Hypoactive Sexual Desire Disorder(HSDD) in Men

1. Hypoactive Sexual Desire Disorder
(HSDD) in Men

2. Definition
Low Sexual Desire/Interest (LSD/I)
• “Diminished or absent
– feelings of sexual interest or desire,
– absent sexual thoughts or fantasies and
– lack of a responsive desire.
• Motivations (defined as reasons/incentives) for
attempting to become sexually aroused are
scarce or absent.”

3. Desire
“The motivation or inclination to be sexual”
• Drive –The biological component (anatomy,
neuroendocrine)
• Motivation – The psychological component
mental states
interpersonal states and
social context
• Wish – The cultural component

4. Libido = Directed to own ego and
indicate mental states(Freud)
• Relationship dimensions, psychological
adaptation, cognitive factors and
biological determinants have all been
related to sexual desire
• HSDD limited to a single partner is not
SD but a relationship problem

5. • Persistently or recurrently deficient/absent
sexual/erotic thoughts or fantasies and desires for
sexual activity
• The judgment of deficiency is made by the
clinician, taking into account age and general and
socio cultural contexts of the individual’s life
• The symptoms persisted for a minimum
duration of 6 months
Definition of HSDD – DSM V

6. Definition – DSM V cont..
• The symptoms cause clinically significant distress
in the individual
• The sexual dysfunction is not better explained by
 a non sexual mental disorder or
as a consequence of severe relationship distress
or other significant stressor and
 is not attributable to the effects of
substance/medication or another medical
condition.

7. • Specify whether:
• Lifelong or Acquired
• Specify whether:
• Generalized or Situational
• Specify current severity according to
distress:
• Mild
• Moderate
• Severe
Definition – DSM V cont..

8. Epidemiology of HSDD in men
• Surveys conducted in the US and UK:
- Prevalence in men aged 16 to 59 years
14% to 17%
- Greater in older men
- In all literature: 3-50%
• Demographic survey in the US (1455 men aged 57 to 85 years)
-28% of men reported a lack of desire for sex
-65% of affected men being bothered
• 18,000 British men and women
-1% of the population deny ever having experienced sexual
attraction to anyone
-Suggested that ASEXUALITY
Laumann EO, Paik A, Rosen RC. JAMA 1999;281(6):537-544
Mercer CH, Fenton KA, Johnson AM, et al. BMJ 2003;327(7412):426-427
Lindau ST, Schumm LP, Laumann EO, et al. N Engl J Med 2007;357(8):762-774
Johnson MT (1977), in The Sexually Oppressed. Associated Press, New York

9. Epidemiology
• Individuals at middle and old age; natural decline
in
sexual desire
sexual capacity and
frequency of sexual behavior
• Level of sexual interest appears quite stable from
the late teens and up to about the age of 60
• Disorders such as depression or erectile
dysfunction (ED) frequently coexist

10. • Sex has the strongest reward potential
• Inhibition is stronger than excitation and sex can
become boring
• Psychotherapy and pharmacotherapy may alter
brain structure and function

11. Physiology of desire
• Sexual desire is the result of a positive interplay
between
Internal cognitive processes
Neurophysiological mechanisms
Affective components
• Dopamine (DA) is the principal neurotransmitter
mediating sexual arousal and desire
• Brain pathways for sexual excitation involve the
activation of hypothalamic and mesolimbic DA
transmission
These pathways control attention and incentive
motivation and link sexual stimuli to autonomic outflow

13. Physiology of desire
• Brain pathways for sexual inhibition involve the
activation of an inhibitory opioid and serotonergic
feedback to various levels of the excitatory pathway
• Serotonin (5-HT) is thought to be the principal
neurotransmitter mediating sexual arousal and desire
• Hormones, in particular testosterone, can modulate
this system
Hormone Effect on sexual desire
Testosterone ↑↑↑ only in hypogonadal subjects
Dyidrotestosterone ↑↔
Prolactin ↓↓↓ in presence of severe
hyperprolactinemia
Estrogens ↑↔
Cortisol ↓↑

14. Etiology of desire disorders
Organic
Psychiatric disease Depression
Anxiety disorder
psychosis
Endocrine disease Hyperprolactinemia
Hypogonadism
hypothyroidism
Systemic disease Chronic renal disease
Chronic hepatic
disease
Haematological
disease
HIV

15. Etiology cont…
Inrapsychic Work related
Conflicts within the couple
Extended family tension
relational Reduced partner’s libido
Reduced partner’s climax
Partner’s chronic disease
prolong relationship span(>6 years)
Cultural
contexual
Religious mores, belief
Comfort,privacy

