Hypoactive Sexual Desire Disorder Meuleman and Van Lankveld

Home , Erectile dysfunction, Sexual desire

Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalFebruary 2005 953 •••• Review Article MALE HYPOACTIVE SEXUAL DESIRE DISORDER MEULEMAN AND VAN LANKVELD

Hypoactive sexual desire disorder: an underestimated condition in men

ERIC J.H. MEULEMAN and JACQUES J.D.M. VAN LANKVELD* University Medical Centre St Radboud, and *Pompekliniek, Nijmegen, the Netherlands Accepted for publication 12 July 2004

KEYWORDS currently recognized as the most difficult function is to stimulate the male rat to sexual disorder to operationally define, approach a female and to raise his sexual male hypoactive sexual desire disorder, evaluate and treat. excitement to the threshold necessary for erectile dysfunction consummatory elements of sexual behaviour, i.e. mounting and intromission. Thereafter, the consummatory mechanism controls the THE ASSESSMENT OF SEXUAL DESIRE AND INTRODUCTION intromission and ejaculatory elements of the DESIRE PROBLEMS male rat’s sexual behaviour, integrating the One consequence of the availability of sequence of mounts and intromissions, thus HSDD is associated with a wide variety of medication that allows men to enhance their amplifying the male’s arousal until ejaculation biological and psychological causes [1]. erection is that male hypoactive sexual desire occurs. Recent animal research has expanded At present, no single instrument for disorder (HSDD) is erroneously presented and Beach’s model [10], and, for instance, diagnostically assessing HSDD prevails [3]. treated as erectile dysfunction (ED). The lack motivational and consummatory processes Sexual healthcare providers who wish to be of public education on sexual health issues, have been shown to involve separate brain alert to a diagnosis of HSDD are advised to the myth that men are always motivated to be regions [11], independently modulated by pose direct and unambiguous questions to sexual, insufficient sexological knowledge of androgenic and dopaminergic agents [12–14]. their patients, to probe for aspects of sexual health-care providers, and the lack of tools to Animal studies suggest that an intricate desire and motivation. Patients often will not comprehensively assess male HSDD, are interplay between steroid hormone actions in reveal sexual problems unless explicitly causative factors of this misconception, the brain maintains central sexual arousability invited [4]. Collateral information may be which may partly explain the high proportion and the organism’s individual experience with obtained through questionnaires, completed of failures of treatments for symptomatic ED. sexual gratification. From this, expectations of before or after the consultation. Several In population-based studies HSDD has been competent sexual functioning have been reliable and valid questionnaires are available reported in 0–15% of men, and ED in 10–20% developed, including sexual activity, sexual for assessing sexual desire problems, with [1]. Recently, Simons and Carey [2] analysed desire, arousal and sexual performance. easy-to-follow instructions. The Sexual Desire 52 studies published between 1990 and 2000; However, the validity of extrapolating findings Inventory [5] was designed specifically community samples indicate a prevalence of to human sexual functioning remains to be to measure level of sexual desire, the 0–5% for ED and 0–3% for male HSDD, while evaluated in empirical studies. Recent work in International Index of Erectile Function [6] prevalence estimates from primary-care and neurobiology has allowed conceptualisations provides a subscale to measure sexual desire, sexuality clinic samples are characteristically of sexual motivation and performance, the and the Golombok Rust Inventory of Sexual higher. With the aim of putting HSDD on complexity of which far exceeds the models Satisfaction [7–9] provides subscales of sexual the agenda of providers of male sexual based on Beach’s concept. avoidance, and of infrequency of sexual healthcare, here we review publications on contact. the pathophysiology of male HSDD, and its The linear model of the human sexual biological and psychological correlates. response as postulated by Masters and Johnson [15] has dominated clinical research According to the Diagnostic and Statistical THE INTERFACE BETWEEN BIOLOGY AND for several decades. This model omitted sexual Manual of Mental Disorders (Fourth Edition) PSYCHOLOGY OF MALE SEXUAL DESIRE desire and problems of hypoactive desire classification, HSDD is the persistent or completely, probably because Masters and recurrent absence or deficit of sexual The investigation of male sexual behaviour Johnson studied individuals who were highly fantasies and desire for sexual activity, has been greatly influenced by Beach’s motivated to engage in sexual activity. Later accounting for factors that affect sexual concept of the ‘dual nature of sexual arousal authors added the concept of sexual desire, function, e.g. age, sex and life context and performance’, derived from his extensive but still adhered to the linear model, (http://www.psychnet-uk.com/dsm_iv/ research on male rats [10]. He postulated that proposing that sexual desire is needed to hypoactive_sexual_desire_disorder.htm). sexual behaviour depends on two, relatively initiate subsequent sexual arousal and independent, processes controlling orgasmic release [16-18]. They considered the Although many studies have been conducted, motivation and consummation. Motivation presence of sexual thoughts and fantasies, especially of female HSDD, the lack of involves a sexual arousal mechanism that and an innate urge to experience sexual methodological rigor of many studies limits determines a male’s sexual response to tensions and release, as markers of desire [18]. the confidence in the findings [2]. HSDD is perception of a receptive female. Its main Over time, the linear model of the sexual

