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The essential components of sexual function assessment in the male always include: erectile response (onset, duration, progression, sever- ity of the problem, nocturnal/morning erections[r]

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Library of Congress Cataloging-in-Publication Data:

Handbook of sexual and gender identity disorders : edited by David L.

Rowland, Luca Incrocci.

p ; cm.

Includes bibliographical references and index.

ISBN 978-0-471-76738-1 (cloth : alk paper)

1 Psychosexual disorders—Handbooks, manuals, etc 2 Rowland, David

(David L.) II Incrocci, Luca.

[DNLM: 1 Sexual and Gender Disorders—diagnosis 2 Sexual and Gender Disorders—physiopathology 3 Sexual and Gender Disorders—therapy WM 611 H2361 2008]

RC556.H356 2008

616.85 ′83—dc22

2007034474 Printed in the United States of America.

and to the friends, family, and colleagues who havesupported and mentored me over the years.

D L R

To my wife Nicole and my children Jonathan and Carlotta

for their patience and support

L I

Geoffrey Ian Hackett

Characterizing Sexual Desire and

Physiology of Desire and Drive Disorders in Men 10

Clinical Evaluation of Desire Disorders 18

Management of Hypoactive Sexual

Ronald W Lewis, Jiuhong Yuan, and Run Wang

Definition of Erectile Dysfunction 33

Anatomy of the Penis 34

Pathophysiology, Risk Factors, and Clinical

Correlates of Erectile Dysfunction 41

Evaluation of the Patient with

Chapter 4

Michael A Perelman and David L Rowland

Definition and Descriptive Characteristics 101

Androgens and Endocrine Function in Aging Men:

Louis Gooren

Sexuality and Aging in Men: An Introduction 122Physiological Aspects of Male Aging 123Correlations between Androgen and Symptoms of Male Aging 128Impact of Androgens on Sexual Functioning with Age 131

Diagnosis of Late Onset Hypogonadism 138Treatment of Late Onset Hypogonadism 140

Integrated Treatment for Sexual Problems in Aging Men 148

Chapter 6

Jacques van Lankveld

Definitions and Classifications 155Physiological Aspects of Female Sexual Arousal 158

Chapter 7

Cindy M Meston, Brooke N Seal, and Lisa Dawn Hamilton

Melissa A Farmer, Tuuli Kukkonen, and Yitzchak M Binik

Course, Development, and Prevalence of Pain 225

Assessment 229

Therapeutic Mechanisms and Strategies 243

Chapter 9

Lori A Brotto and Mijal Luria

Hormonal Alterations with Menopause and Their Effects 254

Effects of Age versus Effects of Menopause 263Physiological Aspects of Sexual Response in Menopausal Women 264

Cultural Aspects of Menopause and Sexuality 266Classification, Diagnosis, and Treatment 267

Chapter 10

Luca Incrocci and Woet L Gianotten

Appendix I: Cancer and Noncancer Related Factors

Appendix II: Cancer Treatment and Its Effects on Sexual Functioning 320

Part Editor: Kenneth J Zucker

Chapter 11

Eric J N Vilain

Genes of Sexual Differentiation 343

On the Topic of Genetics and Sex: Sexual Orientation 347

Disorders of Sex Development 360Clinical Management of Disorders of Sex Development 370

Children with Gender Identity Disorder 380

Adolescents with Gender Identity Disorder 401

Treatment 442

Treatment of Families of Persons with Gender Identity Disorders 450

Chapter 17

Patrick Lussier, Kristie McCann, and Eric Beauregard

General Etiological Models of Sexual Deviance 530

Specific Etiological Models of Sexual Deviance 541

Theoretical Intergration and Clinical Considerations 552

Chapter 19

Matt O’Brien, Liam E Marshall, and W L Marshall

Sexual Addiction in Sexual Offenders 588Online Sexual Behavior Problems 593

Appendix: Alphabetical Listing of DSM-IV Sexual

In this volume, we have brought together thoughts and

recommendations of notable international experts in the

field of sexual disorders, based on their understanding and

evaluation of the research literature and on their assessment

of current diagnostic and treatment practices The text is

written to benefit mental health clinicians and primary care

physicians, as well as specialists in the fields of sex therapy

and sexual medicine The intersection of these multiple

per-spectives is becoming increasingly inevitable and thoughtful

integration is becoming critically important Health providers

from many disciplines, both in and outside the field of

sexol-ogy, will benefit not only from greater understanding of these

merging viewpoints but also from exposure to new

develop-ments within their own expert and cognate fields

The volume is organized around the three major sexual

disorder classifications:

