Recommendations For Clinical Practice

• Assessment needs to be biopsychosocial, as well sexual (Table 3.1).

• Consider predisposing, precipitating, and maintaining factors.

• Endeavor to see the couple together and separately.

• Create a model of the woman's sexual response cycle showing the various breaks or areas of weakness.

• Interpersonal issues need to be addressed first.

• When abuse is elicited in the history, determine whether recovery has taken place. When this is not complete, defer addressing sexual issues and make appropriate referral.

• When negative outcome needs specific treatment (e.g., chronic dys-pareunia), address that in parallel with addressing the low desire. Meanwhile, normalize and encourage nonpenetrative sex.

• Psychological therapies are the mainstay of treatment and include sex therapy, sensate focus therapy, CBT, psychodynamic treatment, couple treatment, and promotion of the individual as a separate self.

• There are no firm nonhormonal pharmacological recommendations at this time. However, clinical experience and a recent study (104) suggest increased arousability to sexual cues from administering bupro-pion to nondepressed women diagnosed with hypoactive sexual desire/ interest, again in keeping with the lowering of desire if arousability is impaired.

• When arousability and accessed desire sharply declines in conjunction with a known cause of reduction of androgens (e.g., younger premeno-pausal women with loss of all ovarian function), consider investiga-tional testosterone therapy using a formulation that produces physiological as opposed to pharmacological levels. Hopefully, there will be such formulation in the near future.

• Remember safety data regarding T treatment are only short-term and only for the estrogen replete woman. There are no data on T supplementation to premenopausal women whereby the achieved androgen levels have been strictly physiological.

Table 3.1 Components of a Comprehensive Sexual, Medical, and Psychosocial History

Biological

Psychosocial

Sexual

Symptoms

Current general health

Current mood, mental health

The sexual difficulties in her own words

Present context

Medications / substance

Nature and duration of current

Context when activity is

(precipitating / maintaining)

abuse, fatigue, presence

relationship. Societal values/beliefs

attempted—type of

of nonsexual pain

impacting the sexual problems

sexual stimulation, the woman's feelings towards her partner, safety, and privacy

Past context

Past medical history

Particularly for lifelong problems,

Past sexual experiences

(predisposing/precipitating)

developmental history, including relationships with caregivers, siblings, traumas, and losses

alone and partnered, wanted, coercive, abusive

Onset (precipitating)

Medical, psychiatric

Psychosocial circumstances including

Sexual details at onset of

details at time of onset

relationship at time of onset of sexual

dysfunctions

of sexual problems

problems

Full picture of her current

Details regarding effects of

Personality factors including control

Rest of the sexual response

sexual response

medical condition on sexual activity, e.g., cardiac compromise

issues, ability to express nonsexual emotions

cycle including pain

Role of the partner

Partner's medical health

Partner's mood and mental health,

Partner's sexual response

(precipitating / maintaining)

partner's reaction to sexual problems

cycle including pain

Distress

Level of distress regarding

Level of distress regarding psychosocial

Reaction to the sexual

medical issues

issues

difficulties, level of distress

• Analogue assays for free-T are currently unreliable—but total T alone is insufficient owing to SHBG bound T being relatively unavailable to the tissues. Thus, modifying T formulations designed for men is fraught with difficulties due to lack of reliable laboratory monitoring.

• If and when hormonal and pharmacological treatments become available, a biopsychosocial approach to treatment will still be needed. Secondary dysfunctions, changed expectations, adaptations to the low arousability, and disinterest will have occurred. These may negate any potential benefit.

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