Sexual Desire and the Female Sexual Function Index (FSFI): A Sexual Desire Cutpoint for Clinical Interpretation of the FSFI in Women with and without Hypoactive Sexual Desire Disorder

IntroductionA validated cutpoint for the total Female Sexual Function Index scale score exists to classify women with and without sexual dysfunction. However, there is no sexual desire (SD) domain-specific cutpoint for assessing the presence of diminished desire in women with or without a sexual desire problem.AimsThis article defines and validates a specific cutpoint on the SD domain for differentiating women with and without hypoactive sexual desire disorder (HSDD).MethodsEight datasets (618 women) were included in the development dataset. Four independent datasets (892 women) were used in the validation portion of the study.Main Outcome MeasuresDiagnosis of HSDD was clinician-derived. Receiver-operator characteristic (ROC) curves were used to develop the cutpoint, which was confirmed in the validation dataset.ResultsThe use of a diagnostic cutpoint for classifying women with SD scores of 5 or less on the SD domain as having HSDD and those with SD scores of 6 or more as not having HSDD maximized diagnostic sensitivity and specificity. In the development sample, the sensitivity and specificity for predicting HSDD (with or without other conditions) were 75% and 84%, respectively, and the corresponding sensitivity and specificity in the validation sample were 92% and 89%, respectively.ConclusionsThese analyses support the diagnostic accuracy of the SD domain for use in future observational studies and clinical trials of HSDD. Gerstenberger EP, Rosen RC, Brewer JV, Meston CM, Brotto LA, Wiegel M, and Sand M. Sexual desire and the female sexual function index (FSFI): A sexual desire cutpoint for clinical interpretation of the FSFI in women with and without hypoactive sexual desire disorder.     

The Prevalence of Hypoactive Sexual Desire Disorder in Surgically Menopausal Women: An Epidemiological Study of Women in Four European Countries

IntroductionInsufficient documentation exists regarding the prevalence of hypoactive sexual desire disorder (HSDD) in surgically menopausal (SM) women in European countries. Women who have undergone hysterectomy and bilateral oophorectomy experience a loss of ovarian hormones. Inclusion of these women in an epidemiological study provided the opportunity to study biological and cultural impacts on sexual function.AimThe aim of this study was to compare the prevalence of HSDD among SM women in France, Germany, Italy, and the United Kingdom, as well as the relationship between low sexual desire and sexual activity or behavior, and sexual or partner relationship satisfaction.MethodsCross-sectional survey of a convenience sample of 427 SM women aged 20–70 years.Main Outcome MeasuresThe desire domain of the Profile of Female Sexual Function (PFSF) to identify women with low sexual desire, Personal Distress Scale (PDS) to measure distress caused by low sexual desire, and a sexual activities measure. Women with low sexual desire who were distressed were classified as having HSDD.ResultsSM women having low sexual desire ranged from 35% (United Kingdom) to 44% (Italy); of these women, 16% (Germany) to 56% (France) were distressed because of their low sexual desire. Overall, SM women classified with HSDD ranged from 7% (Germany) to 22% (France). A strong positive correlation was observed between sexual desire and arousal, orgasm, and sexual pleasure in all countries (P < 0.001). Low sexual desire leads to less sexual activity, more dissatisfaction with sex life and partner relationship, and more negative emotional or psychological states, than normal desire in each country.ConclusionsA similar percentage of SM women with low sexual desire were found across countries suggesting the role of biological factors (i.e., losing ovarian hormones) in determining sexual desire. Differences in the percentage of SM women with HSDD suggest a role for cultural factors in determining how low sexual desire is perceived. Graziottin A, Koochaki PE, Rodenberg CA, and Dennerstein L. The prevalence of hypoactive sexual desire disorder in surgically menopausal women: An epidemiological study of women in four European countries. J Sex Med 2009;6:2143–2153.     

Content validity of the Female Sexual Function Index (FSFI) in pre- and postmenopausal women with hypoactive sexual desire disorder