Part I Sexual Dysfunctions, that is, problems in

re-sponding adequately to achieve a sexually

satis-fying life, usually within the context of a sexual

relationship

Part II Gender Identity Disorders, that is, strong

cross-gender identification and a general discomfort

with one’s assigned sex, as usually is

biologi-cally determined

Part III Paraphilias and Atypical Sexual Behaviors, that is,

strong sexual urges, behaviors, and/or fantasies

that involve sexual activity with inappropriate

objects or in inappropriate situations

An underlying assumption of each disorder is that the

condition causes significant distress and/or that it leads to

im-pairment in social or interpersonal functioning Many of the

disorders are classified in the Diagnostic and Statistical Manual

of Mental Disorders (DSM; as well as the International Statistical

Classification of Diseases and Related Health Problems or ICD) We

have included an Appendix listing the DSM descriptions.

Each part includes a brief introduction, followed by a

series of chapters meant to bring breadth to the

understand-ing of the disorder classification Each chapter addresses a

specific aspect of the disorder classification—including an

introduction to the issue, definition and description of the

disorder, prevalence and risk factors, assessment strategies,

and finally, recommendations for treatment Each part also

includes at least one chapter on an emerging issue or alternativeviewpoint, selected because it steps in some way beyond the tradi-tional boundaries of sexological inquiry.

We have asked authors to present their topics from a holisticperspective, attending to the multiple audiences of the volume

We encouraged the use of tables, figures, and summary sidebarsand bullets to make the information more easily understood andreferenced While some authors responded enthusiastically tothese tasks and others had to be coaxed, in the end, because theybrought their own discipline-specific perspective and “culture” tothe text, we are confident that the overall coverage is fair and bal-anced At the same time, we recognize that research and treat-ment gains have not been spread evenly across perspectives; thisresults—not surprisingly—in chapters inevitably weighted towardone approach or another (e.g., biological/medical or psychologi-cal/ developmental) Our hope is that no matter what the reader’sperspective, the material in this volume will both answer ques-tions and raise new ones

We are grateful to the authors who contributed their time,labor, expertise, and intellectual investment to this handbook Wehope you, the reader, take as much from these chapters as the au-thors put into them, that you find this volume thoughtful, inform-ative, and useful, whether you are a seasoned expert in the field, acurious professional expanding horizons, or a student embarking

on an exploratory voyage into the field of sexology

The editors appreciate the careful eye, organizational

skills, and persuasive communication abilities of

Kim-berly Wampler—her tireless work with the authors and her

calm demeanor staved off many potential panic attacks by the

editors Kathleen Mullen’s thoughtful readings and feedback

on a number of chapters helped greatly with the progression

of ideas within chapters and consistency across chapters

Melissa Fisher’s continual formatting and reformatting of

chapters, and checking and rechecking this, that, and

every-thing were indispensable contributions to the handbook

And, of course, we thank our editors at Wiley

Montreal, Quebec, Canada

Lori A Brotto, PhD, R Psych

Department of Obstetrics and Gynaecology

University of British Colombia

Vancouver, British Columbia, Canada

Peggy T Cohen-Kettenis, PhD

Gender Clinic

Vrije Universiteit Medical Center

Amsterdam, The Netherlands

Royal Ottawa Health Care Center

Ottowa, Ontario, Canada

Free University Medical Center

Amsterdam, The Netherlands

Goeffrey Ian Hackett, MD

Fisherwick, Lichfield, United Kingdom

xxi

Lisa Dawn Hamilton, BA

Department of Psychology

University of Texas—Austin

Austin, Texas

Luca Incrocci, MD, PhD

Department of Radiation Oncology

Erasmus MC-Daniel den Hoed

Sexual Medicine Clinic

Hadassah University Hospital

Jerusalem, Israel

Patrick Lussier, PhD

School of Criminology

Simon Fraser University

Burnaby, British Columbia, Canada

Liam E Marshall, MA

Rockwood Psychological Services

Kingston, Ontario, Canada

W L Marshall, OC, PhD, FRSC

Rockwood Psychological Services

Kingston, Ontario, Canada

Kristie McCann, MA

School of Criminology

Simon Fraser University

Burnaby, British Columbia, Canada

Serena Nanda, PhD

Department of AnthropologyNew York University

New York, New York, andJohn Jay College of Criminal JusticeCity University of New York

