Low sexual desire is the most common sexual complaint in women, with multinational studies finding that at least a third of women experience low sexual desire. No single etiology for the development of Female Sexual Interest/Arousal Disorder. There has been considerable interest in pharmacological approaches to improving low desire, and agents targeting a range of neurotransmitters have been examined. To date, only flibanserin, a centrally acting medication targeting the serotonin, dopamine, and norepinephrine systems, has been approved by the Food and Drug Administration (FDA). Despite statistically significant effects on sexual desire, sexual distress, and sexually satisfying events, side-effects are significant, and flibanserin is completely contraindicated with alcohol. As such, there has been renewed interest in advancing the science of psychological approaches to low desire, including cognitive behavioral and mindfulness therapies.
Low sexual desire in women
Prevalence, predictors, and points of controversy Though there is a strong societal perception that sex is a universally desired and experienced activity, national probability data indicate high rates of sexual dysfunction in both men and women. Low sexual desire is the most common sexual complaint in women across the life cycle, with representative studies carried out across a variety of countries finding that at least a third of women experience low sexual desire lasting several months over the past year. When one factors in the co-occurrence of clinically significant distress, these prevalence rates drop, yet remain significant at approximately 7 to 10% of women reporting a sexual dysfunction. Given that up to 40% of women report difficulties with loss of sexual desire when assessed cross sectionally at a given point in time, it is critically important to determine whether those symptoms evoke clinically significant distress, and are thus associated with a sexual dysfunction, or whether they are transient and adaptive changes to the particular context or situational factors in the woman’s life at the time. As such, the criterion of clinically significant distress is required in order to diagnose a prolonged reduction in, or loss of, sexual desire into a sexual dysfunction.
A diagnosis of a sexual desire dysfunction has historically been guided by criteria set out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). From 1980 until 2013, a diagnosis of Hypoactive Sexual Desire Disorder (HSDD) depended on the symptom of absent or reduced desire for sexual activity and lack of sexual fantasies, with associated clinically significant distress. The DSM-5 introduced polythetic criteria to the diagnosis, in recognition of the varied ways in which women experience sexual desire (and sexual desire problems). Moreover, duration and severity criteria were introduced into the diagnosis of Sexual Interest/Arousal Disorder (SIAD) in the DSM-5, with a diagnosis made when a woman experiences three of the following for a period of at least six months:
- reduced or absent desire for sex
- reduced or absent sexual thoughts/fantasies
- reduced or absent initiation and receptivity of sexual activity
- reduced or absent sexual pleasure
- reduced desire triggered by sexual stimuli, and/or
- reduced or absent genital or nongenital sensations
In addition to the persistence of these symptoms, the woman must experience clinically significant distress, and the symptoms must not be attributable to severe relationship distress, significant stress, the effects of a substance, medication, another medical condition, or another non-sexual mental disorder. The scientific and clinical community have engaged in a lively debate about the merits and pitfalls of this revised diagnosis. Critics have argued that polythetic criteria introduce too much heterogeneity into the diagnosis, resulting in women with the same diagnosis having markedly different symptom profiles. On the other hand, comprehensive reviews of the literature demonstrate that women express and experience their sexual desire and arousal in vastly different ways, thereby suggesting that polythetic criteria may be warranted. Furthermore, critics believe that the symptom duration criteria of 6 months unnecessarily raise the bar for reaching a diagnosis, and lead to women with subthreshold criteria without access to needed care. On the other hand, studies that do not impose these symptom severity or duration criteria lead to prevalence rates suggesting that half of women have a sexual dysfunction, and may encourage providers to inadvertently administer treatment when the symptoms may reflect a transient and adaptive response to a particular life context.
The causes of low sexual desire in women have been studied at length, and no single etiology for the development of Female Sexual Interest/Arousal Disorder (SIAD) has been established. There has been considerable interest in the role of hormones in the development of low desire. In particular, the cessation of ovarian production of estrogen with menopause was assumed to trigger the onset of a sexual dysfunction, and contributed to a societal belief that sexual desire dwindled with age in women. Comprehensive, longitudinal, and methodologically rigorous research from around the world, but in particular from Melbourne, Australia, found that whereas the decline in estrogen was associated with vaginal dryness and discomfort, it was not directly associated with a loss of sexual desire. The hormone, testosterone, has also been of tremendous interest given a vast amount of literature in non-human animals demonstrating the impact of testosterone removal on sexual behavior, clinical conditions, such as hypogonadism, which is often associated with loss of sexual desire, and the observation of an ovulatory peak in sexual desire, around the time when testosterone is elevated. However, studies that have directly compared women with and without sexual desire difficulties have failed to find significant differences in testosterone levels, regardless of whether testosterone was assessed with mass spectrometry, saliva, or other methodologies. Nonetheless, testosterone is a popular form of therapy among some health care providers.
Evidence-based treatments for low sexual desire in women by Lori A. Brotto.