IntroductionThe Female Sexual Function Index (FSFI) has consistently been shown to have discriminant validity, test–retest reliability, and internal consistency as a measure of female sexual function. However, the content validity (relevance, clarity, comprehensiveness) of the instrument in women with hypoactive sexual desire disorder (HSDD) must also be established.AimThe aim of this study were to assess the content validity of the FSFI, specifically the FSFI desire domain, in pre‐ and postmenopausal women with HSDD.MethodsTwo single‐visit content validation studies were conducted in the United States. Eligible premenopausal (both studies) and postmenopausal (second study only) women with HSDD completed the FSFI followed by one‐on‐one, face‐to‐face cognitive debriefing interviews including open‐ended questions to capture information on their perceptions of the instrument. Information on women's experiences of decreased sexual desire was also captured.Main Outcome MeasuresThe main outcome measures of this study were the women's ratings of the clarity, ease of understanding, comprehensiveness, and relevance of the 19 items of the FSFI.ResultsInterviews with 15 premenopausal women (first study), and 30 pre‐ and 31 postmenopausal women (second study), were analyzed. Across the whole sample, most women (80–100%) found every item of the FSFI clear and easy to understand. The majority (53–70%) felt that the FSFI captured all their feelings about decreased sexual desire and other sexual problems, and most (84–90%) indicated that additional questions were unnecessary. Most women in both studies (93–100%) reported that the two items comprising the FSFI desire domain were clear, easy to understand, and were relevant to them. The majority of women thought that a recall period of ≥7 days is most relevant for recall of their sexual desire.ConclusionsThese studies establish the content validity of the FSFI in pre‐ and postmenopausal women with HSDD, supporting the use of this instrument as a measure of sexual function in women with this condition. Revicki DA, Margolis MK, Bush EN, DeRogatis LR, and Hanes V. Content validity of the female sexual function index (fsfi) in pre‐ and postmenopausal women with hypoactive sexual desire disorder (HSDD). J Sex Med 2011;8:2237–2245.     

Physician attitudes regarding hypoactive sexual desire disorder in a primary care clinic: a pilot study

IntroductionFemale sexual dysfunction (FSD), in particular, complaints of low desire, affects many American women. Despite the impact FSD may have on these women, many do not present their symptoms to their physicians.AimTo determine physician attitudes and practices regarding hypoactive sexual desire disorder (HSDD) in the primary care setting.Main Outcome MeasuresA 10-item questionnaire regarding HSDD.MethodsAll residents and faculty in an academic primary care clinic were invited to participate in a web-based survey regarding HSDD. Return of the questionnaire was considered consent. Responses were downloaded into Excel and converted into an spss database.ResultsIn total, 53 of 155 physicians responded (46% response rate—41.5% women, 58.5% men). Of respondents, 90% reported little confidence in making the diagnosis of HSDD, 90% of physicians had not screened a patient for HSDD, and 98% of the physicians had not prescribed medication for patients with HSDD. No significant gender differences among physicians were identified, but faculty providers had more confidence in diagnosing and treating HSDD than resident physicians.ConclusionsThese results indicate there is an opportunity to improve patient care and life satisfaction by offering physicians training on diagnosis and management of HSDD. Harsh V, McGarvey EL, and Clayton AH. Physician attitudes regarding hypoactive sexual desire disorder in a primary care clinic: A pilot study     

Neural bases of hypoactive sexual desire disorder in women: an event-related FMRI study

IntroductionAlthough there is an abundant debate regarding the mechanisms sustaining one of the most common sexual complaints among women, i.e., female hypoactive sexual desire disorder (HSDD), little remains known about the specific neural bases of this disorder.AimThe main goal of this study was to determine whether women with HSDD showed differential patterns of activation within the brain network that is active for sexual desire in subjects without HSDD.MethodsA total of 28 right‐handed women participated in this study (mean age 31.1 ± 7.02 years). Thirteen out of the 28 women had HSDD (HSDD participants), while 15 women reported no hypoactive sexual desire disorder (NHSDD participants). Using event‐related functional magnetic resonance imaging (fMRI), we compared the regional cerebral blood flow responses between these two groups of participants, while they were looking at erotic vs. non‐erotic stimuli.Main Outcome MeasureBlood‐oxygenation level dependent (BOLD) signal changes in response to erotic stimuli (compared with non‐erotic stimuli). Statistical Parametric Mapping was used to identify brain regions that demonstrated significant differential activations between stimuli and between groups.ResultsAs expected, behavioral results showed that NHSDD participants rated erotic stimuli significantly higher than HSDD participants did on a 10‐point desirable scale. No rating difference was observed for the non‐erotic stimuli between NHSDD and HSDD participants. Our functional neuroimaging results extended these data by demonstrating two distinct types of neural changes in participants with and without HSDD. In comparison with HSDD participants, participants without HSDD demonstrated more activation in brain areas involved in the processing of erotic stimuli, including intraparietal sulcus, dorsal anterior cingulate gyrus, and ento/perirhinal region. Interestingly, HSDD participants also showed additional activations in brain areas associated with higher order social and cognitive functions, such as inferior parietal lobule, inferior frontal gyrus, and posterior medial occipital gyrus.ConclusionTogether, these findings indicate that HSDD participants do not only show a hypo activation in brain areas mediating sexual desire, but also a different brain network of hyper activation, which might reflect differences in subjective, social, and cognitive interpretations of erotic stimuli. Collectively, these data are in line with the incentive motivation model of sexual functioning. Bianchi‐Demicheli F, Cojan Y, Waber L, Recordon N, Vuilleumier P, and Ortigue S. Neural bases of hypoactive sexual desire disorder in women: An event‐related fMRI study. J Sex Med 2011;8:2546–2559.     