New York, New York

North Hampton Square, London,United Kingdom

Michael A Perelman, PhD

Departments of Psychiatry,Reproductive Medicine, and UrologyPresbyterian Weill Cornell

Medical CenterNew York, New York

David L Rowland, PhD

Department of PsychologyValparaiso UniversityValparaiso, Indiana

Brooke N Seal, MA

Department of PsychologyUniversity of Texas—AustinAustin, Texas

Renee Sorrentino, MD

Institute for Sexual WellnessShirley, Massachusetts

Jacques van Lankveld, PhD

Department of Medical/Clinical and

Experimental Psychology

University of Maastricht

Maastricht, The Netherlands

Eric J N Vilain, MD, PhD

Department of Human Genetics

UCLA School of Medicine

Los Angeles, California

Houston, Texas

Kenneth J Zucker, PhD, CPsych

Center for Addiction and Mental HealthToronto, Ontario, Canada

S E X U A L D YS F U N C TI O N S

I

Consistent with our peculiarly Western tendency to analyze,organize, and label things, the field of sexology has typicallydescribed sexual response as having desire, arousal, and resolu-tion (orgasm) phases This convenient (with respect to a nosology

of diagnosing and treating sexual problems), but misleading acterization of sexual response has, for sexologists, been both ablessing and a bane It enables us to speak a common language, toinvestigate more discrete units of analysis, and to thoroughlypiece together small puzzles to produce greater understanding Atthe same time, such structures impose artificial boundaries on ourinvestigations, limit our abilities to incorporate theories and ideasfrom outside disciplines, and diminish the creativity with which

char-we go about solving problems in the field

We editors have complacently and expediently permittedourselves to fall into this organizational trap, though, of course,differentiating between the responses of men and women The re-sult is that the various chapters purporting to cover a specifictopic cannot do so without making reference to concepts andideas germane to the other topics But this is an asset rather than

a liability, resulting in the reader sometimes being exposed to ilar ideas multiple times through different lenses

sim-Thus, we include chapters dealing with the normal elements

of sexual response and dysfunction on sexual desire (a slipperyconstruct, but one with both a phenomenological reality and ability

to help explain the frequency and intensity of sexual behaviors),sexual arousal, and sexual resolution (orgasm and ejaculation inthe man) We are certain you will be struck by the substantial dif-ferences in approach in the chapters discussing male versus femalesexual response Whether this is a function of differences in the ac-tual phenomena under discussion, in the advances made in each ofthe fields, in the importance of specific outcomes to treatment or inthe perspectives and supporting language of the authors alignedwith the issue is not always evident

Beyond this basic coverage, we have included chapters onemerging or evolving topics, dealing specifically with vaginal pain

in women (Is it a sex or a pain disorder?), hormones and aging inmen (androgens affect more than just sexual health), aging and

3

menopause in women (the challenge of separating the effects ofone from the other), and sexuality and disease (people who arechronically ill lament the loss of their sexuality or face specialchallenges in realizing it).

Significant advances have been made with respect to men’ssexuality, however, there are challenges facing researchers as theytry to better understand women’s sexuality, work with our cur-rent (and even recently modified) models of sexual response, andthe systematic exploration of other areas

Part I has two sections: Male sexual dysfunctions are cussed in Chapters 1 through 5, and female sexual dysfunctionsare discussed in Chapters 6 through 10

1

C h a p t e rGeoffrey Ian Hackett

Learning Objectives

In this chapter, we discuss the:

• Nature and components of sexual desire

• Epidemiology of desire problems in men

• Physiology of sexual desire

• Medical and psychological factors related to desire disorders

• Management of hypoactive sexual desire disorder

• Ethical concerns surrounding treatment

Low sexual desire in men, clinically referred to as male

hy-poactive sexual desire disorder (HSDD), is a condition acterized by diminished or absent intensity or frequency of desire

char-for sexual activity The Diagnostic and Statistical Manual char-for Mental

Disorders (DSM) first included male HSDD as a sexual disorder in

1977, and most recently DSM-IV (American Psychiatric

Associa-tion, 2004) has defined it as:

A Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity The judgment of deficiency or ab- sence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person’s life.

