Subtypes of HSDD
Clinicians are directed to subtype the diagnosis of HSDD, that is, to say if the pattern has been (A) “lifelong” or “acquired” (i.e., always existed since puberty or followed a period of “normal” sexual desire), (B) “situational” or “generalized” (i.e., has existed only in some sexual circumstances or all) and (C) due to psychological or combined factors. Maurice (12; pp. 54 – 55) considers diagnostic subtyping to be clinically useful in helping to point towards the etiol- ogy and thus assessment and treatment—for example, acquired problems would require a more diligent search for the explanation of change than those which are lifelong. Likewise, if a man has a situational difficulty, for example, not sexually active with his partner but masturbating several times each week, there is little rationale for considering some biological explanation since his SRC is obviously intact.
Maurice has described four HSDD syndromes: (i) desire discrepancy, (ii) lifelong and generalized, (iii) acquired and generalized, and (iv) acquired and situational (12; pp. 161 – 165). On the basis of clinical impression, the most common desire difficulties in men are those that are (A) lifelong but also situational (very unusual in women) and (B) acquired and generalized— usually resulting from a medical, psychiatric, or other sexual, disorder (Fig. 4.1).
Although clinically useful, these syndromes have not been the subject of empirical research. Nevertheless, one can sometimes extract information from survey data that seem to apply to this scheme. For example, Kinsey et al. described a small group of men (147 from approximately 12,000 interviewed) who they referred to as “low rating” [defined as under 36 years old and whose
rates (of sexual behavior) averaged one event in 2 weeks or less] (13; p. 207). They also described another group of men about half as large in number as “sexually apathetic” in that “they never, at any times in their histories, have given evidence that they were capable of anything except low rates of activity” (p. 209). One could conclude from Kinsey’s observations that not only did these men have a lifelong and generalized disinterest in sexual matters, but also they were quite unusual.
Lifelong and Situational
“The most striking feature that differentiates a situational desire disorder from one that is generalized is the continued presence of sexual desire in some form. The sexual feelings that do exist in the present occur typically when the person is alone and are manifest either in thought and/or action (through mastur- bation), rather than in sexual activity with the patient’s usual partner … the present level of sexual activity (with the partner) often represents a … change from the beginning of the relationship when the frequency was … greater.” (12; p. 165) Detailed history-taking reveals that even at the start of the relation- ship, the woman often took the sexual initiative and even then, sexual experiences took place infrequently.
In this syndrome, the man’s desire disorder represents a lifelong pattern but is also situational, because there are times when he can be quite sexual, typically when alone through masturbation, or at the beginning of a new relationship with a partner.
Alex is 35 years old and Sharon is 33 (not their real names). They have been married for 7 years and have no children. Neither have had any major health dif- ficulties, smoke, or use street drugs. She asked her family doctor to refer both of them because of his disinterest in “sex.” Three injections of testosterone did not result in any sexual change. Alex was initially reluctant to talk with someone else about this issue but eventually acceded to Sharon’s strongly worded request (and that of the consultant) that they been seen together.
When a consultation took place and when they were asked for details of their sexual difficulties, she said that the last time that any sexual activity occurred was 1 week ago but before that was 3 months, and before that was 5 months.
In talking with them of the history of their premarital sexual relationship, it became apparent that she particularly appreciated the fact that she did not have to fend-off his sexual advances as she had to do with other men, and more often than not, she would take the initiative sexually. The difference in sexual interest became more apparent immediately after their marriage. To her great distress, no sexual activity occurred on their honeymoon and since then, had been only a few times each year.
When she was seen alone, she related that in the first few years of their mar- riage, she would make her sexual interest known to him but stopped doing so because of constant rejection. She described regularly comparing herself to women friends who would complain about the opposite, namely that they were not particularly interested themselves and frequently had to resort to subterfuge to control the sexual insistence of their husbands. She initially blamed herself for this state of affairs and wondered whether he found her attractive anymore and if he, in fact, still loved her. She also considered the idea that maybe he was inter- ested in another woman, or that he was gay and interested in a man. She even- tually satisfied herself that those worries were baseless and concluded that it was he that had some sexual difficulty. She thought that his trouble related to his strong attachment to his mother.