MEULEMAN and VAN LANKVELD

response acquired normative properties, FIG. 1. The dual-stage information-processing model of sexual responding, adapted from Janssen et al. [20] prescribing that the personal experience of and Öhman et al. [21]. lustful desire in both sexual partners should precede any initiation of sexuality. However, real-life experiences of numerous ‘steady’ Subliminal couples show almost universal differences in stimulus the experience of sexual desire between partners, regarding both timing and frequency of sexual activity, and sometimes giving rise to serious marital conflicts. Preattentive analysis Moreover, humans engage in sexual contacts for countless motives, only one of which is the awareness of an intrinsic urge for sexual activity. Many motives are not sexual, such as pleasing or appeasing a partner, banishing Preattentive elaboration Subconscious gloomy thoughts, chasing away boredom, or disinhibition monetary or other material rewards. Recognition of this gave rise to the notion of a ‘receptive sexual desire’, as opposed to Awareness ‘active desire’ [19]. Biological and psychological factors Thus the linear model of sexuality gave way Subjective arousal influence processing in limbic to circular or multifactorial hypotheses system regarding the interrelationships of sexual desire, arousal and performance, and the influence of unconscious, involuntary and automatic processes, along with conscious Physical arousal motives and deliberations, was recognized. Building on new findings from neuroscience, Janssen et al. [20] proposed a two-stage information-processing model of sexual Sexual activity arousal, based on the concepts of ‘the multiplicity of meaning of sexual stimuli’ and of ‘the interaction of automatic and controlled processing’ of such information. According to this model, in the first stage, subliminal stimuli render the sexual system Mental sexual arousal alters the descending laboratory) in response to erotic stimulation receptive to sexual stimuli, and prepare the neurotransmission from limbic centres to the consistently show no correlation with the organism to respond with physical arousal lumbar sacral centres of the spinal cord. There female’s subjective arousal [26,27]. Thus, [20,21] (Fig. 1). Many psychological and is evidence that this involves increasing women may not have this direct confirmation biological factors might preclude the oxytocinergic signalling from the of their genital arousal, which might explain deployment of the genital sexual response, paraventricular nuclei of the hypothalamus, why many women need direct stimulation of but if processing of stimuli in the limbic with concurrent reduction of inhibitory their congesting vulvar structures for the centres is such that some degree of arousal is serotonergic input, particularly from the second level confirmatory stimulus. Clearly, experienced, the individual can continue to nucleus paragigantocellularis in the medulla some sexual styles, particularly intercourse- focus on sexual stimuli. Depending on the [22]. When this balance of signalling to the focused, may preclude this. unconscious processing of either the mere pelvic autonomic outflow occurs, the erotic meaning of the sexual stimuli, or of subsequent physical tumescence constitutes Although the two-stage model remains to be many meanings, including negative valence an additive or compounding second-level validated by empirical testing, it may guide (particularly in sexually dysfunctional men), sexual stimulus. The engorgement is usually the present discussion of sexual desire further arousal might follow in the second accurately detected and enjoyed. Men with problems in men. The most prominent stage. After the priming-based and chronic situational ED typically underrate implications of the Janssen et al. [21] model unconscious motivational engagement, the their physical response [23], whereas sexually are: (i) the unconscious and automatized man may become aware of this motivation as functional men have higher correlations initiation of genital response preparation a desire to continue the experience for the between genital and subjective measures of upon (subliminal) perception of erotic stimuli; sake of the sexual tension and enjoyment. In arousal. In contrast, in women these measures (ii) the nonlinear relationship between sexual this cycle, sexual stimuli can be processed at a tend to show little overlap [24,25]. desire and sexual arousal, implying the pre-attentive level, and arousal can be Psychophysiological data of objective possibility of sexual arousal preceding desire; experienced before desire. increases in vaginal blood flow (in the and (iii) the possible inhibitory effect of

