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 ; 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.
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 . 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 :
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 , who have been shown to have differences in the pattern of activation in response to sexual stimuli .
Identifying these patients is essential in directing therapeutic interventions more efficiently.