B The disturbance causes marked distress or interpersonal difficulty.

C The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condi- tion (p 541)

DSM-IV further qualifies HSDD as “acquired” if it develops

after a period of normal sexual functioning or “generalized” if it isnot limited to certain types of stimulation, situations, or partners

A number of issues arise from the DSM definition For

exam-ple, the validity of the statement “unless explained by anothermedical disorder” has been the subject of discussion for two rea-sons First, medical disorders such as depression and erectile dys-function frequently coexist with low sexual desire, yet even themost thorough sexual history cannot always determine whichvariable explains the other Second, it is not always clear when aparticular factor affecting sexual desire might be classified as a

“medical disorder.” For example, testosterone deficiency may tribute to low sexual desire, yet researchers and clinicians havenot yet reached a consensus regarding a threshold level for normaltestosterone, below which would constitute a deficiency and thuswarrant a medical diagnosis of hypogonadism

con-Characterizing Sexual Desire and Its Components

Kaplan’s (1995) model of the male sexual response concludes thatdesire in men is innate and spontaneous, leading to arousal, com-prising erection and excitement, and further leading to orgasmand detumescence Today, most experts would regard this view assimplistic because sexual desire is not a singular phenomenon thatserves merely as a precursor to the other stages of the sexual re-

sponse cycle The Oxford English Dictionary’s (1989) definition for

libido, a term frequently used in the clinical literature to denote

sexual desire, hints at the true complexity of this construct So fined, libido involves spontaneous sexual thoughts and fantasies,

de-as well de-as attentiveness to external sexual stimuli that may be sual, auditory, or tactile

vi-Although no broad consensus exists regarding an accepteddefinition for sexual desire (and, indeed, it may differ for menversus women: see Chapter 6), in an attempt to capture its com-plex nature, Levine (2003) defines desire as “the motivation or in-clination to be sexual” and suggests that this construct beconsidered in terms of the following components:

Table 1.1 Gender Differences in Sexuality

Disparity often the issue

• Drive is the biological component of desire Levine suggests

that this component might one day be described in terms of

a series of specific neurophysiological events Male sex drivefocuses primarily on intercourse and orgasm, whereas fe-male sex drive focuses primarily on intimacy, with sexualactivity viewed in this broader context and orgasm seen asoptional (see Table 1.1)

• Motive is specific to the individual and related to the

particu-lar relationship dynamics (i.e., pertaining to the ship” reasons for wanting to have sex), as might beconsidered in terms of “she might leave me unless I have sexwith her.” Presumably this component is more pronounced

“relation-in female desire

• Wish refers to the cultural expectations that lead a person to

want to have sex; in some instances it reflects the gender pectation of what it means, for instance, to be a “true man.”Hypoactive sexual desire disorder (HSDD), the nomencla-ture representing a clinical diagnosis of a low-desire problem, is

ex-a condition chex-arex-acterized by the ex-absence or noticeex-able decreex-ase

in the frequency with which the man experiences the desire forsexual activity Whether this condition constitutes a problem forthe couple or causes distress within the relationship is frequentlyrelated to the desire disparity within the couple A high level

of disparity between partners is likely to distress one or bothpartners In contrast, a low level of desire in both parties can beassociated with low distress and a satisfactory relationship As aresult, low desire in either partner might never reach the point

of clinical diagnosis

HSDD frequently coexists with other sexual disorders(Meuleman & van Lankveld, 2005) For example, an importantdistinction concerning the diagnosis of low sexual desire is the ex-clusion of sexual aversion disorder, a condition where negativeemotions such as fear, disgust, revulsion, or anger are expressed

when engaging in sexual activity with a partner or when simplythinking about sex, either with that partner or more generally.Aversion cases are often the result of sexual trauma such as childabuse, conflict about sexuality, or abuse or infidelity by a partner.Such conditions clearly require specific targeted therapy that ad-dresses these primary issues (Leiblum & Rosen, 2000) becauselow desire in these individuals is a by-product of these other con-ditions Both in clinical practice and in epidemiological surveysexploring sexual desire, these components are frequently inter-woven In men, HSDD may also be associated with erectile dys-function and is frequently erroneously diagnosed and treated assuch, often with disappointing results because the primary sexualproblem, namely sexual avoidance due to erectile failure, has notbeen addressed Such complex situations where comorbid sexualproblems exist require both astute diagnostic practices and treat-ment protocols.

