The International Society for the Study of Women’s Sexual Health describes Hypoactive sexual desire disorder (HSDD) as a lack of interest in sexual activity.

This means experiencing a decrease or absence of spontaneous desire (like sexual thoughts or fantasies), not responding to erotic cues or stimulation, or being unable to maintain interest during sexual activity.

It can also involve losing the desire to initiate or take part in sexual activities and may lead to avoiding situations that could lead to sexual activity.

Importantly, this lack of interest should not be due to any pain-related issues, and it should be causing significant distress.

HSDD brings along not just a lack of interest in sex, but also comes with a lot of emotional stress and can make life less enjoyable. People dealing with HSDD may also be at a higher risk of facing mental health challenges like major depressive disorder. Importantly, HSDD isn’t limited to a particular age – it can happen at any stage of life.

Physiology of Sexual Desire

When we talk about how the body responds to sexual stimuli, most models distinguish between different aspects: desire (the want and motivation for sex), arousal (physical changes that make sexual activity easier, like vaginal lubrication), and consummatory reward (the pleasure and satisfaction, often accompanied by orgasm).

Although these elements work together, they probably have separate physiological processes. What’s important to note is that, despite many potential physiological factors influencing female sexual desire, we haven’t yet found a clear, definitive explanation for the physical changes associated with HSDD. The puzzle is still missing a piece.

The Dual Control Model

Think of your sexual desire like a tug-of-war in your brain. This model says that desire happens when the forces pushing you to be excited outweigh the ones holding you back. HSDD, or a lack of sexual desire, can happen if something goes wrong with these forces – either the things that should excite you aren’t doing their job, or the things that should keep you from getting too excited are working too much.

Studies using brain imaging show that in women with HSDD, the parts of the brain responsible for sexual desire are not as active as they should be. On the flip side, areas linked to self-focus and moral judgment are more active. It’s like the balance is off, and the brain is focused on other things instead of revving up the desire.

HSDD seems to happen when there’s a drop in signals that usually get you excited about sex, an increase in signals that put the brakes on, or maybe a mix of both. It’s not a one-size-fits-all situation – there isn’t a single, clear explanation for why HSDD occurs. Instead, it looks like there are various ways that a woman might end up with less activity in the brain areas that control sexual desire. It’s a bit like many different roads leading to the same destination of reduced brain activity in those desire-related regions.

HSSD screening

Decreased Sexual Desire Screener 

The initial four questions in the screener focus on figuring out if there’s a lack of sexual desire and if it’s causing distress. The fifth question takes a closer look at factors that could be changed or improved before confirming a diagnosis of HSDD. These include things like other health issues, problems in the relationship, or high levels of stress or fatigue. It’s like making sure to check and address any possible reasons before jumping to a conclusion

Assessment of decreased sexual desire

When a clinician conducts a biopsychosocial assessment, they dig into the patient’s history to understand the biological, psychological, and social aspects that might influence their sexual function (see Table 1). For biological factors, they look at any other health issues like diabetes, thyroid problems, or hormonal changes. They also consider medications that could have effects on sex, such as certain antidepressants or painkillers. Physical factors like sexual pain related to conditions such as endometriosis or fibroids are also taken into account.

On the psychological side, the clinician checks for the presence of issues like depression, anxiety, substance use problems, and any history of physical or sexual trauma.

In terms of social and interpersonal aspects, they explore the quality of current and past relationships, partner techniques, and concerns about things like sexually transmitted infections or pregnancy. They also consider the broader sociocultural context by looking at the patient’s cultural background, upbringing, beliefs about sex and bodies, and practical factors like privacy or work schedule, which might affect sexual desire. It’s like putting all the pieces together to get a full picture of what might be influencing the patient’s experience.

Laboratory testing and physical exam

For women who appear healthy, it’s not advised to routinely conduct hormone tests, especially for testosterone, as it doesn’t really help in diagnosing HSDD.

However, if there’s reason to suspect an issue with the ovaries, like premature ovarian failure or polycystic ovarian syndrome, then hormone testing might be considered by the clinician.

The physical examination may involve checking for signs of hormonal imbalances, assessing genital health, and looking for any physical factors that might affect sexual function. For instance, the clinician might check for issues related to hormones, such as thyroid function, or physical conditions that could cause sexual pain.

Treatment Of Hypoactive Sexual Desire Disorder

Treating Hypoactive Sexual Desire Disorder (HSDD) involves a combination of education, specific therapeutic interventions, and sometimes prescription medications.

Education and Counseling

Education about normal sexual function and changes throughout life is crucial. Clinicians discuss the impact of chronic diseases on sexual desire and introduce concepts like responsive desire and the role of sexual stimulation.

Cultural messages that portray sexual desire as always spontaneous are challenged. Responsive desire, where desire arises from positive or pleasurable sexual experiences, is highlighted.

Additional education may include book recommendations, regular use of lubricants, and the use of devices like vibrators to enhance arousal and orgasm.

Strategies to adapt to changes in sexual habits over time, especially when physical limitations are involved, are discussed. For instance, accommodating back and leg pain due to osteoarthritis by exploring alternative intimate activities.

Counseling on Intimacy

Intimate activities beyond penetrative intercourse are explored, encouraging communication with partners about desires and boundaries.

Clinicians help patients navigate potentially uncomfortable conversations with their partners, providing support and examples to ease the dialogue.

Therapeutic Interventions

Mindfulness-based therapies and cognitive behavioral therapy (CBT) designed for HSDD show promise. CBT, in particular, has proven effective, although its availability may be limited in some communities.

Ongoing research explores the effectiveness of internet-based mindfulness-based cognitive therapy for sexuality, potentially expanding access to care, especially in remote or underserved areas.

Summary

Hypoactive Sexual Desire Disorder in women involves a lack of sexual desire, leading to distress. Treatment includes education on sexual function, counseling for communication with partners, and therapeutic interventions such as mindfulness and cognitive behavioral therapy. Prescription medication may be considered in some cases.

Reference: Pettigrew, J. A., & Novick, A. M. (2021, November). Hypoactive sexual desire disorder in women: Physiology, assessment, diagnosis, and treatment. Journal of midwifery & women’s health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8673442/