Introduction

The term "female hypoactive sexual desire disorder" clearly focuses on lack of sexual desire, as opposed to lack of interest or motivation (reasons/incentives), to be sexual. It encourages the belief that sexually healthy women agree to sex or initiate it mostly because they are aware of sexual desire—before any sexual stimulation begins. Indeed, this is in accordance with the traditional model of human sexual responding of Masters, Johnson, and Kaplan. In that model, after an unspecified time of awareness of desire, arousal occurs. As we will see, this conceptualization contradicts both clinical and empirical evidence—women in established relationships infrequently engage in sex for reasons of sexual desire (1-6). That sense of desire, or need, or "hunger" is nevertheless felt once subjectively aroused/excited. When that arousal is insufficient or not enjoyed, motivation to be sexual typically fades. In other words, although not usually the prime reason for engaging in sex, enjoyable subjective arousal is necessary to maintain the original motivation. So, lack of subjective arousal is key to women's complaints of disinterest in sex. However, their distress is typically presented in terms of "absent desire," as, again stemming from Masters and Johnson's model, the focus of arousal complaints has been on genital congestion rather than the subjective experience. This is despite the fact that psychophysiological studies of women with chronic arousal complaints show genital congestion in response to erotic videos that is comparable to healthy controls (see Chapter 6). This imprecision presents a major dilemma to both clinicians and the women requesting their help.

Any formulation of a hypoactive sexual desire/interest disorder must take into account the normative range of women's sexual desire across cultures (7), age, and life cycle stage (8). For instance, the postpartum period is normally sexually subdued (9). Desire for sex typically lessens with relationship duration and increases with a new partner (6).

Women's sexual enjoyment and desire for further sexual experiences were acknowledged early last century. Before that time, there had been variable denial or intolerance and endeavors to curb women's sexuality. Unfortunately, subsequent to that acknowledgement, came the assumption that women's sexual function mirrors men's experiences. Two particular aspects are fundamentally different. First, the majority of sexually healthy women do not routinely sense sexual desire before sexual stimulation begins; and second, women's sexual arousal is not simply a matter of genital vasocongestion. These misconceptions have led to:

1. the perception that as many as 30-40% of women in nationally representative community studies have abnormally low sexual desire (10-13);

2. current research to find a "desire" drug for women (14);

3. misunderstanding of women's viewpoint of lack of arousal (incorrectly assuming for the majority that genital congestion is impaired) (15);

Thus, lack of subjective arousal has been subsumed under "lack of desire." Women have great difficulty in distinguishing loss of desire/interest, from loss of arousal/ pleasure/intensity of orgasm. The comorbidity of desire, arousal, and orgasm disorders is clear (16-24). The only published randomized controlled trial using physiological (or at least close to physiological) testosterone supplementation did not result in any increased "desire" as in having sexual thoughts, over and beyond placebo, but did show increased pleasure and orgasm intensity and frequency. Subjective arousal was not reported, but, given the improvement in pleasure and orgasmic experiences, its improvement is implied (25).

The objectives of this chapter include:

• To identify reasons women willingly initiate/ agree to sex—with a view to understanding why some do not.

• To review a model of sexual response that permits motivations (reasons/incentives), for being sexual, over and beyond sexual desire.

• To clarify that it is the woman's arousability (along with the usefulness of sexual stimuli and context) that determines whether she will access sexual desire. In other words, for women, the concept of "responsive desire" or "desire accessed during the sexual experience" may be as or more important than initial desire as measured by sexual thoughts and sexual fantasies.

• To critique the traditional markers of sexual desire as they apply to women—and the questionable relevance of their lack.

• To outline the assessment of low desire and the associated low arousa-bility, thereby identifying therapeutic options.

• To review what is known of the biological basis of women's sexual desire and arousability, including the role of androgens.

• To review psychotherapy, pharmacotherapy, and the biopsychosexual approach to the management of women's lack of sexual interest/desire.

• To make recommendations for clinical practice.

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