UBC Departments of Psychiatry and Obstetrics & Gynaecology, B.C. Centre for Sexual Medicine, Vancouver General Hospital, Vancouver, BC, Canada
The term “female hypoactive sexual desire disorder” clearly focuses on lack of sexual desire, as opposed to lack of interest or motivation (reasons/incentives), to be sexual. It encourages the belief that sexually healthy women agree to sex or initiate it mostly because they are aware of sexual desire—before any sexual stimulation begins. Indeed, this is in accordance with the traditional model of human sexual responding of Masters, Johnson, and Kaplan. In that model, after an unspecified time of awareness of desire, arousal occurs. As we will see, this conceptualization contradicts both clinical and empirical evidence—women in established relationships infrequently engage in sex for reasons of sexual desire (1 – 6). That sense of desire, or need, or “hunger” is nevertheless felt once subjectively aroused/excited. When that arousal is insuf- ficient or not enjoyed, motivation to be sexual typically fades. In other words, although not usually the prime reason for engaging in sex, enjoyable subjective arousal is necessary to maintain the original motivation. So, lack of subjective arousal is key to women’s complaints of disinterest in sex. However, their dis- tress is typically presented in terms of “absent desire,” as, again stemming from Masters and Johnson’s model, the focus of arousal complaints has been on genital congestion rather than the subjective experience. This is despite the fact that psychophysiological studies of women with chronic arousal complaints show genital congestion in response to erotic videos that is comparable to healthy controls (see Chapter 6). This imprecision presents a major dilemma to both clin- icians and the women requesting their help.
Any formulation of a hypoactive sexual desire/interest disorder must take
into account the normative range of women’s sexual desire across cultures (7), age, and life cycle stage (8). For instance, the postpartum period is normally sexu- ally subdued (9). Desire for sex typically lessens with relationship duration and increases with a new partner (6).
Women’s sexual enjoyment and desire for further sexual experiences were acknowledged early last century. Before that time, there had been variable denial or intolerance and endeavors to curb women’s sexuality. Unfortunately, sub- sequent to that acknowledgement, came the assumption that women’s sexual function mirrors men’s experiences. Two particular aspects are fundamentally different. First, the majority of sexually healthy women do not routinely sense sexual desire before sexual stimulation begins; and second, women’s sexual
arousal is not simply a matter of genital vasocongestion. These misconceptions have led to:
1. the perception that as many as 30 – 40% of women in nationally represen- tative community studies have abnormally low sexual desire (10 – 13);
2. current research to find a “desire” drug for women (14);
3. misunderstanding of women’s viewpoint of lack of arousal (incorrectly assuming for the majority that genital congestion is impaired) (15);
Thus, lack of subjective arousal has been subsumed under “lack of desire.” Women have great difficulty in distinguishing loss of desire/interest, from loss of arousal/ pleasure/intensity of orgasm. The comorbidity of desire, arousal, and orgasm disorders is clear (16 – 24). The only published randomized controlled trial using physiological (or at least close to physiological) testosterone supplementation did not result in any increased “desire” as in having sexual thoughts, over and beyond placebo, but did show increased pleasure and orgasm intensity and frequency. Subjective arousal was not reported, but, given the improvement in pleasure and orgasmic experiences, its improvement is implied (25).
The objectives of this chapter include:
. To identify reasons women willingly initiate/agree to sex—with a view to understanding why some do not.
. To review a model of sexual response that permits motivations
(reasons/incentives), for being sexual, over and beyond sexual desire.
. To clarify that it is the woman’s arousability (along with the usefulness of sexual stimuli and context) that determines whether she will access sexual desire. In other words, for women, the concept of “responsive desire” or “desire accessed during the sexual experience” may be as or more important than initial desire as measured by sexual thoughts and sexual fantasies.
. To critique the traditional markers of sexual desire as they apply to women—and the questionable relevance of their lack.
. To outline the assessment of low desire and the associated low arousa- bility, thereby identifying therapeutic options.