16. Drugs/Substance associated with
low desire
Drugs Antidepressants with
serotonergic activity
•Selective serotonin reuptake inhibitor
•Tricylic antidepressants
•Monoamineoxidase inhibitors
Antipsychotics •Typical
•Atypical
Drugs interfering with
androgen action/
production
•Steroidal
• nonsteroidal antiandrogens
•Anabolic steroid, GnRH analogues
•5α-reductase inhibitors,
•Anti epileptics
Others Lithium, Clonodine, Resepines, opioids
Substance
abuse
Alcohol, Opioids,
Amphitemine cocaine

17. Main causes of HSDD in these days are
• Depression and its treatment
• Permanent overload and stress in the job
and/or private life.
• Long-term presence of erectile
dysfunction

18. Manifestation of Desire
• Masturbation
• Attempts to initiate sexual behavior with a partner
or receptivity to partner initiative
• Erotic fantasies
• Sexual attractions and responses to others
• Spontaneous genital sensations of arousal
accompanying erotic thoughts, identified as
“horniness” or “randiness” by men

19. Assessment
Clinical History
• Lifelong or Acquired?
– Predisposing, precipitating and maintaining factors?
• Global or situational?
– Partnered activity?
– Solo activity?
• Sexually functional?
– With sexual concerns?
– Without sexual concerns?
• Sexual “secret”?
– Variant arousal pattern?
– Conflicted sexual or gender identity?
– Past trauma?
• Medical and Iatrogenic factors

20. Assessment (cont)
Examination
• Look for physical signs of Endocrinopathy or chronic
illness
• Investigations
• Testosterone
• Prolactin
• TSH
Summary
• Lifelong or acquired?
• Generalized or situational?
• Primary problem or secondary to another problem?

21. Life long HSDD in men
• Lifelong low desire is less common but is likely
to be more challenging in its management
• Men usually present with a low desire for
intercourse and partnered sexual activity
• A variant arousal pattern, perhaps involving a
preference for autoeroticism, frequently
involving Internet porn, or paraphilia
• Conflicted sexual orientation or gender
identity
• Past sexual and/or relationship trauma

22. Acquired HSDD in men
• Acquired, situational, secondary low desire is
probably the commonest type in men
• Because of social and cultural mores regarding
desire in men, low desire is likely to be
• Concealed
• Unrecognised
• underdiagnosed

23. Partner impact
• Feelings of confusion, frustration and rejection may
lead to anger
• Low desire men frequently blame their partner for
the problem
• Loss of sexual intimacy is usually followed by a more
general loss of intimacy
• They may adopt a new, but unsatisfactory, narrative
for their lives that does not involve sex, which is
difficult to change

24. Relationship dynamics associated with
LSD/I
• Sexual interaction bogged down in ritual and
routine
• Issues of privacy
• Discovery of extramarital relationships
• Issues related to jealousy and/ or possessiveness
• Issues related to infertility and pregnancy
• Life-cycle changes and aging process

25. Treatment Algorithm
Low sexual desire/interest
Adequate medical & psychosexual evaluation+
first line lab inv (Testosterone, TSH & Prolactin)
Not confirmed confirmed
Investigate associated
sexual dysfunction
Investigate associated
factors

26. Investigate associated factors
Absent
HSDD
Consider
psychological/pharmacological
support
Present

27. Drugs
affecting
libido
Hypo
gonadism
Relational
factor
Interpsychic
factor
Substance
abuse
Situational
Change
drugs/dose
Hormone
therapy
Couple
therapy
Psychologic
al/pharmac
ological
support
Lifestyle
change/
psychological
support
reasurance
• present

28. Treatment principals: lifelong and acquired
A comprehensive, integrative bio-psycho-social
approach to male and couple
 Prior agreement of treatment goals – outcome,
changes
 Psychotherapy (brief or detailed) is appropriate in
all presentations
 Prescribing or changing medication alone – not
satisfactory

29. Treatment of acquired HSDD
Sexual function and satisfaction are different
things
(Successful PDE5i treatment for ED often not
continued)
Testosterone facilitates desire but is not always a
requirement for desire
 Desire ≠ Testosteron
 Encourage the recreational and hedonistic
aspect of sexuality stimulating the abandonment
to the erotic experience

30. Goal oriented Pleasure oriented

31. Treatment of acquired HSDD
LSD/I is one of the symptoms of depression and
antidepressants themselves can induce or aggravate
LSD/I
Clinician should carefully evaluate the opportunity to
change or adequately reduce current therapy
 Mirtazapine, bupropion and venlafaxine and
duloxetine have less impact on sexual dysfunction

32. Thank you