Does the Female Sexual Distress Scale‐Revised Cover the Feelings of Women with HSDD?

IntroductionDistress associated with low sexual desire is a key feature of hypoactive sexual desire disorder (HSDD). Accurate, reliable, and easy‐to‐use diagnostic tools to measure such distress are required. The Female Sexual Distress Scale‐Revised (FSDS‐R) has been shown to have good discriminant validity, test–retest reliability, and internal consistency in measuring sex‐related personal distress in women with HSDD. However, the content validity (relevance, clarity, comprehensiveness) of the scale must also be established.AimThe aim of this study was to assess the content validity of the FSDS‐R and to examine the potential of Item 13 as a stand‐alone measure of distress associated with decreased sexual desire.MethodsA single‐visit content validation study was conducted in three centers in the United States. Women were screened for HSDD; those with HSDD completed the FSDS‐R and then underwent debriefing to capture information on their perceptions of the instrument. Participants also rated the relevancy of every FSDS‐R item, from 0 (“not at all relevant”) to 4 (“extremely relevant”).Main Outcome MeasuresFemale HSDD patients' ratings of the relevance and ease of understanding of the 13 items of the FSDS‐R.ResultsTwenty‐five women with HSDD were interviewed. Mean relevancy ratings ranged from 1.96 (Item 9) to 3.33 (Item 13). Most participants (76–100%) found every item clear and easy to understand. Item 13 alone demonstrated good content validity, and 56% of participants felt that it covered all of their feelings about their low sexual desire.ConclusionsThis study established the content validity of the FSDS‐R and demonstrated that the FSDS‐R total score is a relevant endpoint for women with HSDD. The tool's one item specific to low sexual desire (Item 13) was given the highest score and highest relevancy of all items, and over half the sample felt that it covered all of their feelings about their low sexual desire. DeRogatis L, Pyke R, McCormack J, Hunter A, and Harding G. Does the female sexual distress scale‐revised© (FSDS‐R©) cover the feelings of women with HSDD? J Sex Med 2011;8:2810–2815.     

Evaluation of the Sexual Desire Relationship Distress Scale (SDRDS) in Women with Hypoactive Sexual Desire Disorder

IntroductionThe Sexual Desire Relationship Distress Scale (SDRDS) was developed to address the need for a patient‐reported outcome (PRO) measure of sexual distress associated with hypoactive sexual desire disorder (HSDD). The SDRDS is a 17‐item PRO that includes items related to personal distress and distress related to relationship with partner.AimThe aim of this article was to evaluate the psychometric properties of the SDRDS among women with HSDD.MethodsPre‐ and post‐menopausal women with HSDD or with no sexual dysfunction completed the SDRDS, Sexual Activity Questions, Female Sexual Distress Scale‐Revised (FSDS‐R), and desire domain of the Female Sexual Function Index (FSFI) at baseline and 2 and 4 weeks later.Main Outcome MeasuresThe main outcome measures of this article were item performance, internal consistency, test–retest reliability, construct validity, known groups validity, and responsiveness of the SDRDS.ResultsData from 260 women were analyzed: 101 in each of the pre‐ and post‐menopausal HSDD groups and 29 in each of the pre‐ and post‐menopausal control groups. No differences emerged between pre‐ and post‐menopausal women. Least‐squares mean (±standard errors [SE]) SDRDS score was higher in women with HSDD than in women with no sexual dysfunction (43.1 ± 0.9 vs. 6.1 ± 1.7; P < 0.0001), supporting known groups validity. Individual item scores correlated with total scores (r = 0.7–0.9; P < 0.0001). Internal consistency was high, with a Cronbach's alpha of 0.973 at baseline. Test–retest reliability was good, with an intraclass correlation coefficient of 0.89. SDRDS scores correlated strongly with other measures of sexual distress and sexual function including the FSDS‐R and FSFI desire domain items. Preliminary analyses suggested that the SDRDS was sensitive to changes in clinical status.ConclusionsThe SDRDS provides a comprehensive and reliable assessment of distress due to decreased sexual desire in women with HSDD and may be a useful measure of treatment effects in clinical trials in women with this condition. Revicki DA, Margolis MK, Fisher W, Rosen RC, Kuppermann M, Hanes V, and Sand M. Evaluation of the Sexual Desire Relationship Distress Scale (SDRDS) in women with hypoactive sexual desire disorder. J Sex Med 2012;9:1344–1354.     