. To review what is known of the biological basis of women’s sexual desire and arousability, including the role of androgens.
. To review psychotherapy, pharmacotherapy, and the biopsychosexual approach to the management of women’s lack of sexual interest/desire.
. To make recommendations for clinical practice.
REASONS WOMEN INITIATE OR ACCEPT SEXUAL ACTIVITY WITH THEIR PARTNERS
Both the literature and clinical experience attest to the large number of reasons that sexually motivate women (1 – 6). Many of these are to do with enhancing
emotional intimacy with the partner (2,5,6). Further reasons include increasing the woman’s sense of well being, of attractiveness, womanliness—even to feel more normal (26). Simply wanting to share something of herself that is very precious, to sense her partner as sexually attractive (be it his/her strength and power, or ability to be tender/considerate—or both), are further reasons. Incen- tives that might superficially appear unhealthy are also common, for example, to placate a needy (and increasingly irritable) partner (26), or “do one’s duty.” When the experience proves rewarding for the woman such that part way through she herself starts to feel—that she, too, would not wish to stop—it becomes unclear whether the original reasons (to placate/do one’s duty) are truly unhealthy. The concept of “rewards” or “spin offs” from being sexual is currently being empirically researched.
MODEL OF SEXUAL RESPONSE SHOWING VARIOUS INCENTIVES AND MOTIVATIONS TO BE SEXUAL AND AROUSAL TRIGGERING AND ACCOMPANYING DESIRE
For one or more of the earlier mentioned reasons, a woman choosing to be recep- tive to sexual stimuli (or to provide them) can subsequently become sexually aroused. The degree of emotional intimacy with her partner that may have even been the major motivating force, is also a very important influence on her arousability to the sexual stimuli. Various other psychological and biological factors will influence this arousability such that the processing of the sexual information in her mind may or may not lead to subjective arousal (27 – 31). On those occasions she becomes subjectively aroused, providing the arousal remains enjoyable, and the stimulation continues sufficiently long, and she remains focused, then the arousal can become more intense and an urge or “sexual desire” for more of the sexual sensations and emotions is triggered. This accessed or “triggered” sexual desire and the subjective arousal continue together, each reinforcing the other (32,33). A positive outcome, emotionally and physically, increases the woman’s motivation to be sexual again in the future (32). (Fig. 3.1).
Sexual desire that appears to be innate or spontaneous and reflected by sexual thoughts/fantasies, awareness of wanting sexual sensations per se before any activity actually begins, may or may not augment or sometimes over- ride the previously described cycle (Fig. 3.2). Typically, women are more aware of this type of initial desire early on in their relationships (6). For some women, it continues for decades even with the same partner. But for the majority, it is infrequent (1,3 – 5).
Some would argue that there is no such thing as apparent innate or spontaneous desire (26). This presupposes that desire is always part of arousal, triggered by a stimulus with a sexual meaning. It is facilitated or inhibited by situational and partner variables, such that sexual motivation will occur only when appropriate sexual stimuli are present and the woman has a sufficiently
Figure 3.1 Sex response cycle showing many motivations to be sexual, and responsive/ triggered desire. A positive outcome emotionally and physically allows sexual satisfaction (goal set enroute) plus other rewards that motivated initially. Reprinted from Obstet Gynecol 2001; 98:350 – 353. Basson, with permission from the American College of Obstetricians and Gynecologists.
sensitive sexual response system. The assumption is that the occurrence of sexual motivation, including fantasies, must be the result of sexual information proces- sing of some kind even though in some, or even most cases, the initiating sexual stimulus may not be known. For most people, their sexual response system reacts
Figure 3.2 Blended sex response cycle: “spontaneous” desire augments or overshadows other motivations and increases arousability. Reprinted from Obstet Gynecol 2001; 98:350 – 353. Basson, with permission from the American College of Obstetricians and Gynecologists.
with the stimuli in an automatic effortless manner. Thus, sexual desire is some- times experienced “as if ” it were spontaneous (27).