Epidemiology

Prevalence Rates for Low Sexual Desire and Male

Hypoactive Sexual Desire Disorder

The 1992 National Health and Social Life Survey (NHSLS; mann, Paik, & Rosen, 1999), which surveyed 1,410 men ages 18

Lau-to 59 in the United States, reported a prevalence rate of 5% forsexual desire disorders in men, 5% for erectile dysfunction (ED),and 22% for premature ejaculation The prevalence of desire dis-orders in the female cohort was 23% Although this study usedsuitable statistical methods for generating prevalence rates, thedisparity between the low prevalence of ED reported in thisstudy and much higher rates reported in subsequent studiescasts doubt on the accuracy of the estimates, including those forsexual desire disorders One of the potential problems of theNHSLS was that it required the participants’ subjective evalua-tion on an item only indirectly related to low sexual desire:specifically, participants were asked whether they felt “reduced,normal, or higher than average” levels of sexual desire

More recently, the Global Sexual Attitudes and BehaviorsStudy (GSSAB; Laumann, Nicolosi, Glasser, Paik, & Gingell,2005), an international survey of 13,618 men from 29 countries,included a single item as to whether lack of sexual interest oc-curred occasionally, periodically, or frequently, with self-assessed ranges for these categories occurring between 13% and28% Because the GSSAB surveyed almost 10 times the number

of men and included more detailed questions than the NHSLS,

its prevalence rates are generally considered better estimates Noless important, these rates are more consistent with the clinicalexperiences of many health providers, and they are consistentwith an earlier large United Kingdom population study on menages 18 to 59 that found 14% to 17% reporting a lack of interest

in sex (Seagraves & Seagraves, 1991)

However, self-reported low sexual desire is not mous with clinically diagnosed HSDD, and rates for male HSDDare still not clear In population-based studies, HSDD has beenreported in 0% to 15% of men and ED in 10% to 20% (Rosen,2000) An analysis of 52 studies published between 1990 and

synony-2000 using community samples yielded prevalence rates of 0%

to 3% for male HSDD and 0% to 5% for ED (Simons & Carey,2001) Not surprisingly, prevalence estimates from primary careand sexuality clinic samples have been characteristically muchhigher

Covariates of Low Sexual Desire

A number of covariates of low desire have been identified; theNHSLS project found low desire related to such items as “think-ing about sex less than once per week”; “having any sexual activ-ity with a person of the same sex”; “partner ever having anabortion”; and “being sexually touched before puberty.” In theGSSAB study, risk factors for low sexual interest included depres-sion, high alcohol consumption, emotional problems or stress,and poor general health

Perhaps the one factor that most consistently predictslow sexual desire is age Low sexual desire was strongly corre-lated with age in both the NHSLS and GSSAB study, as well as

in other studies (e.g., Dunn, Croft, & Hackett, 1998b) Onecommunity-based U.S study found that 26% of men ages 70and over had HSDD compared with only 0.6% ages 40 to 49(Panser et al., 1995)

Gradual decreases in sexual desire are often considered anatural consequence of aging by respondents of many surveys.Decreased desire is less likely to cause distress to an individual ifthe onset is gradual (as occurs with aging) rather than sudden;many older couples simply adjust to this gradual age-related de-cline in sexual desire and activity Nevertheless, at least 25% ofmen report an ongoing interest in having regular sexual activity(i.e., more often than monthly) into their eighties (Balon, 1996),and many older individuals and couples view sexual activity as

an important aspect of individual and relationship well-being.Even though many men suffer a decline in sexual interest andactivity, they are often too embarrassed to raise the topic withtheir physician