Sexual Desire in Trans Persons: Associations with Sex Reassignment Treatment

IntroductionSex steroids and genital surgery are known to affect sexual desire, but little research has focused on the effects of cross‐sex hormone therapy and sex reassignment surgery on sexual desire in trans persons.AimThis study aims to explore associations between sex reassignment therapy (SRT) and sexual desire in a large cohort of trans persons.MethodsA cross‐sectional single specialized center study including 214 trans women (male‐to‐female trans persons) and 138 trans men (female‐to‐male trans persons).Main Outcome MeasuresQuestionnaires assessing demographics, medical history, frequency of sexual desire, hypoactive sexual desire disorder (HSDD), and treatment satisfaction.ResultsIn retrospect, 62.4% of trans women reported a decrease in sexual desire after SRT. Seventy‐three percent of trans women never or rarely experienced spontaneous and responsive sexual desire. A third reported associated personal or relational distress resulting in a prevalence of HSDD of 22%. Respondents who had undergone vaginoplasty experienced more spontaneous sexual desire compared with those who planned this surgery but had not yet undergone it (P = 0.03).In retrospect, the majority of trans men (71.0%) reported an increase in sexual desire after SRT. Thirty percent of trans men never or rarely felt sexual desire; 39.7% from time to time, and 30.6% often or always. Five percent of trans men met the criteria for HSDD. Trans men who were less satisfied with the phalloplasty had a higher prevalence of HSDD (P = 0.02).Trans persons who were more satisfied with the hormonal therapy had a lower prevalence of HSDD (P = 0.02).ConclusionHSDD was more prevalent in trans women compared with trans men. The majority of trans women reported a decrease in sexual desire after SRT, whereas the opposite was observed in trans men. Our results show a significant sexual impact of surgical interventions and both hormonal and surgical treatment satisfaction on the sexual desire in trans persons. Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, Weyers S, Hoebeke P, and T'Sjoen G. Sexual desire in trans persons: Associations with sex reassignment treatment. J Sex Med 2014;11:107–118.     

ORIGINAL RESEARCH–WOMEN'S SEXUAL HEALTH: Clinically Relevant Changes in Sexual Desire,Satisfying Sexual Activity and Personal Distress as Measured by the Profile of Female Sexual Function,Sexual Activity Log,and Personal Distress Scale in Postmenopausal Women with Hypoactive Sexual Desire Disorder

IntroductionTransdermal testosterone patch (TTP) treatment produced statistically significant improvements in a satisfying sexual activity (SSA), sexual desire, and personal distress in postmenopausal women suffering from hypoactive sexual desire disorder (HSDD), but clinical significance of these changes was not determined.AimTo quantify the magnitude of change in three principal outcomes measures determined by HSDD patients as associated with the perception of meaningful benefit with TTP therapy.MethodsThe criteria for defining responders were determined using anchoring methodology and receiver operating characteristics analysis to establish minimum important differences (MIDs) in a representative subsample of 132 patients in two randomized, controlled trials in surgically menopausal women with HSDD (N = 1,094). Perceived benefit was established based upon the question “Overall, would you say that you experienced a meaningful benefit from the study patches?”. These data defined responders and established MIDs for changes in sexual desire, SSA, and personal distress. The MIDs were applied to the two trials to establish responder rates in each treatment group.Main Outcome MeasuresChanges in score that correspond to the MID for sexual desire, SSA, and personal distress, and responder rates in each treatment group based upon these values.ResultsIncreases in frequency of SSA of greater than 1 activity/4 weeks, increases in sexual desire score of ≥8.9, and decreases in the personal distress score of ≥20.0 were identified as threshold improvements best able to differentiate responders and nonresponders. The responder rate was significantly higher (P < 0.001) in the testosterone group vs. placebo for all three outcomes measures (sexual desire, 50% vs. 34%; SSA, 44% vs. 30%; personal distress, 51% vs. 39%).ConclusionsChanges in sexual desire, SSA, and personal distress observed with TTP treatment in surgically menopausal women with HSDD were clinically significant and were associated with a meaningful treatment benefit. DeRogatis LR, Graziottin A, Bitzer J, Schmitt S, Koochaki PE, and Rodenberg C. Clinically relevant changes in sexual desire, satisfying sexual activity and personal distress as measured by the profile of female sexual function, sexual activity log, and personal distress scale in postmenopausal women with hypoactive sexual desire disorder. J Sex Med 2009;6:175–183.     

