Summary And Conclusions

Some may see it as a truism that men and women are sexually different, but in the latter half of the 20th century there has been a strong effort to view the two as functionally symmetrical. In spite of this attempt at equation, evidence about just how men and women differ, especially in the crucial area of sexual desire, is rapidly accumulating. Although doubtlessly unintentional, investigations of sexual desire in women have shed light on the same in men. These observations have insinuated that the pattern of sexual desire resulting in arousal is more true of men than women (where desire might follow arousal), and that sexual desire tends to be quantitatively greater in men.

According to several different studies, at any one time —16% of men experience HSDD. However, sexual desire manifests in different ways (both psychologically and behaviorally), and it is far from clear just who is included in this 16%. Does it represent, for example, men who have sexual thoughts but do not act on them? Men who act on some occasions but not others (acquired and situational)? Men who had sexual thoughts and feelings in the past but not nowadays (acquired and generalized)? Men who do not have those feelings now and never have thought much about sexual issues (lifelong and generalized)? The tendency of sexual desire in men to decline as they become older has been repeatedly demonstrated. But does this observation mean that an elderly man who experiences diminished sexual desire has HSDD and is part of the 16% (men who are sometimes referred to as having "andropause," "ADAM" or "PADAM"? Or, conversely, should we look at the age-related decline not as pathological, but rather as a "normal" part of the process of becoming older? And who decides the answer? Is this a medical decision made by health professionals or one which is social? Lots of questions and few answers. The "bottom line" is that the definition of HSDD in men in most studies is quite unclear, so one might fairly ask (at least rhetorically): just what are the boundaries surrounding the diagnosis?

Apart from the issue of diagnostic borders, the assessment of HSDD in men is not complicated and involves a few questions in the history about sexual thoughts, fantasies, activities with a partner or oneself, a consideration of health status, and conducting a few laboratory tests. Those procedures will help in the process of subtyping, which, in turn, is essential for determining etiology and treatment.

Each of the subtypes of HSDD has many possible origins. For example, if a man finds that he is completely absorbed sexually at the beginning of a new relationship and not otherwise, or only when watching a computer screen displaying engaging women without clothes, then obviously his sexual desire is quite intact but is highly focussed. In this instance, biomedical speculation about the etiology will not (with the possibly exception of hyperprolactinemia) be fruitful and does not make clinical sense. Thinking in psychosocial ways about etiology and treatment in such an instance will be more productive and, on the basis of clinical experience, intrapersonal issues involving the capacity for intimacy loom large.

If, on the other hand, the man has desire difficulties of relatively recent origin which extend to all circumstances when he would be expected to react with sexual feelings, then a clinician might indeed think about biomedical matters. Medical and psychiatric disorders, or medications used in treatment, appear to be a frequent cause of acquired HSDD. If the man is ostensibly healthy, considering subtle problems like hormone aberrations might prove helpful. Two hormones in particular greatly influence sexual desire, namely, testosterone and prolactin, and both must be scrutinized if the problem is generalized.

Published information on the treatment of HSDD in men who do not have any obvious explanation for their difficulties, leaves clinicians with little guidance. First, diagnostic subtyping is virtually nonexistent. Second, there are no controlled studies on a homogeneous sample of men in which psychotherapy was the mainstay of treatment. As well, a review of the use of couple therapy resulted in pessimistic conclusions. Third, only one placebo-controlled drug study (bupropion in a nondepressed mixed population of men and women) has taken place but fortunately suggested improvement. Fourth, only one study of the use of a hormone (testosterone) alone has occurred but included a mere 10 patients, a fact which even one of the authors decried.

HSDD in men can be an agonizing condition, especially when sexual desire is actually present but is not expressed in a way that involves the patient's partner. The reproductive consequences can be severe. To suggest that more research is needed into this disorder would be an understatement. All aspects of HSDD in men need to be carefully examined, starting with as basic an issue as trying to clarify what is encompassed within the definition.

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