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mental preoccupation and non-sexual normal low range, or increasing them to the man to admit that his lack of sexual desire is thoughts on both desire and arousal. high normal range in eugonadal men, has no associated with his dissatisfaction with the appreciable effect on sexual function. This relationship, or with resentment towards his leads to the conclusion that androgens are partner; masculine myths in many cultures TESTOSTERONE AND PROLACTIN only beneficial in men whose endogenous hold that men are always ready to engage in levels are abnormally low. However, O’Carroll sexual activity, even in unfavourable It is not clear whether the neural circuits and Bancroft [32] indicated that, with conditions, or imply that a lack of desire for involved in sexual desire operate in parallel or increasing levels of endogenous androgen sex with his partner reflects the man’s waning in series to orchestrate the normally supply, it becomes more difficult to love for her. Subtle cases of relationship integrated pattern of sexual behaviour, i.e. manipulate circulating levels with exogenous discord require meticulous history-taking, appetitive responses that enable a male to hormones. The homeostatic mechanisms are sometimes including the scheduling of visits gain close proximity with a female in heat so powerful, and the more testosterone is to a physician without the partner being that the reflexive and stereotyped pattern of administered, the more the endogenous present. Anger may be an important copulatory responses can occur. Importantly, supply is suppressed or the metabolic mechanism through which sexual desire and extensive studies have shown that clearance rate is increased [34]. Benkert et al. arousal are inhibited [40]. For women, both testosterone is necessary for the full range of [35] delivered testosterone undecanoate daily anger and anxiety significantly reduce desire, sexual responses [28,29]. The physiological to treat ED in eugonadal men, but achieved no with anger showing the more marked effect. range of testosterone concentrations increase in circulating hormone levels. Their For men, similar results have been noted, (3–12 ng/mL) is considerably higher than failure to produce any behavioural effect on although with fewer differences reported necessary for normal sexual function. Critical erectile function therefore may not be a result between the anxiety and anger conditions. testosterone levels for sexual function in of ineffective androgens, but of a failure to Significantly more women than men indicate males are ª 3 ng/mL, but with large inter- alter hormone levels. that they would terminate a sexual activity subject variation [30], whereas levels at which during anger [41]. androgen-related sexual behaviour in men Indeed, a significant relation between declines appear to be reproducible [31]. In physiological androgen levels and male sexual HSDD is the most frequent form of sexual patients with induced or spontaneous behaviour has been observed in several disorder experienced by psychiatric hypogonadism, either pathological studies. In a Swedish epidemiological outpatients. Underlying causes are withdrawal and re-introduction of exogenous investigation of 500 men aged 51 years, low multifactorial in most cases. The patients androgens affects the frequency of sexual levels of free testosterone were associated most frequently affected are schizophrenics fantasies, sexual arousal and desire, with low sexual interest [36]. In young soldiers on neuroleptic medication, whereas spontaneous erections during sleep and in the aged 18–22 years, serum concentrations of schizophrenic patients on no medication have morning, ejaculation, sexual activities with 5a-dihydrotestosterone were a significant fewer dysfunctions [45]. Major depression is and without a partner, and orgasms through determinant of orgasmic frequency [37]. In associated with decreased sexual interest in coitus or masturbation. young healthy volunteers, Knussmann et al. >40% of men [42,43] although Bancroft et al. [38] showed positive correlations of salivary [44] found that the depressive effect was There is only limited evidence on the effects of and total serum testosterone levels with the associated with an increase in sexual desire in testosterone administration to eugonadal frequency of orgasms. Most intra-individual 9% of a group of heterosexual men. It remains men with or without sexual problems, but in a correlation coefficients were also positive, unclear how these differential effects are controlled study of eugonadal men with but some were negative or insignificant, mediated. Sexual dysfunction commonly diminished sexual desire, O’Carroll and indicating the great intra- and inter- occurs during antidepressant treatment. Bancroft [32] showed that injections of individual variability of behavioural responses Although depressed patients care about their testosterone esters produced a significant to hormones, which might explain sexual function, they may be reluctant, for increase in sexual interest compared to contradictory results from other studies on fear of embarrassment, to report HSDD placebo injections. However, in most of the testosterone levels and frequency of orgasm. spontaneously to their physicians. HSDD is men studied, the increase in sexual interest probably under-reported and may result in was not translated into an improvement of Hyperprolactinaemia may be a cause of covert non-compliance and relapse into their sexual relationship, perhaps because hypogonadism and therefore lead to HSDD. depression. Physicians thus need to assess psychological problems with their partner had Moreover, the neuroleptic activity of prolactin sexual function during the initial evaluation not been resolved with hormonal treatment itself may lead to depression and anxiety in and throughout treatment. The importance of only. When supra-physiological doses of conjunction with HSDD [39]. sexual function to sexually active patients testosterone were administered to healthy with major depression should be considered volunteers as a potential hormonal male carefully when planning antidepressant contraceptive, this resulted in a significant PSYCHIATRIC CONDITIONS therapy. Viable options exist to prevent or increase in psychosexual stimulation or treat HSDD, including use of relatively new arousal, but there were no changes in sexual Relationship difficulties are often antidepressants and appropriate adjunctive activity or spontaneous erections [33]. As encountered as concomitant to HSDD. The regimens [46]. healthy males produce much more androgen cause-effect relationship is sometimes hard than necessary to maintain sexual function, to disentangle, especially if the problem has a Improvement in sexual functioning related to lowering serum testosterone levels to the long history. It might often be difficult for a antidepressant effects may be more common