Androgens and Psychosocial Factors Related to Sexual Dysfunctions in Premenopausal Women1: 12016 ISSM Female Sexual Dysfunction Prize

IntroductionThe female sexual response is complex and influenced by several biological, psychological, and social factors. Testosterone is believed to modulate a woman's sexual response and desire, because low levels are considered a risk factor for impaired sexual function, but previous studies have been inconclusive.AimTo investigate how androgen levels and psychosocial factors are associated with female sexual dysfunction (FSD), including hypoactive sexual desire disorder (HSDD).MethodsThe cross-sectional study included 428 premenopausal women 19 to 58 years old who completed a questionnaire on psychosocial factors and had blood sampled at days 6 to 10 in their menstrual cycle. Logistic regression models were built to test the association among hormone levels, psychosocial factors, and sexual end points.Main Outcome MeasuresFive different sexual end points were measured using the Female Sexual Function Index and the Female Sexual Distress Scale: impaired sexual function, sexual distress, FSD, low sexual desire, and HSDD. Serum levels of total and free testosterone, androstenedione, dehydroepiandrosterone sulfate, and androsterone glucuronide were analyzed using mass spectrometry.ResultsAfter adjusting for psychosocial factors, women with low sexual desire had significantly lower mean levels of free testosterone and androstenedione compared with women without low sexual desire. None of the androgens were associated with FSD in general or with HSDD in particular. Relationship duration longer than 2 years and mild depressive symptoms increased the risk of having all the sexual end points, including FSD in general and HSDD in particular in multivariate analyses.ConclusionIn this large cross-sectional study, low sexual desire was significantly associated with levels of free testosterone and androstenedione, but FSD in general and HSDD in particular were not associated with androgen levels. Length of relationship and depression were associated with FSD including HSDD.Wåhlin-Jacobsen S, Kristensen E, Tønnes Pedersen A, et al. Androgens and Psychosocial Factors Related to Sexual Dysfunctions in Premenopausal Women. J Sex Med 2017;14:366–379.     

Reduced Gray Matter Volume and Increased White Matter Fractional Anisotropy in Women with Hypoactive Sexual Desire Disorder

IntroductionModels of hypoactive sexual desire disorder (HSDD) imply altered central processing of sexual stimuli. Imaging studies have identified areas which show altered processing as compared with controls, but to date, structural neuroanatomical differences have not been described.AimThe aim of this study is to investigate differences in brain structure between women with HSDD and women with no history of sexual dysfunction, and to determine sexual behavioral correlates of identified structural deviations.MethodsSexual functioning and gray matter (GM) and white matter (WM) were assessed in 29 women with HSDD and 16 healthy control subjects of comparable age and socioeconomic status with no history of sexual dysfunction.Main Outcome MeasuresWM properties were measured using diffusion‐weighted imaging and analyzed using fractional anisotropy (FA). GM volume was measured using three‐dimensional T1‐weighted recordings and analyzed using voxel‐based morphometry. Sexual functioning was measured using the Sexual Function Questionnaire.ResultsWomen with HSDD, as compared with controls, had reduced GM volume in the right insula, bilateral anterior temporal cortices, left occipitotemporal cortex, anterior cingulate gyrus, and right dorsolateral prefrontal cortex. Also, increased WM FA was observed within, amongst others, the bilateral amygdalae. Sexual interest and arousal correlated mostly with GM volume in these regions, whereas orgasm function correlated mostly with WM FA.ConclusionHSDD coincides with anatomical differences in the central nervous system, in both GM and WM. The findings suggest that decreased salience attribution to sexual stimuli, decreased perception of bodily responses and sexual emotional stimulus perception, and concomitant altered attentional mechanisms associated with sexual response induction. Bloemers J, Scholte HS, van Rooij K, Goldstein I, Gerritsen J, Olivier B, and Tuiten A. Reduced gray matter volume and increased white matter fractional anisotropy in women with hypoactive sexual desire disorder. J Sex Med 2014;11:753–767.     

Transdermal testosterone gel prn application for hypoactive sexual desire disorder in premenopausal women: a controlled pilot study of the effects on the arizona sexual experiences scale for females and sexual function questionnaire

IntroductionSeveral studies suggest that increased plasma testosterone can improve sexual function and desire in post-oophorectomy or postmenopausal women. However, side effects of chronic daily testosterone raise questions about the generalizability of this treatment approach. Sublingual testosterone was reported to cause testosterone levels to peak after 15 minutes and then decline to baseline levels within 90 minutes. Three to 4 hours after reaching testosterone peak, increased genital sensations and sexual lust were reported.AimWe hypothesized that a singe dose of testosterone given 4–8 hours prior to planned intercourse in women with hypoactive sexual desire disorder (HSDD) might increase desire without side effects associated with chronic use.MethodsThe design was randomized double-blind crossover. Premenstrual women with HSDD received eight packets of gel or identical placebo for use before intercourse twice weekly for 1 month. For a second month, the alternate treatment was given.Main Outcome MeasuresRatings were performed using the patient-rated Arizona Sexual Experiences Scale for females and the clinician-rated Sexual Function Questionnaire (SFQ-V1).ResultsTen patients completed the study. On the five-item self-report Arizona, the item “How easily are you aroused?” was significantly improved on testosterone gel vs. placebo, P = 0.03. There were similar trends on the physician-rated SFQ-V1 “arousal–sensation” cluster.ConclusionsThese preliminary results suggest that testosterone gel given prn before intercourse has effects on sexual arousal, and further research is needed to define dosage and time schedule to optimize this effect and determine its clinical relevance. Chudakov B, Ben Zion IZ, and Belmaker RH. Transdermal testosterone gel prn application for hypoactive sexual desire disorder in premenopausal women: A controlled pilot study of the effects on the Arizona Sexual Experiences Scale for females and Sexual Function Questionnaire. J Sex Med 2007;4:204–208.     

