to allow for intercourse on occasions when both partners wished it and at Mrs. P’s initiation. It was recommended that nonsexual contact continue on a more regular basis and that its initiation should be shared between them as much as possible, even if this meant longer gaps when Mrs. P was initiating.
The frequency of appointments was reduced, as Mr. and Mrs. P were satisfied with the progress they were making. At their final appointment, they felt that there had been significant improvement in their situation, even though their frequency of intercourse was not as high as Mr. P had originally suggested. Both had revised their expectations of how desire should operate within the relationship. The changes made in their behavior had led a to sustainable improvement, and Mrs. P reported enjoying sex more and feeling more confident and motivated to initiate it. Her level of desire had increased during the program, and she now spontaneously engaged in sexual “daydreaming,” which had not previously been a familiar activity for her. The couple were offered suggestions and strategies for monitoring the situation for themselves on an ongoing basis, with plans for remedial action should things begin to revert to their former pattern, and discharged.
Secondary Hypoactive Sexual Desire
Secondary hypoactive sexual desire has the advantage of comparison, in that the patient is able to contrast current levels of libido with those enjoyed at some previous time and may well have a more informed sense of what seems to enhance desire or, conversely, suppress it further. Problems of loss of desire for a specific partner, rather than a global absence of motivation for sexual contact, are more prevalent in this group and, thus, the person with lowered libido is more likely to be masturbating and aware of sexual interest in alternative circumstances, reducing the need for sexual growth work.
Work with individuals Individuals seeking therapy are often motivated more by a wish to enhance their own capacity for sexual gratification than by a desire to reduce conflict with a partner. For individuals who are not in a relationship, there is plenty of space and freedom to explore aspects of sensuality and sexuality entirely for themselves, without the pressure of pleasing someone else. For individuals who are in a relationship, therapy can be compromised by the nonpresent partner, who has an important influence on the therapy despite not always being personally influenced by the therapeutic process.
Work with couples Assessment of secondary hypoactive sexual desire requires careful consideration of the factors that may have led to the situation. It is important to consider broader sexual functioning, evaluating such features as erectile and ejaculatory adequacy and orgasmic confidence in women. Concurrent relationship assessment and psychological/psychiatric evaluation may need to be carried out. Severe relationship conflict normally necessitates couples therapy, as distinct from sexual therapy, before the latter can be of real use. It is not unusual for individuals and couples to have unrealistic expectations of what can be changed without addressing either precipitating or maintaining factors. Expectations are often of a return to previously experienced levels of desire (patients typically recall high levels of desire characterizing the early courtship stages of a relationship, when mutual idealization and a state of “limerance” tend to prevail); however, for a variety of reasons, this is not always possible. In cases of ongoing relationship conflict, raised levels of chronic stress, or a permanent change in lifestyle, a more realistic approach is to facilitate adaptation to and optimizing of sexual contact in the current circumstances. The initial work of identifying relevant factors in the reduction of experienced desire and reappraising expectations is often painful for couples and may involve issues of loss and grieving.
Secondary hypoactive sexual desire that is of specific onset - for example, following the birth of a child, an affair, an operation, job loss, or illness - tends to be identified more quickly than that of gradual onset, and the therapy may therefore adopt a damage-limitation approach, which can focus closely on the precipitating and maintaining factors. Facilitating communication about painful issues between the partners and providing a safe environment within which these can be explored may be an important precursor to the initiation of a treatment program. Secondary hypoactive sexual desire of more gradual onset may have the effect of “blurring” contributing factors. A primary discrepancy of desire between the partners, worsening over time with the loss of novelty, may be central, and negotiated reciprocity can play an important role in restoring some balance and sense of control for such couples. Conflict over the division of labor within the relationship, both practical and emotional, is common in cases of secondary hypoactive sexual desire and requires skilled therapeutic work, a degree of self-awareness and honesty on the part of each partner, and a mutual desire for change.
Etiology and Terminology
We mentioned earlier that at the opposite end of the sexual desire continuum from hypoactive sexual desire is a very small minority of individuals who have extremely high levels of sexual desire. Most such individuals adapt to their high levels of sexual desire, can exert a high degree of control over their sexual needs, and derive satisfaction from orgasmic experience. There are other individuals, however, who are preoccupied with sexual feelings and thoughts; they are insatiable, often respond to a variety of erotic stimuli, and continually seek sexual activity. Their behavior may involve unconventional sexual activity, such as paraphilias, or criminal activities, including rape. However, in our experience, it is mainly conventional sexual practices (i.e., masturbation and intercourse), undertaken with high frequency and without consideration of the consequences, that characterize such hypersexual individuals.
