Treatment General Considerations

The DSM-IV-TR (6) diagnosis of any sexual dysfunction has four requirements: first, diagnostic subtyping must occur (see "Classification" section in this chapter); second, another Axis I diagnosis be excluded (except another sexual dysfunction); third, an existing medical condition could not explain the dysfunction; and fourth, substance abuse also not be present. In the absence of a thorough assessment (history, physical and laboratory exams when appropriate), the clinician is actually considering a presenting symptom rather than a diagnosis. The two should not be confused. The distinction is crucial.

Treatment follows diagnostic subtyping (Fig. 1). (A) If HSDD is acquired and generalized, the clinician must make substantial efforts towards finding the explanation(s) for the change. HSDD is sometimes (the frequency appears to be unknown) accompanied by another sexual dysfunction, especially ED, and when both occur together, it may be revealing and useful to find out which came first and to act accordingly. One might envision how a lack of sexual desire can cause erectile problems. However, the opposite is not so clear. The extent to which the presence of ED can result in a generalized lack of sexual desire appears to be entirely unknown. (B) If HSDD is lifelong but situational, a biogenic explanation is unlikely and individual psychotherapy undertaken by a mental health professional seems preferred. (C) If HSDD is acquired but situa-tional, a biogenic explanation is, again, unlikely (with the possibly exception of hyperprolactinemia). In this circumstance, psychotherapy seems indicated but depending on the apparent etiology, could be provided individually or together with a partner. (D) If the history reveals that HSDD has been lifelong and generalized, change is unlikely and the clinician should direct therapeutic energy towards helping the person (or, more likely, the couple) to adapt. Kinsey's admonition seems relevant: "... there is a certain skepticism in the profession of the existence of people who are basically low in capacity to respond. This amounts to asserting that all people are more or less equal in their sexual endowments, and ignores the existence of individual variation. No one who knows how remarkably different individuals may be in morphology, in physiological reactions, and in other psychologic capacities, could conceive of erotic capacities (of all things) that were basically uniform throughout a population" (13).

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