Hypoactive sexual desire disorder in men: Biopsychosocial approaches

What follows is a short research paper I wrote for my sexuality and psychotherapy class - I thought I'd post it here because so many men have internalized the belief that men are always ready, willing and able to have sex - and want sex more than anything else.

The reality is that men and women are not that far apart in their levels of desire, especially if we strip away the cultural beliefs and training around this topic.
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Hypoactive sexual desire disorder in men: Biopsychosocial approaches

The cultural myth is that men think about sex every seven seconds (Ahuja, 2006). Furthermore, men are always ready, willing, and able to have sex (Brizendine, 2006, p. 91; Meuleman & Van Lankveld, 2004, p. 293; Pleck, Sonenstein & Ku, 1993, p. 21). The reality is that many men think about sex once a day or less:

According to the Kinsey Report (Sexual Behavior in the Human Male), 54 percent of men think about sex every day or several times a day, 43 percent a few times a week or a few times a month, and 4 percent less than once a month. (Dixit, 2007)

On the other hand, it is assumed and widely verified that sexual desire occurs less frequently in women and that arousal is much more complicated. One could argue the etiology of this fact, whether it is that women possess lower endogenous testosterone or that female children are socialized to be and feel less sexual, but that is another topic. What is true, however, is that women suffer from desire disorders more than men, most commonly hypoactive sexual desire disorder (HSDD) (Goldstein et al., 2006; Laumann, et al, 1994, p. 370 & 371). To be precise, the prevalence among men versus women is about 15% versus 35%, respectively (Levine, 2010, p. 40).

The Diagnostic and Statistics Manual of Mental Disorders, 4th edition, text-revision (DSM-IV-TR, American Psychiatric Association, 2000) defines hypoactive sexual desire disorder as, in summary, “Persistently or recurrently deficient (or absent) sexual fantasies and desires for sexual activity” that causes personal and relational stress, and that cannot be accounted for by Axis I disorders, substance use (including medications), or other medical conditions (p. 541). The disorder is further defined through lifelong versus acquired, generalized versus situational, and psychological versus combined factors (p. 541). There are many chemical factors that can lead to HSDD in men, most commonly anti-depressant medications (specifically, selective serotonin reuptake inhibitors and anti-hypertensive medications) as well as hormonal issues (hypogonadism or endocrine dysfunction as a result of environmental xenoestrogens) and psychological issues (anxiety, depression, and other Axis disorders) (Levine, 2010, p. 40). All of this makes a differential diagnosis more challenging.

Once ruling out medications, mood disorders, and hormonal issues, it becomes important to identify whether the situation is lifelong or acquired and situational or generalized. Further, men will often report erectile dysfunction rather than low sexual desire, further complicating diagnostic efforts (Levine, 2010, p. 41). This tendency to underreport desire disorders can likely be traced back to the cultural myths about male sexuality—a mechanical problem is bad enough, but male socialization conveys that not wanting sex is simply not masculine (Fracher & Kimmel, 1992). When clients find it difficult to discuss sexuality or sexual desire issues, The Sexual Desire Inventory (Spector, Carey & Steinberg, 1996) can be a useful tool for acquiring information in a way that allows more openness for the client (Meuleman & Van Lankveld, 2004, p. 291).

For those clients who profess they always have experienced low desire (lifelong variety), and who also believes that the low desire is ego syntonic, continued treatment may not be desirable unless the client is dissatisfied with the situation. For example, 27.4% of men aged 18 to 59 who were living with a partner had sex three times or less in the last year (10% had zero sex) and two-thirds of the men who had no sex were not troubled by it (Laumann, et al, 1994). For these men, lack of sex drive may be a character trait or an aspect of temperament with which they were born.

However, as Levine suggests, the situation is seldom as simple as innate low desire and no feelings about that loss of intimacy:

Lifelong HSDD usually reflects the constitutional endowment of sexual drive, although the internalization of antisexual values and experiences of abuse or neglect may produce a lifelong low sexual interest level. (2010, p. 41)

Levine goes on to suggest that attachment issues, which can inhibit adolescent sexual development can sometimes be at the root of low desire. In women, low desire or frequency of sexual behavior is associated with avoidant attachment, but in males it is associated with ambivalent attachment patterns (Feeney, 1999, p. 371). However, this is only one opinion—a study by Hazan, Zeifman, and Middleton (1994) found that avoidant men and women report low enjoyment of sexuality whereas ambivalent subjects of both sexes enjoy cuddling but not overt sexuality (cited in Feeney, p. 371)—there are very few studies that look at attachment issues and male hypoactive sexual desire.

Most often, HSDD manifests later in a relationship after a time of relatively normal sexual function and behavior (acquired variety). The reasons for this loss of desire can be physical, especially low androgen levels, as noted by many researchers (Knussmann, Christiansen & Couwenbergs, 1986; Mantzoros, Georgiadis & Trichopoulos, 1995; Nilsson, Moller & Solstad, 1995). There also can be other physical issues to rule out, including “various combinations of direct illness effects: treatment effects from medication, radiation, or surgery; psychological reactions to being ill; spousal reactions to the ill partner” (Levine, p. 41).

