MANAGEMENT OF LOW DESIRE/INTEREST: PSYCHOLOGICAL, PHARMACOLOGICAL, AND BIOPSYCHOSOCIAL APPROACH
Psychological therapy is the mainstay of the management of low sexual desire/ interest. Given the mandatory blending of mind and body, making deliberate changes in thoughts, attitudes behavior, leads not only to changed feelings and emotions but altered sexual physiology. Under the term “sex therapy” typically the woman’s negative thoughts and attitudes to sex, her distractions during sexual stimulation, the need for more varied, more prolonged, or simply different sexual stimuli, the need for the couple to guide each other; and the usual needs of safety, privacy, and optimal timing of sexual interaction will be addressed. Sensate focus techniques whereby there is a graded transition from touching and caressing that is not specifically sexual to that which is sensual to that which is frankly sexual, may sometimes be included. The approach is one of systematic desensitization common to other behavioral therapies. Cognitive
behavioral therapy (CBT) focuses on the restructuring of myths or distorted think- ing about sex. Couple therapy may be necessary focusing on interpersonal issues including trust, respect, as well as ways to relate to each other, which foster sexual attraction. Psychodynamic therapy is often recommended to address issues in the woman’s past developmental period. Particular attention to family of origin and relationships to parental figures is often needed. A further component is that of systemic therapy/sexual differentiation, that is, the ability to balance desire for contact with the partner vs. desire for uniqueness as an individual. Schnarch (79) suggests that this is extremely important for healthy sexual desire.
In directing the types of interventions, construction of the woman’s sex response cycle will clarify the breaks or the sites of weakness (80). When emotional intimacy with the partner is minimal such that motivation and arousability are negatively affected, the couple is advised to receive relationship counseling before or possibly instead of any sex therapy. When problems are due to lack of effective stimuli, contexts, negative thoughts, and attitudes about sex, or nonsexual distractions are present, a combination of CBT and sex therapy is usually given. Similarly, explanation, CBT, and sex therapy can be given when the main issue seems to be expectation of an inevitably negative outcome.
Recent outcome studies include one in 2001 of 74 couples randomized to 12 weeks of CBT or an untreated control group (81). Of the women recei- ving CBT who met the criteria of hypoactive sexual desire pretreatment, 26% continued to do so at the end of treatment and 36% met the criteria 1 year later. The CBT group experienced significant improvements in sexual satisfaction, perception of sexual arousal, dyadic adjustment, improved self- repertoire, sexual pleasure, and perceived self-esteem, as well as general increase in motivation, mood, and lessening of anxiety. In a noncontrolled study of the same year (82), CBT was assessed in 54 women having a broad spectrum of sexual dysfunction. Fifty-four percent of the women still had the same sexual complaints after treatment, although the overall levels of sexual dysfunction were reduced and there were more positive attitudes towards sex and increased sexual enjoyment and less perception of being a sexual failure. A study of 39 women with low desire in 1993 (83) randomized one group of women to receive standard interventions of sex therapy vs. a group also receiving specific orgasm consistency training. Although both groups improved, benefit was greater in those in the combined group, particularly regarding arousal. A larger study in 1997 of CBT in 365 couples with a range of sexual dysfunction, showed 70% of women improved at 1-year after treatment (84).
Studies have identified factors associated with better prognosis. Those factors include the overall quality of a couple’s nonsexual relationship (85), the couple’s motivation to enter treatment (86,87), the degree of physical attrac- tion between the partners (85), an absence of major psychiatric disorder (88), attention to systemic issues in the relationship (89), the male partner’s motivation to obtain a successful outcome to therapy (90), and the amount of sensate focus experiences the couple complete in their last week of therapy (84).
However, benefit from psychological treatment is to some degree unclear because the outcome measures used reflect male sexual desire but show a broad normative range across sexually healthy women. In addition, subjective arousal and excitement is rarely addressed despite the data confirming its major importance relative to genital congestion, and its close blending with desire.
Nonhormonal Pharmacological Treatment of Low Desire/Interest The place of pharmacological management for women’s complaints of low desire/interest is undecided. This is because of broad normative range of women’s appreciation of sexual desire, especially in the long-term relationship; and because of the importance of women’s subjective arousal in influencing and triggering their desire and the minimal focus until now on the whole entity of sub- jective arousal. Thus, the appropriate outcome criteria for a “desire drug” are unclear. Studies with bupropion hydrochloride have suggested benefit over placebo. Of 30 women with active drug, 19 improved during a 12-week double blind placebo-controlled study for nondepressed women having a spectrum of sexual complaints, including low desire/interest (91). A more recent study, again of nondepressed women, this time diagnosed with hypoactive sexual desire, were treated in a single blinded manner and 29% responded to the active drug and none had responded to the initial 4-week placebo phase (14). The entity of sexual interest as well as sexual desire was monitored and shown to improve. Despite these two studies, the clinical experience is of limited benefit from this intervention. Larger placebo-controlled randomized studies of bupropion or other molecules that alter the neurotransmitters known to influence desire and arousability, including dopamine, serotonin, and noradrenaline, are needed.