Hypoactive Sexual Desire in Men

Abstract

Hypoactive sexual desire is a common complaint in men of all ages. By recognizing different etiologies that contribute to low libido in men, clinicians can initiate a patient-centered evaluation and treatment plan. A thorough history, physical exam, and appropriate laboratory investigations can identify men with underlying medical and/or psychiatric conditions that can be addressed to improve sexual desire. Men without modifiable comorbid conditions represent a current challenge, as there are no treatments specific to male hypoactive sexual desire. As the understanding of male hypoactive sexual desire evolves, more modalities will become available for both assessment and treatment.

Appendices

Commentary: Hypoactive Sexual Desire in Men

• Eusebio Rubio-Aurioles M.D., Ph.D. 

1. Departamento de Psiquiatrí a y Salud Mental, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico

   Eusebio Rubio-Aurioles M.D., Ph.D. (Asociación Mexicana para la Salud Sexual, A.C. Profesor de posgrado)

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 16.5 presents 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.

5.1 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.

5.2 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).

5.3 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

6.1 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].

6.2 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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