Intended or Unintended Consequences? The Likely Implications of Raising the Bar for Sexual Dysfunction Diagnosis in the Proposed DSM‐V Revisions: 1. For Women with Incomplete Loss of Desire or Sexual Receptivity

IntroductionCombining female sexual desire and arousal disorders is proposed for the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5). Brotto et al. challenged our findings that the proposed criteria could potentially exclude from diagnosis or treatment a large number of women with distressing loss of function or in sexual desire, because (i) our samples were insufficiently severe; (ii) we sought to retain the current diagnostic criteria, whereas they contend that “the bar should be raised”; and (iii) the current sexual function diagnostic criteria are unreliable.AimHere we provide additional data to support our view suggesting that the proposed criteria would potentially exclude large numbers of women from diagnosis or treatment if they have moderate‐to‐marked (rather than severe) hypoactive sexual desire disorder (HSDD), or HSDD with incomplete loss of receptivity.MethodsIn nontreatment validation studies of 481 women in North America and Europe, 231 women diagnosed with HSDD only were compared to women with no female sexual desire.Main Outcome MeasuresClinicians experienced in sexual medicine determined the severity of HSDD using the standard Clinical Global Impression of Severity. Rating scale data were also used, including the clinician‐rated Sexual Desire and Interest Inventory‐Female and the self‐rated Female Sexual Function Index, Changes in Sexual Functioning Questionnaire, Female Sexual Distress Scale, and an e‐Diary about desire during sexual events.ResultsThe severity of the HSDD was rated by clinicians as generally moderate‐to‐marked, not mild. The women with HSDD scored as manifestly sexually dysfunctional and significantly sexually distressed, and reported markedly fewer satisfying sexual events compared to age‐matched, non‐dysfunctional controls, even for those with moderate or milder degrees of severity, providing compelling evidence that our sample of women with HSDD had clinically disordered sexual function. Yet the proposed criteria would apparently allow diagnosis (and therefore treatment) of only severe desire dysfunction.ConclusionIt would be counterproductive to combine the two disorders, to make individual criteria for the disorders more stringent or to require more such criteria for a diagnosis because such disorders tend to be distinct in presentation, in treatability with currently available therapies, and in logical approaches to be tested to improve therapy. Clayton AH, DeRogatis LR, Rosen RC, and Pyke R. Intended or unintended consequences? The likely implications of raising the bar for sexual dysfunction diagnosis in the proposed DSM‐V revisions: 1. For women with incomplete loss of desire or sexual receptivity. J Sex Med 2012;9:2027–2039.     

Satisfying sexual events as outcome measures in clinical trial of female sexual dysfunction

IntroductionAssessing the sexual response in women with female sexual dysfunctions (FSDs) in clinical trials remains difficult. Part of the challenge is the development of meaningful and valid end points that capture the complexity of women's sexual response.AimThe purpose of this review is to highlight the shortcomings of daily diaries and the limitations of satisfying sexual events (SSEs) as primary end points in clinical trials of women with hypoactive sexual desire disorder (HSDD) as recommended by the Food and Drug Administration (FDA) in their draft guidance on standards for clinical trials in women with FSD.MethodsClinical trials in women with HSDD using SSEs as primary end points were reviewed.Main Outcome MeasuresThe agreement between three outcome measures (SSEs, desire, and distress) was assessed to illustrate to what degree improvements in SSEs were in agreement with improvements in sexual desire and/or personal distress.ResultsNine placebo-controlled randomized trials in women with HSDD were reviewed: seven with transdermal testosterone and two with flibanserin. In four trials, all using transdermal testosterone 300 µg/day had agreement between changes in SSEs, desire, and distress. In five studies (testosterone 300 µg/day, n = 2; testosterone 150 µg/day, n = 1; flibanserin n = 2), changes in SSEs did not correlate with changes in desire and/or distress and vice versa. It should be noted that in the flibanserin trials, SSEs did correlate with desire assessed using the Female Sexual Function Index but not when it was assessed using the eDiary.ConclusionsFindings in the literature do not uniformly support the recommendations from the FDA draft guidance to use diary measures in clinical trials of HSDD as primary end points. Patient-reported outcomes appear to be better suited to capture the multidimensional and more subjective information collected in trials of FSD. Kingsberg SA and Althof SE. Satisfying sexual events as outcome measures in clinical trial of female sexual dysfunction. J Sex Med **;**: **–**.     

