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 © 2005 BJU INTERNATIONAL | 95, 291–296 | doi:10.1111/j.1464-410X.2005.05285.x 291 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