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than drug-associated deterioration in sexual is also associated with hypersexual desire, psychological factors in the generation and function. Among patients who report specifically in manic episodes, and lithium modulation of sexual functioning aspects of worsening, the effects may be most treatment has been found to reverse the desire and arousal. pronounced on orgasm. Deterioration in sexual symptoms of this condition. sexual function does not appear to be a late- HSDD is more common in men than in onset, drug-specific event, but is strongly Although hyposexuality is a common problem women. In public opinion and in medical related to worsening depressive symptoms in stroke patients, some may present with practice, HSDD is often misinterpreted as ED, [47]. Moreover, the reported rates of sexual hypersexuality [59]. Patients with isolated and treated as such. There is a need for dysfunction vary with the antidepressant symmetric damage to the amygdala and physicians and patients to be educated, and used and are typically under-reported in their cortical connections show marked for the development of reliable clinical tools product literature. Tricyclic antidepressants, behavioural changes, including visual agnosia, to assess this aspect of male sexual function. selective serotonin reuptake inhibitors and hypersexuality, hyper-orality, a tendency to venlafaxine XR are associated with higher react to every visual stimulus, and memory rates of sexual dysfunction than bupropion deficits. The cluster of neurobehavioural CONFLICT OF INTEREST or nefazodone [48,49]. As physicians symptoms is similar to previously reported considerably underestimate antidepressant- accounts of Kluver–Bucy syndrome, and None declared. associated sexual dysfunction, greater suggests the importance of bilateral recognition and education are imperative amygdala involvement in these changes [60]. when prescribing antidepressants [50]. REFERENCES Lack of sexual desire is reported significantly more often by both bodybuilders and men 1 Rosen RC. Prevalence and risk factors of MEDICAL CONDITIONS with eating disorders than by controls [56]. sexual dysfunction in men and women. Bodybuilders show a pattern of eating and Curr Psychiatry Report 2000; 2: 189–95 Although not a medical condition, ageing is exercising as obsessive as that of subjects 2 Simons JS, Carey MP. Prevalence of the most significant risk factor for HSDD. 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