approaches to Treatments for low sexual desire
- Low sexual desire is the most prevalent sexual concern in women
Before the approval and blockbuster success of the oral phosphodiesterase type 5 inhibitor, sildenafilcitrate (Viagra), for men with sexual dysfunction, most of the published literature on treatments for women’s sexual dysfunction focused on non pharmacological approaches. William Masters and Virginia Johnson are considered by most to be the pioneers of sex therapy, and their intensive, inpatient program viewed sexual problems through the lens of the couple. As a result, treatments, which was largely focused on sensate focus therapy, required participation of both members of the couple. Sensate focus consisted of specific, systematic touching by one person of the other, with early stages prohibiting any breast or genital touch, and subsequent stages including them. While the giver of the touch used their own curiosity to guide where and how they touched, the receiver was instructed to pay attention to the sensations of touch while relaxing. Both partners were instructed that the goal was not pleasure oriented or to obtain arousal, but rather, to tune into the touch, and to provide the partner verbal and non verbal feedback about the touch. Their outcomes were remarkable, with 95% of couples responding positively to treatment, and an extremely low remission rate when couples were assessed five years later. Adaptations of the inpatient sensate focus program to an outpatient setting were similarly effective, and thus spurred the genesis of countless sex therapy clinics around North America. For approximately two decades, sex therapy and sensate focus were the predominant clinical approach to treating sexual problems.
Pharmacologic treatments of female sexual difficulties
- Flibanserin: A breakthrough for female sexual dysfunction?
“Flibanserin is the only medication approved by the FDA, but has marginal efficacy compared to placebo”
The landscape shifted on June 4, 2015, when an advisory committee to the FDA voted 18-6 in favor of approving flibanserin for the treatment of low desire in women. Two months later, on August 18, 2015, the FDA approved flibanserin (sold under the trade name Addyi), and two months after that, on October 17, 2015, Addyi was available for prescription in the United States. Two meta-analyses reviewing the available literature on flibanserin produced conflicting findings. The first reviewed four published clinical trials of flibanserin based on n = 3,414 women and found statistically greater increases in sexually satisfying events, sexual desire, overall sexual function, and significant reductions in sex related distress compared with placebo. A second meta analysis based on five studies, including unpublished randomized controlled trials, demonstrated a less optimistic picture, showing that flibanserin led to a mean increase of only 0.5 sexually satisfying events per month as well as clinically significant risk of dizziness, somnolence, nausea, and fatigue. The conflicting findings in these two meta-analyses further fueled the debate associated with the nature of and optimal treatment for low desire in women. More recently, a third meta-analysis of flibanserin studies has been published based on six published and four unpublished studies on a total of 8,345 women. This analysis concluded that although flibanserin was associated with significant increases in sexual desire, the magnitude of this increase did not differ from the effect of placebo. If prescribing patterns are any indication of its popularity, flibanserin is not likely to make monumental shifts in improving sexual desire for women given that only a few hundred prescriptions were made for flibanserin during the same period of time that a half million prescriptions for Viagra (sildenafil) were written for men. It is possible that flibanserin’s complete contraindication with alcohol (due to the finding that it potentiates the risk for dizziness, hypotension, and syncope) for the entire duration of its use may be contributing to the lack of uptake. What is remarkable about the (unpublished) study of alcohol interactions with flibanserin is that it was based on 23 men and only 2 women, highlighting, for some, the ongoing gender based biases in sex research.
Psychological treatments for sexual desire difficulties in women
“There is evidence favouring cognitive behavioral therapy and mindfulness meditation to cultivate sexual desire in women”
- Methodological challenges
In very recent years, the pendulum seems to have shifted again towards a renewed interest in evaluating psychological treatments for female sexual dysfunction, though there is recognition that judging the effectiveness of psychological therapies in treating sexual problems is inherently more complex than pharmaceutical trials. Psychological therapies seek not only to ameliorate sexual problems, but also to address broader domains of relationship functioning and quality of life. Linear models of sexual response such as the human sexual response cycle, which provided the foundation for diagnosing HSDD for three decades, have been criticized as inadequate to capture the complexity and variability of women (and men’s) sexual experiences. Circular models of sexual response, instead, deemphasize the primacy of genital response, and instead, also emphasize the role of relationship factors and intimacy, both as motivations for engaging in sexual activity as well as outcomes of a satisfying sexual encounter. A comparison of models in large samples of women reveals that no single model of sexual response captures women’s sexual experiences.
A key challenge in evaluating psychological treatments is how we best define treatment “success”, given that more often than not the specific “dysfunction” is only one aspect of the sexual relationship and therapy can sometimes result in improved communication and relationship satisfaction, without any resolution of the “dysfunction”. Furthermore, sexual problems are not always associated with sexual dissatisfaction or distress, and may reflect adaptive, short-term changes. In studies of women, many variables beyond sexual function e.g., psychological well being, relationship adjustment predict sexual satisfaction.
Sexual desire is difficult to define and difficult to measure. Does one count sexual frequencies of various sexual behaviors or attempt to assess the degree of internal motivation to engage in sexual activity? Do we tally sexual fantasies or frequency of various sexual behaviors as a proxy measure of desire or interest? And, perhaps more importantly, what should be considered indicative of a successful treatment outcome? It should be noted that most pharmaceutical trials have focused on “sexually satisfying events” as the primary endpoint, at the recommendation of the FDA, despite the finding that these endpoints do not consistently correlate with women’s self reported desire or distress.
