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Hypoactive sexual desire disorder HSDD and sexual aversion disorder SAD are an under-diagnosed group of disorders that affect men and women. Despite their prevalence, these two disorders are often not addressed by healthcare providers and patients due their private and awkward nature. Using the Sexual Response Cycle as the model of the physiological changes of humans during sexual stimulation and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition this article will review the current literature on the desire disorders focusing on prevalence, etiology, and treatment.
Despite their prevalence, these disorders are often not addressed by healthcare providers or patients due to their private and awkward nature. Using the Sexual Response Cycle as the model of the physiological changes of humans during sexual stimulation and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition DSMIV-TRthis article will review the current literature on the two desire disorders, focusing on prevalence, etiology, and treatment.
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Sexuality is a complex interplay of multiple facets, including anatomical, physiological, psychological, developmental, cultural, and relational factors. Sexuality in adults consists of seven components:. Gender identity, orientation, and intention form sexual identity, whereas desire, arousal, and orgasm are components of sexual function. The interplay of the first six components contributes to the emotional satisfaction of the experience.
In addition to the multiple factors involved in sexuality, there is the added complexity of the corresponding sexuality of the partner. The sexual response cycle consists of four phases: desire, arousal, orgasm, and resolution. Phase 1 of the sexual response cycle, desire, consists of three components: sexual drive, sexual motivation, and sexual wish.
These reflect the biological, psychological, and social aspects of desire, respectively.
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Sexual drive is produced through psychoneuroendocrine mechanisms. The limbic system and the preoptic area of the anterior-medial hypothalamus are believed to play a role in sexual drive. Drive is also highly influenced by hormones, medications e.
Multiple physiologic changes occur in men and women that prepare them for orgasm, mainly perpetuated by vasocongestion. In men, increased blood flow causes erection, penile color changes, and testicular elevation. Vasocongestion in women le to vaginal lubrication, clitoral tumescence, and labial color changes. In general, heart rate, blood pressure, and respiratory rate as well as myotonia of many muscle groups increase during this phase.
Phase 3, orgasm, has continued elevation of respiratory rate, heart rate, and blood pressure and the voluntary and involuntary contraction of many muscle groups. In men, ejaculation is perpetuated by the contraction of the urethra, vas, seminal vesicles, and prostate.
In women, the uterus and lower third of the vagina contract involuntarily. The duration of the final phase, resolution, is highly dependent on whether orgasm was achieved.
If orgasm is not achieved, irritability and discomfort can result, potentially lasting for several hours. If orgasm is achieved, resolution may last 10 to 15 minutes with a sense of calm and relaxation. Respiratory rate, heart rate, and blood pressure return to baseline and vasocongestion diminishes. Women can have multiple successive orgasms secondary to a lack of a refractory period.
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As ly stated, there are two sexual desire disorders. These are substance-induced sexual dysfunction and a sexual disorder due to general medical condition. The prevalence of desire disorders is often underappreciated. The National Health and Social Life Survey found that 32 percent of women and 15 percent of men lacked sexual interest for several months within the last year.
The study population was noninstitutionalized US English speaking men and women between the ages of 18 and 59 years. The desire disorders can be considered on a continuum of severity with HSDD being the less severe of the two disorders.
The proposed etiology of HSDD influences how it is subtyped i. For example, lifelong HSDD can be due to sexual identity issues gender identity, orientation, or paraphilia or stagnation in sexual growth overly conservative background, developmental abnormalities, or abuse.
Conversely, difficulty in a new sexual relationship may lead to an acquired or situational subtype of HSDD. Although it is theoretically possible to have no etiology, all appropriate avenues should be explored, including whether the patient was truthful in responses to questions regarding sexuality and if the patient is consciously aware that he or she has a sexual disorder. Diagnosis and treatment of desire disorders is often difficult due to confounding factors, such as high rates of comorbid disorders and combined subtype sexual disorders involving medical and substance-induced contributors.
Even with a detailed and accurate longitudinal history, honing in on the main factor can be difficult.
Decreased sexual desire has been seen in multiple psychiatric disorders. For example, individuals with schizophrenia and major depression experienced decreased sexual desire. Before treatment commences for HSDD and SAD, a thorough work-up must be done to first rule out a general medical condition or a substance that caused decreased desire or aversion. This would include a thorough physical exam and laboratory work-up.
An important physiological maker for which to test is a thyroid profile, which would be abnormal in hypothyroidism and could cause decreased sexual desire. A variety of medical conditions can also decrease sexual desire e. Also, as we naturally age, desire can lessen. Decreases the neural monoamine oxidase enzymatic metabolic breakdown of norepinephrine and serotonin I.
Two important biological mediators of sexual desire are dopamine and prolactin.
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Dopamine acting through the mesolimbic dopaminergic reward pathway is hypothesized to increase desire, whereas prolactin is thought to decrease libido, although the mechanisms are poorly understood. Dopamine directly inhibits prolactin release from the pituitary gland. Medications that increase prolactin release or inhibit dopamine release can decrease sexual desire along with other sexual side effects. If a patient has no history of sexual desire problems and has started a new sexual relationship, other possibilities for low sexual desire must be excluded.
Separate interviews with each partner are important to obtain a more accurate picture of the relationship. Important to remember that HSDD in men is often misdiagnosed as erectile dysfunction because of the common misconception that all men desire sex. This myth has caused men to not seek treatment and has also led to misdiagnosis by health professionals.
This may partly explain the failure rate of adequately treating erectile dysfunction. As part of an initial history and physical examination, a sexual history is necessary because most patients will not divulge any sexual problems unless explicitly asked. There are tests that deal entirely with sexual desire Sexual Desire Inventory and others have subscales for sexual desire International Index of Erectile Function. Although there are many proposed treatments for desire disorders, there are virtually no controlled studies evaluating them.
From a psychodynamic perspective, sexual dysfunction is caused by unresolved unconscious conflicts of early development.
While improvement may occur, the sexual dysfunction often becomes autonomous and persists, requiring additional techniques to be employed. An approach that has shown some success in the treatment of desire disorders as well as other sexual dysfunctions, pioneered by Masters and Johnson, is dual sex therapy.
The relationship is treated as a whole, with sexual dysfunction being one aspect of the relationship. Another important underlying premise of this form of therapy is that only one partner in the relationship is suffering from sexual dysfunction and absence of other major psychopathology. The aim is to reestablish open communication in the relationship.
Homework asments are given to the couple, the of which are discussed at the following session.
The couple is not allowed to engage in any sexual behavior together other than what is ased by the therapists. Asments start with foreplay, which encourages the couple to pay closer attention to the entire process of the sexual response cycle as well as the emotions involved and not solely on achieving orgasm.
Eventually the couple progresses to intercourse with encouragement to try various positions without completing the act. Cognitive behavioral therapy has been shown to be efficacious in the treatment of anxiety, depression, and other psychiatric disorders. Its core premise is that activating events lead to negative automatic thoughts. These negative thoughts in turn result in disturbed negative feelings and dysfunctional behaviors. The goal is to reframe these irrational beliefs through structured sessions.
These sessions often include both partners. For example, men with sexual desire disorder or male erectile disorder may be instructed to masturbate to address performance anxiety related to achieving a full erection and ejaculation. Finally, analytically oriented sex therapy combines sex therapy with psychodynamic and psychoanalytic therapy and has shown good .
SAD is often progressive and rarely reverses spontaneously.