TRADITIONAL MARKERS OF SEXUAL DESIRE
Evidence from nationally representative community samples of midlife women confirms that spontaneous sexual thinking is rather infrequent in the majority of sexually healthy women in long-term relationships (38,46,47).
Fantasies, which are a marker of sexual desire in DSM-IV-TR may, in fact, serve as a deliberate means of creating arousal and reinforcing desire. Data confirm the clinical experience that women fantasize to deliberately focus on their sexual feelings and avoid the distractions that are interfering with their sexual response (47).
Awareness of sexual desire is not the most frequent reason women accept or initiate sexual activity (1 – 6).
ASSESSMENT OF LOW DESIRE/INTEREST AND THE ASSOCIATED LOW AROUSABILITY TO IDENTIFY THERAPEUTIC OPTIONS
The DSM-IV-TR definition of hypoactive sexual desire disorder is problematic because its only focus is on initial desire, does not acknowledge the many reasons that motivate the woman towards sexual activity, and ignores the broad range of frequency of fantasies among sexually healthy women. An inter- national group has recently proposed the following definition for women’s sexual interest/desire disorder
There are absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies and a lack of responsive desire. Motivations (here defined as reasons/incentives), for attempting to become sexually aroused are scarce or absent. The lack of interest is considered to be beyond a normative lessening with lifecycle and relationship duration (48).
Note that it is the additional lack of responsive desire that indicates dysfunction. The word “interest” was preferred (to “desire”) given the aforementioned relative infrequency of desire being the reason/incentive for engaging in sexual activity. However, for practical purposes of literature review, both words were included in the definition.
There is no clear division between assessment and management of desire/ interest concerns. The assessment often makes it clear why motivation is lacking, what is amiss with the context, what may be negatively influencing her arousability, and what is unsatisfactory about the outcome. The assessment is biopsychosocial as well as sexual and is aimed at identifying predisposing, precipitating, and maintaining etiological factors. Given the women’s sexuality is so contextual and given the known importance of partner factors including emotional intimacy (39,46), and sexual well being of the partner (37,39,49,50), there is need to interview both partners. Ideally, the couple is seen together as well as separately.
The current and past context—biological, psychosocial, as well as sexual— is clarified along with contextual details at the time of onset of the difficulties. The full picture of the woman’s sexual response and her partner’s response is obtained and importantly the degree of resulting distress is clarified. Predisposing factors are essentially intrapersonal—psychological factors that impair her arou- sability such as a fear of being vulnerable, guilt or shame regarding sex, past negative sexual experiences, distractions while trying to be sexually responsive, and excessive need for control. Recent careful assessment of consecutive women with low desire found significant disturbance in emotional stability and self- esteem (17). These researchers emphasized how low desire cannot be thought of as a discrete phase disorder. Rather, the evidence is that there is a generalized muting of the sexual response, together with mood instability and fragile self-regulation. Of biological factors reducing arousability, fatigue is perhaps the most common. Although, typically, there may be no definite mood disorder at the onset, women with low desire have a higher lifetime prevalence of depression (17,51,52) and clinical anxiety states (52). Recent studies suggest 50% of women with depression, experience low desire and arousal, even taking into account the potential lowering of desire from antidepressant medication (45). Debility from chronic disease such as renal failure, medications including most antidepressants, chronic pain, and less commonly, hyperpro- lactinemia and hypothyroid states are further inhibitors of arousability. The importance of the role of low androgen activity in reducing arousability in some young women with sudden loss of ovarian androgen and in women with pituitary disease where testosterone levels are suddenly reduced, appears secure. However, minimal scientific study exists on the role of low androgen simply in relation to age and natural menopause and will be addressed in detail later.
A hypothesis that women, and men, have a variable proneness to sexual excitement as well as a variable inhibition, is currently being scrutinized (53). This variability may or may not be genetically programmed. Early results suggest that women are more prone to inhibition than men, and this inhibition is more to do with negative consequences of activity, than fear of performance failure. Theoretically, women with higher inhibition proneness are more vulner- able to low desire/interest, whereas high-risk sexual behaviors may be a reflec- tion of low proneness to inhibition.
Lack of appropriate sexual context and sexual stimulation is a frequent pre- cipitating and maintaining cause of low interest/desire. Common examples include too little nongenital caressing and lack of privacy or safety. Interpersonal issues can be both precipitating and maintaining, particularly when there is minimal emotional intimacy with the partner. Expectation of a negative outcome, for example, from dyspareunia or partner dysfunction is a further potent precipitating and/or maintaining factor. Clearly, a number of factors usually contribute. Occasionally, women with an emotionally traumatic past tell of sexual interest only when there is minimal emotional closeness with the partner in question. In other words, there is inability to sustain that interest/ desire when emotional intimacy with the partner develops. This is, therefore, a fear of intimacy—not strictly a sexual dysfunction.