While finding that sexual offers from other men bolstered her opinion of herself, these were consistently declined because “that wasn’t what I wanted.” She wondered if she should divorce Alex and find someone else but was also con- cerned about giving up the life that the two of them had built together.
When he was seen alone, he explained that the same thing happened on the two occasions when he lived together with women before he married, that is, that his sexual desire for them quickly disappeared. With considerable hesitation he revealed that nowadays, he would masturbate several times each week while looking at pictures of nude women on the internet. He knew that his wife would be angry and might even leave him if she discovered his private sexual interests. Given the fact that the testosterone injections did not prove helpful, he accepted the notion that psychologically oriented care might be fruitful. He started to wonder if his sexual difficulties related to his family-of-origin and growing-up years.
Acquired and Generalized
The major differences between the acquired and generalized form of a sexual desire disorder, and the lifelong and situational form, are twofold: (a) the present status represents a considerable change from the past when the patient’s sexual desire was not problematic for either him or his partner and (b) sexual desire is presently absent in any form.
Bob is a 55-year-old man who had been married for 27 years to Marie (not their real names). He works as a sales manager. They have two children, the youngest of whom moved out 1 year ago. She has had no major health problems. He has had diabetes for 5 years and the main treatment was diet, exercise (because he was greatly overweight), and an oral medication.
He described erection problems and waning sexual desire over the previous 2 years. He could not say which developed first. He reported thinking little about sexual matters in the present and only occasionally trying to engage in sexual activity with his wife—usually on her initiative. He also reported no inclination to masturbate and added that since he married, he “didn’t need to”, given that sexual activity with his wife was sufficient for his sexual needs. In the present,
he said that pictures of women undressed did not “do anything” for him. His erections with his wife were 5/10 (on a scale of 0 – 10 where 0 meant no erection whatsoever, and 10 was full and stiff. He was not aware of morning erec- tions although would sometimes wake up with some swelling of his penis (about
2– 3/10). The last time he recalled a full erection under any circumstance was about 4 years prior. He did not report ejaculation difficulties now or in the past but did say that the intensity of his orgasm had lessened.
Bob was all the more distressed because his current sexual status was markedly different than in the past. Until recent years, he would have sexual thoughts regularly, took the initiative in inviting his wife to bed (several times each week), enjoyed looking at women’s bodies especially in the summertime when they were less covered, and had no erection problems prior to about 4 years ago.
He wondered if the sexual changes were a result of his age. He had read an article in a newspaper about “andropause” and thought that this might be the explanation of his difficulties. He asked his family doctor about oral medi- cations for “ED” (he had seen advertisements on television), and testosterone, and received both. Neither oral medications nor three injections of testo- sterone resulted in any sexual change. When he was seen in consultation by a “sex specialist” who asked about his knowledge of the connection between diabetes and sexual difficulties, he recalled hearing something in a diabetic clinic he had attended but confessed that his knowledge was only fragmentary.
Unfortunately, most of the empirical research on HSDD in men has either not subtyped the syndrome, or the report is unclear and results are embedded in a difficult-to-interpret melange of information. For example, one study separa- ted three groups of college-age men: those with “Inhibited Sexual Desire” (ISD—a term that was used in earlier versions of the DSM for HSDD), erectile dysfunction, and controls (14). Not surprisingly, the men with ISD fantasized less about sexual matters than the other two groups. However, the ISD group masturbated more than the other two. Evidently, there were many men with a situational desire disorder in the ISD group. To illustrate the lack of clarity about what constituted a diagnosis of ISD as well as the absence of subtyping, two men who described no fantasy at intake were excluded from the study!