Disorders of Sexual Desire and Arousal

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Prevalence

It is difficult to estimate the prevalence of desire disorders. Laumann and colleagues [1] reported on a national probability sample of 1749 women aged 18 to 59 years. Of these, 43% reported a sexual dysfunction. Among the 2400 midlife multiethnic women (Hispanic, white non-Hispanic, African American, Chinese, and Japanese) in six United States cities who completed baseline questionnaires in the prospective Study of Women's Health across the Nation, 40% reported that they never or infrequently

Masters and Johnson

Masters and Johnson advanced our knowledge of human sexuality. Masters was the first to describe a physiologic model for the sexual response cycle. His original model did not include a desire phase because he did not consider desire disorders to be sexual dysfunctions; he used the term dysfunction to describe “an altered state of physiologic responsivity.” Rather, he considered inhibited sexual desire and sexual aversion to be nondysfunctional diagnostic categories.

Biphasic model

Masters separated sexual

Hypoactive desire disorder, sexual aversion, and female sexual arousal disorder

Patients often present with the complaint, “I just don't have any interest in sex.” Successful therapy for these patients depends on an accurate diagnosis. Unfortunately, there is no consensus on diagnostic definitions. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (Text Revision) definitions of desire and arousal disorders are shown in Box 1. The international multidisciplinary group gathered by the American Foundation for Urologic Disease definitions are shown in Box 2

Domestic violence

Women who are in a violent relationship have high rates of sexual dysfunction including desire disorders. Chapman [46] found that 61% of women who suffered from domestic violence had sexual dysfunctions. Schei and Bakketeig [47] found an association between sexual problems and domestic violence as well. All women who present with complaints of decreased desire should be screened for domestic violence.

Depression

Depression is strongly associated with decreased desire [27], [48]. The relationships between depression, marital distress, and sexual dysfunction are complex. The relationships between sexual dysfunctions, depression and antidepressants are discussed in detail elsewhere in this issue. Women who present with complaints of decreased desire should be screened for depression.

Substance abuse

Substance abuse is associated with decreased desire. Abuse of alcohol, narcotics, marijuana, and cocaine has been associated with decreased desire. The associations of substance abuse and sexual dysfunctions are discussed in detail elsewhere in this issue. A patient who presents with decreased desire should be screened for substance abuse.

Androgen deficiency

Androgen deficiency is covered in detail elsewhere in this issue.

History

A complaint of decreased desire may be overt or may be uncovered in a review of systems. A complete sexual history is described elsewhere in this issue. A general medical history should be taken, with emphasis on uncovering chronic illness such as those described above. A menstrual history may uncover thyroid disorders or hyperprolactinemia. A complete list of medications including over-the-counter and herbal preparations should be obtained. The patient should be screened for domestic violence,

Therapeutic approaches

Therapy for desire phase disorders is difficult. There is minimal data on the effectiveness of different therapeutic approaches [49]. Masters and Johnson reported a success rate of over 90% for sexual aversion using sensate focus therapy [39]. They reported that low libido required an intensive psychotherapeutic approach. Kaplan stated that only a small proportion of patients who have inhibited sexual desire responded to brief sex therapy. Therapy must be directed toward the etiology of the

Cognitive behavioral therapy

Cognitive behavioral therapy focuses on the role of thinking in how we feel and act. The theory is that thinking causes patients to feel and act the way they do. Therapy is directed to replacing negative thoughts with thoughts that lead to more desirable feelings and behaviors. In this paradigm, decreased sexual desire is caused by negative thoughts about sex or the partner. Replacing these thoughts with positive ones leads to a change in behavior and feelings. Trudel and colleagues [50]

Intensive sex therapy

Intensive sex therapy involves sensate focus exercises as an educational tool. Intensive sex therapy has been reported to be effective in sexual aversion and arousal disorders, but less so in HSDD.

Pharmacologic therapy

A variety of pharmacologic approaches have been advocated. The US Food and Drug Administration has not approved any drugs for treatment of HSDD or female sexual arousal disorder. Prescription drugs and herbal and alternative therapies are discussed in detail elsewehere in this issue.

Summary

Desire and arousal disorders are very common. These disorders can cause significant distress to a patient. A successful approach depends on an accurate diagnosis, which is dependent on history. Laboratory evaluation is usually not helpful, whereas psychosexual therapy is helpful in many cases. Although there is some evidence that drug therapy is helpful in some cases, no drug has been approved for the treatment of these disorders.

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