Controversy centers on the terminology and conceptualization of hypersexuality. The terms “nymphomania” and “satyriasis” were frequently and are now sometimes used to describe excessive and insatiable sexual impulses in women and men, respectively. While there can be no doubt that some people who indulge in high-frequency sexual activity are driven to such behavior by excessively high sexual drive, this is not always the case. Excessive sexual behavior may originate from processes - such as a relatively unusual psychological response to particular patterns of life circumstances - unrelated to biological sexual drive. Hence, hypersexuality better describes excessive sexual behavior than excessive sexual drive. On this basis, hypersexuality has been variously conceptualized as a behavior addictive disorder (sexual addiction), a dependence syndrome (sexual dependence), a compulsive disorder (sexual compulsiveness), and an atypical impulse-control disorder (sexual impulsivity). In discussing the strengths and weaknesses of these various conceptualizations of hypersexuality, Rinehart and McCabe pointed out that there is considerable overlap in the descriptive criteria of each label. They concluded that there is no consensus in the literature about what constitutes hypersexuality. DSM-IV does not recognize the problem of hyperactive sexual desire as sufficiently distinct in nature from paraphilia, mania, and personality disorder to warrant a separate diagnostic category.
If hypersexuality refers to excessive sexual desire or behavior, the major questions are 1) what constitutes “excessive”? and 2) can “excessive” sexual behavior be considered pathological? Although some authors have defined excessive sexual behavior in terms of weekly number of orgasms experienced (e.g., more than 21), there is no generally accepted definition as to what constitutes excessive, or even normal, levels of sexual behavior. Indeed, M. P. Levine and Troiden pointed out that what may appear excessive in one society may be normal in another.
Click here to get 1 Million Guaranteed Real Visitors, FREE! They argued against pathologizing sexual practices, including hypersexuality, that do not follow the majority norms of society, an argument that the present authors endorse, except when the sexual behavior in question leads to personal or interpersonal distress or causes physical or psychological trauma to the person or others.
Perhaps the most helpful diagnostic criterion of hypersexuality is that the (excessive) sexual behavior disrupts the person’s life or causes interpersonal distress. For example, we described the case of a 22-year-old secretary who lost her job because she experienced, during the premenstrual phase of her cycle, such a frequent and intense need for orgasm that she absented herself from her workstation up to 12 times a day to go to the washroom to masturbate. She would also masturbate in her car on her way to and from work. The hypersexuality was confined to the 3 or 4 days preceding the onset of her menstrual period. Suppression of menstruation for 6 months solved the problem, and at follow-up 2 years later, there had been no relapse.
Management of Hyperactive Sexual Desire
All patients presenting with hypersexuality require careful assessment and evaluation, including clinical examination. We have seen hypersexuality in women as a presenting symptom of an androgen-secreting ovarian tumor, a spinal tumor, and organic brain disease. It may be present in temporal lobe
epilepsy, and it can also occur in psychiatric disturbances such as mania and, very rarely, depression. Genital disorders may also cause hypersexual behavior, as a patient treated by one of the authors illustrates. This 64-year-old woman presented with a frequent and urgent need to masturbate by clitoral stimulation, a problem that started abruptly after she had been hospitalized with a fractured leg. She was found to have rock-hard pieces of smegma adhered under her clitoral prepuce. Removal of the smegma, under local anesthesia, cured her sexual problem, which had been caused by poor hygiene because her leg was in plaster.
It is helpful to dichotomize individuals with hypersexuality into those people who simply have a very high sexual drive, over which they can exert a high degree of control, and those who are insatiable and unable to control their need for extremely frequent sexual activity. Individuals in the former group frequently present to sex therapists with their partners, who have lower levels of sexual drive (i.e., discrepant sexual drive presentation). They can generally be managed with sex therapy. Vary rarely, treatment with an antiandrogen is required to suppress such individuals’ sexual drive. We view the latter group as having an obsessive-compulsive disorder, which is treated as such - with psychotherapy, pharmacotherapy (e.g., selective serotonin reuptake inhibitors or clomipramine), or a combination of both. Sex therapy is generally not indicated for this group, although concomitant couples therapy may be needed in cases where the hypersexuality has led to relationship distress.
Hypersexuality is a less common problem than hypoactive sexual desire. It can manifest as antisocial or criminal sexual behavior or simply as excessively high frequency of masturbation or intercourse that interrupts the person’s life activities. Because the causes of hypersexuality include both psychiatric and organic disturbances, comprehensive evaluation is required in all cases.
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