The DSM diagnostic criteria for Hypoactive Sexual Desire Disorder in men

IntroductionHypoactive Sexual Desire Disorder (HSDD) is one of two sexual desire disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and is defined by two criteria: A—“persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity” and B—“marked distress or interpersonal difficulty.”AimThis paper reviews the prevalence and correlates of low desire in men and qualitative and quantitative research on the experience of sexual desire in men and women.MethodsA literature search of Medline, PudMed, and PsychInfo was used to identify any publication on low desire in men.Main Outcome MeasureThe strength of empirical findings was used as a basis for making proposed revisions to the diagnostic criteria for HSDD in men.ResultsThe dilemma of whether desire and arousal can be reliably differentiated in men is discussed, and parallels to the literature in women are drawn. Finally, I consider three options for the diagnosis of low desire in men for DSM-5. Option 1 proposes that the DSM-IV-TR name and criteria are preserved for men in DSM-5. Option 2 proposes that the recently proposed criteria for Sexual Interest/Arousal Disorder in women are also adopted for men, which would result in one gender-neutral category. Option 3 proposes that the criteria for Sexual Interest/Arousal Disorder also be applied to men, with a minor modification to one criterion (i.e., that absent or reduced genital and/or nongenital physical changes not be included as a criterion); this diagnosis would then be applied only to men.ConclusionsThe evidence supporting each of these proposals is presented and critiqued. It is concluded that the proposal for DSM-5 should be made on the basis of field testing of new criteria. Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in men.     

Asexuality: An Extreme Variant of Sexual Desire Disorder?

IntroductionHuman asexuality is defined as a lack of sexual attraction to anyone or anything. Various theories have been proposed to explain how asexuality should best be classified, and some have maintained that asexuality is an extreme variant of hypoactive sexual desire disorder (HSDD)—a sexual dysfunction characterized by a lack of interest in sex and significant distress. To date, this has never been empirically examined.Aim and MethodUsing measures of sexual desire and behavior, sex‐related distress, personality, and psychopathology, the aim of the current study was to compare individuals scoring above the cutoff for asexuality identification (AIS >40) (n = 192) to sexual individuals (n = 231). The sexual group was further divided into a control group (n = 122), a HSDD group (n = 50), and a group with symptoms of low desire that were nondistressing (n = 59).ResultsAnalyses were controlled for age. Individuals in the AIS >40 group had a greater likelihood of never previously engaging in sexual intercourse, fantasies, or kissing and petting than all other groups and a lower likelihood of experiencing sex‐related distress than those with HSDD. For women, those in the HSDD and AIS >40 groups had significantly lower desire than the subclinical HSDD and control groups. Men in the AIS >40 group had significantly lower desire than the other three groups. Symptoms of depression were highest among those with subclinical HSDD and HSDD, whereas there were no group differences on alexithymia or desirable responding. A binary logistic regression indicated that relationship status (long‐term dating/married), sexual desire, sex‐related distress, and lower alexithymia scores were the best predictors of group membership (HSDD vs. AIS >40).ConclusionTaken together, these results challenge the speculation that asexuality should be classified as a sexual dysfunction of low desire. Brotto LA, Yule MA, and Gorzalka BB. Asexuality: An extreme variant of sexual desire disorder? J Sex Med 2015;12:646–660.     

National Differences in Patient–Clinician Communication Regarding Hypoactive Sexual Desire Disorder