After ruling out all other issues (these are commonly seen as acquired generalized causes), the next step is to examine acquired situational issues. According to Levine, these tend to occur shortly after marriage. One variation, the Don Juan “casualty,” typically values the seduction more than conquest, and once he has “won” the women whom he often sees as a wonderful person, the sexual impulse is gone. In another variation, the pornography “casualty,” the man has been shaped and has shaped his sexual scripts through pornography. For him, an actual woman is too complex and intimidating for him to feel sexual toward. Finally, the “practical marriage casualty” results when a man chooses a wife for status and social benefits without really feeling any romantic interest. Each of these assumes a somewhat normal sexual fantasy life but a sexless relationship.

The therapist should also examine more complex, relationship-based issues. Among the variety of reasons a man may feel no sexual chemistry or desire for his wife include the following: he is having an affair, he no longer finds her sexually attractive, he finds her complaints about his sexual functioning overwhelming, her new status as a mother has rendered her asexual in his eyes, and perhaps the most irrevocable issue, he is a closeted homosexual and can no longer pretend to feel attraction for his wife even though he cannot face his sexuality. The job of the therapist is gently to explore these possibilities with the client while always keeping in mind that, “For men, sexual behavior is the ultimate expression of their manhood; beyond manhood—their personhood” (Gaylin, 1992, p. 117).

Levine argues that there are no physiological treatments (magic pills) for low sex drive (p. 42) and that there does not seem to be anything resembling a Viagra for low desire. However, he also states that none of the most common psychotherapies—cognitive-behavioral, psychodynamic, sex therapy, Psychodrama—have proven useful in treating HSDD (p. 42). Therapy can involve the man by himself, the man with his partner, or placement into a group with other men who experience similarly limited interest in their partners. While the group work may not do much to repair or save the relationship, it can help the man better understand his avoidance or motivations.

In lifelong/generalized HSDD, successful therapy may simply entail helping the couple develop strategies to maintain intimacy and a sexual common ground. With situational/acquired HSDD, successful therapy may include exploring relationship issues, physical attraction issues, family of origin issues, and a variety of other factors. Finally, it is also possible that the man developed a part—a subpersonality—whose role it is to suppress sexual desire, generally as a result of some shame-related experience (Schwartz, 1995). If that part’s “burden” can be identified and removed through therapeutic intervention (often a form of active imagination), then therapy can focus on trust-building and the creation of intimacy within the couple, but without sexual contact, until physical desire returns. However, it is handled, sensitivity to the importance men generally place on their sexuality as a major construct of their personal identity is crucial.


References
Ahuja, A. (2006, February 1). Every 7 seconds? That’s a fantasy. The Times (UK). Retrieved from http://www.timesonline.co.uk/tol/life_and_style/article723673.ece

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Text Revision ed.). Washington, DC: APA.

Brizendine, L. (2006). The female brain. New York: Broadway Books.

Dixit, J. (2007, June 4). Five shocking stats about men and sex. Psychology Today. Retrieved from http://www.psychologytoday.com/articles/200706/five-shocking-stats-about-men-and-sex

Feeney, J. A. (1999). Adult romantic attachment and couple relationships. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 355-377). New York: Guilford Press.

Fracher, J., & Kimmel, M. S. (1992). Hard issues and soft spots: Counseling men about sexuality. In M. S. Kimmel & M. A. Messner (Eds.), Men’s lives (2nd edition), (pp. 438-450). New York: Macmillan Publishing Company.

Gaylin, W. (1992). The male ego. New York: Penguin Books.

Goldstein, I., Meston, C., Davis, S., & Traish, A. (Eds.). (2006). Female sexual dysfunction. New York: Parthenon.

Knussmann, R., Christiansen, K., & Couwenbergs, C. (1986). Relations between sex hormone levels and sexual behaviour in men. Archive of Sexual Behavior, 15, 429-445.

Laumann, E. O., Gagnon, J. H., Michael, R. T., & Michaels, S. (1994). The social organization of sexuality: Sexual practices in the United States. Chicago: University of Chicago Press.

Levine, S. (2010, June). Hypoactive sexual desire disorder in men: Basic types, causes, and treatment. Psychiatric Times, 40-43.

Mantzoros, C. S., Georgiadis, E. L., & Trichopoulos, D. (1995). Contribution of dihydrotestosterone to male sexual behaviour. British Medical Journal, 310, 1289-1291.

Meuleman, E. J., & Van Lankveld, J. J. (2004, July 12). Hypoactive sexual desire disorder: An underestimated condition in men. BJU International, 95, 2 9 1 – 2 9 6. DOI: 10.1111/j.1464-410X.2005.05285.x

Nilsson, P., Moller, L., & Solstad, K. (1995). Adverse effects of psychosocial stress on gonadal function and insulin levels in middle-aged males. Journal of Internal Medicine, 237, 479-486.

Pleck, J. H., Sonenstein, F. L., & Ku, L. C. (1993). Masculinity ideology: Its impact on adolescent males’ heterosexual relationships. Journal of Social Issues, 49(3), 11-29. Retrieved from SocINDEX with Full Text database.

Schwartz, R. C. (1995). Internal family systems therapy. New York: Guilford Press.

Spector, I. P., Carey, M. P., & Steinberg, L. (1996). The Sexual Desire Inventory: Development, factor structure, and evidence of reliability. Journal of Sexual and Marital Therapy, 22, 175–90.

Tags: Hypoactive sexual desire disorder, men, Biopsychosocial, DSM-IV-TR, masculinity, sexuality, Sexual Dysfunction, health, desire, HSDD, Diagnostic and Statistics Manual of Mental Disorders, desire disorders, stereotypes, cultural constructs, SSRI