- Cognitive behavioral approaches
Nearly 30 years ago, Hawton (1992) questioned whether sex therapy outcome research had “withered on the vine.” Surprisingly, although experts described cognitive behavioral sex therapy in 1980, and many sex therapists rely on cognitive behavioral therapy (CBT) in their management of sexual complaints, there have been very few controlled studies evaluating CBT for women’s sexual desire complaints. An exception to the scarcity of treatment outcome studies evaluating CBT for women is in the area of sexual pain disorders, where there have been a number of well-designed controlled outcome studies demonstrating the short and long-term efficacy of CBT for the symptom of genital pain intensity and associated psychological domains.
Because sexual difficulties are associated with cognitive distraction, and negative or biased thoughts during sexual activity, and negative affect, CBT is ideally suited to address these domains of sexual desire in women. Distraction may contribute to women’s difficulties noticing sexual sensations in their bodies, and interfere with responsive desire that often emerges following sexual arousal because they are not attending to their emerging sexual arousal, and/or judging their own responses negatively.
- Mindfulness-based approaches
Mindfulness, a secular practice derived from Buddhist traditions of meditation, involves the practice of observing one’s present-moment thoughts, emotions, and bodily sensations in a non judgmental manner . Through mindfulness training, women with low desire may become more aware of the physical changes they experience during or in anticipation of sexual activity (e.g., genital vasocongestion, tingling), which may boost and maintain their subjective sexual arousal and desire. Mindfulness training may also target the myriad negative judgments women with sexual difficulties have about themselves as they consider their distressing situation characterized by absent, highly infrequent and/or unsatisfying sexual activity. Though the mechanisms by which mindfulness may impact sexual desire in women have not been thoroughly studied, there is some evidence that it may impact interoceptive awareness, or women’s ability to detect and observe bodily sensations.
Over the past decade, a collaborative of clinician researchers in sexual medicine, psychology, and mindfulness have worked together to develop and test a group mindfulness-based intervention for women with low sexual desire. Of note, most of the research in this area is based on uncontrolled research, so the previously mentioned concerns about expectancy effects cannot be ruled out when considering this literature. Early research was focused on a three or four session intervention, and revealed improvements in sexual functioning for survivors of gynecologic cancer, women seeking treatment for heterogeneous sexual desire and arousal concerns, and women with a history of childhood sexual abuse. Even when administered to women seeking treatment for chronic vulvodynia, mindfulness led to significant improvements in their level of sexual desire.
Consistent feedback from women was that they requested more sessions of longer duration. We therefore expanded the four to an eight-session intervention, and modelled the in-session mindfulness exercises largely after those utilized in Mindfulness-Based Cognitive Therapy for Depression (MBCT). At least one hour in each of the eight weekly sessions was spent guiding participants through a mindfulness exercise, followed by an in-depth inquiry during which they were asked to reflect on how focusing on a particular target (be it a raisin, their breath, their body sensations, sounds, or thoughts) might be relevant to their concerns with low sexual desire. Women were also encouraged to practice mindfulness sessions at home on a daily basis.
In a recent study of 39 women meeting criteria for SIAD, compared to pretreatment, women experienced statistically significant improvements in sexual desire, overall sexual function, sex-related distress, sexual arousal, orgasm, and satisfaction. Improvements in sexual desire showed a very large effect size. Various domains of interoceptive awareness, including, non-distracting, attention regulation, self-regulation, and body-listening also significantly improved, as did mood and rumination. In an analysis of mediators, the study found that improvements in interoception mediated the improvements seen in sexual desire. In other words, it is possible that women’s ability to notice and tune in to physical sensations, including sexual ones, directly contributed to increasing their level of sexual desire. Mood was also found to be a mediator, however it mediated improvements in overall sexual functioning, not sexual desire specifically.
Though there has been an impressive body of research devoted to adapting and testing mindfulness-based therapies for women with sexual concerns, it remains to be seen how such an approach compares to other established treatments.
Online therapies for low sexual desire
A recent Cochrane review indicated a positive effect of bibliotherapy for sexual dysfunction, however, mostly small studies of low quality provide limited evidence. No significant differences were found between interventions that did versus those that did not provide adjuncts to the online therapy. Moreover, none of the studies reported on acceptability of the intervention or adherence to treatment requirements. More large, high-quality, comparison studies using online modalities are needed.
Our understanding of the factors that contribute to sexual desire as well as to development of a sexual desire difficulty, remain poorly understood. What is clear, however, is that a sizable proportion of women across ages and reproductive and life stages are dissatisfied with their sexual desire. As advances in the science of understanding women’s sexual desire continue to evolve, we hope that there is a concomitant increase in the science evaluating treatments. There is an urgent need for developing better control groups in psychological treatment outcome studies given that psychological expectancies can bolster outcomes, and because there may be non-specific factors unassociated with a particular treatment modality that contribute to improved sexual desire. There is also hope that both sides of the age-long debate over the nature of women’s desire can come together in a collaborative effort to understand and improve women’s experiences.
Evidence-based treatments for low sexual desire in women by Lori A. Brotto.