IntroductionDespite greater awareness and openness about sexual problems among women, many patients remain reserved about discussing such problems with their doctor. Clinicians are often reluctant to ask about sexual dysfunction.AimTo learn how clinicians can communicate more effectively with patients who have hypoactive sexual desire disorder (HSDD) by exploring the language used by patients and clinicians in the United States, France, and Germany when describing the symptoms, causes, and correlates of HSDD.MethodsIndependently conducted face-to-face, semi-structured interview with 127 clinicians involved in the treatment of female sexual dysfunction (FSD) and 95 women with FSD who were screened for HSDD using a brief adaptation of the Sexual Interest and Desire Inventory-Female®.Main Outcome MeasureLanguage used by clinicians and patients.ResultsClinicians and patients found FSD a difficult subject to discuss. Recognition of the term HSDD was low, with “decrease in sexual desire” preferred. Distress, currently integral to the diagnosis of HSDD, was an unpopular term. It implied to participants a state of fear or anxiety and a degree of severity not reflected by their feelings about the condition. Key feelings conveyed by patients included low self-esteem, frustration, confusion, dissatisfaction/discontent, concern, anger, embarrassment, stress, depression, and a sense of being incomplete. Clinicians were frustrated by the lack of effective treatment options for HSDD, which contributed to reluctance in discussing sexual health with patients. Patients were increasingly motivated to seek treatment, with an “improvement in level of desire” identified as the most meaningful treatment outcome, rather than an increase in satisfying sexual events.ConclusionsMore carefully constructed definitions, based on understanding the common language between clinicians and patients, would improve doctor–patient communications and set common expectations for treatment of HSDD. Defining HSDD in simpler, non-psychiatric terms such as “decreased sexual desire” illustrates how HSDD can be translated into more patient-friendly language. Goldstein I, Lines C, Pyke R, and Scheld JS. National differences in patient–clinician communication regarding Hypoactive Sexual Desire Disorder. J Sex Med 2009;6:1349–1357.     

Methods to determine the minimum important difference for a sexual event diary used by postmenopausal women with hypoactive sexual desire disorder

IntroductionRecently, there has been much discussion in the literature about how to determine the meaningfulness of results generated from a patient-reported outcome measure. A number of reviews have shown that there are two main approaches: anchor- and distribution-based approaches for determining the minimum important difference (MID) for a new measure. There are issues with calculating an MID using each method: Will the two approaches give the same estimate? If the estimates differ, how do you decide on one estimate? Would asking patients directly be more beneficial?AimA case study was presented to address these issues based on a newly developed diary assessing number of satisfactory sexual events (SSEs) per week in women with hypoactive sexual desire disorder (HSDD).MethodsAnchor- and distribution-based estimates were generated from data gathered in two double-blind, placebo-controlled, parallel group trials for the treatment of HSDD (N = 788). A novel interview study was used to ask women directly about an MID for SSEs (N = 77).Main Outcome MeasuresDefining the MID for an SSE diary in women with HSDD.ResultsThe estimates varied, producing a range of mean MID estimates between 0.04 and 0.46 SSEs per week.ConclusionsWe recommend that rather than defining the MID, a range should be selected from the set of estimates formed by the limits of the 95% confidence intervals. Symonds T, Spino C, Sisson M, Soni P, Martin M, Gunter L, and Patrick DL. Methods to determine the minimum important difference for a sexual event diary used by postmenopausal women with hypoactive sexual desire disorder.     

The Presentation of Hypoactive Sexual Desire Disorder in Premenopausal Women

IntroductionLittle is known about the clinical presentation of hypoactive sexual desire disorder (HSDD) in premenopausal women or their perceptions of sexual problems.AimDescribe characteristics of premenopausal women with clinically diagnosed acquired, generalized HSDD, and investigate factors perceived to contribute to desire problems.MethodsCross-sectional analysis of baseline data from premenopausal women with clinically diagnosed and confirmed HSDD enrolled during the first year of the HSDD Registry for Women (N = 400).Main Outcome MeasuresRelationship, demographic, and clinical characteristics were assessed by clinician's medical history review and self-administered questionnaire. Sexual desire function was measured by the validated Female Sexual Function Index (FSFI).ResultsOver 85% of women cited multiple factors that contributed to ongoing decreased desire (mean 2.9 ± 2.3 factors, range 0–12). Most commonly cited contributing factors were “stress or fatigue” (60.0%), “dissatisfaction with my physical appearance” (40.8%), and other sexual difficulties (e.g., inability to reach orgasm) (33.5%). Exploratory analyses of the FSFI score confirmed that self-image (P = 0.002) and other sexual problems (P < 0.001) were significantly associated with decreased desire. Almost all (96%) participants were currently in a partner relationship. Antidepressant medication was currently used by 18.0% of women, hormonal contraceptives by 28.5%, and hormonal medications (for noncontraceptive reasons) by 7.3%. Physical functioning was consistent with general population norms (SF-36 mean ± standard deviation, 53.3 ± 7.6 vs. norm of 50 ± 10), while overall mental functioning was slightly lower (SF-36, 44.7 ± 10.6).ConclusionsWithin this sample of premenopausal women with clinically diagnosed HSDD, decreased sexual desire was associated with multiple factors, including poor self-image and stress or fatigue. Clinicians presented with premenopausal women expressing sexual desire problems should assess patients' perceptions of their condition to develop a comprehensive, patient-oriented management plan. Therapy may need to address issues with low self-esteem and mood and offer practical coping mechanisms for stress and fatigue. Maserejian NN, Shifren JL, Parish SJ, Braunstein GD, Gerstenberger EP, and Rosen RC. The presentation of hypoactive sexual desire disorder in premenopausal women.