Physiology of Desire and Drive Disorders in Men

While the psychoanalytic concept of libido is now over a centuryold, the experimental analysis of sexual motivation and drive wasfirst undertaken by Beach in the 1950s Based on research withmale rats, Beach (1956) introduced the concept of the “dual na-ture of sexual arousal and performance,” postulating that sexualbehavior depends on two relatively independent processes, one

controlling motivation (analogous perhaps to sexual desire or bido in humans) and the other consummation Motivation—the use

li-of the term by Beach differs from its use by Levine in the analysis

of sexual desire discussed in the previous section—involves a ual arousal mechanism that determines a male’s sexual response

sex-to the perception of a receptive female Its main function is sex-tostimulate the male rat to approach a female and to raise its sexualexcitement to the threshold necessary to activate the consumma-tory elements of sexual behavior, that is, mounting and intromis-sion Thereafter, the consummatory mechanism controls theintromission and ejaculatory elements of the male rat’s sexual be-havior, integrating the sequence of mounts and intromissions,thus amplifying the male’s arousal until ejaculation occurs Re-cent animal research has expanded Beach’s model, showing, forinstance, that the motivational and consummatory processes in-volve separate brain regions within the hypothalamic and limbicsystems (Hamann, Herman, Nolan, & Wallen, 2004), indepen-dently modulated by androgenic and dopaminergic agents (Balt-hazart & Ball, 1998; Everitt, 1990; Pfaus, 1999) These animalstudies suggest an intricate interplay among steroid hormone ac-tions, specific brain regions, and environmental (including part-ner) stimuli that maintain central sexual arousability From this,expectations of competent sexual functioning have been devel-oped, including sexual desire, arousal, and performance How-ever, extrapolation of findings based on animal models to humansexual functioning remains controversial Although recent work

in neural and behavioral sciences has allowed exploration of themany factors that affect sexual motivation and performance inhumans, even with this, the understanding of sexual desire inmen remains incomplete The following sections discuss a number

of factors that are well-known to affect sexual desire

Biological and Medical Factors Related to

Low Sexual Desire and Hypoactive Sexual

Desire Disorder

Research exploring sexual desire suggests that it may be related toany number of sexually specific and nonspecific factors Some,such as androgen deficiency and relationship conflict, may be spe-

Table 1.2 Common Factors Associated with

Hypoactive Sexual Desire Disorder in Men

Bodybuilding and eating disorders

cific to the expression of sexual response Others factors such asanger, depression, and related negative emotional states may entailbroad psychological responses that depress sexual interest in gen-eral (see Table 1.2) Several factors known to affect men’s sexualdesire, along with several putative influencers, are discussed next

Androgen Deficiency and Hypoactive Sexual Desire Disorder

Androgens (see Meston & Frohlich, 2000) are the major mones regulating the biological component of desire in men (seeTable 1.3) Extensive studies have shown that testosterone isnecessary for the full-range of sexual responses (Everitt, 1995;Nelson, 2000) and is associated with depression in aging men(McIntyre et al., 2006) The normal physiological range of testos-terone is usually above 10 to 12 nmol/L and is considerably higherthan that necessary for normal sexual function Critical testos-terone levels for sexual function in males appear to be around 6 to

hor-7 nmol/L (Traish & Guay, 2006), but with large intersubject ation (Nieschlag, 1979; also see Chapter 2, this volume)

vari-The effect of androgens on sexual desire is robust and ily reproducible (Gooren, 1987) In hypogonadal patients (i.e.,testosterone levels typically under 7 nmol/L), pathological with-drawal of androgens, followed by reintroduction of exogenousandrogens, reliably affects variation in such parameters as thefrequency of sexual fantasies, sexual arousal and desire, sponta-neous erections during sleep and in the morning, ejaculation,sexual activities with and without a partner, and orgasmsthrough coitus or masturbation (Gooren, 1987) However, ineugonadal men with or without sexual problems, the effect oftestosterone administration on sexual parameters has receivedonly limited study In a controlled study of eugonadal men withdiminished sexual desire, O’Carroll and Bancroft (1984) showedthat, compared with placebo, injections of testosterone estersproduced a significant increase in sexual interest; although inmost participants, this increase did not lead to a general im-provement of the sexual relationship In other research, whensupraphysiological doses of testosterone have been administered

read-to healthy volunteers as a potential hormonal male tive, significant increases in arousal were found, but sexualactivity and spontaneous erections did not increase (Bagatell,Heiman, Matsumoto, Rivier, & Bremner, 1994; Bancroft, 1984).Thus, androgens may affect isolated aspects of sexual response inhealthy men; but because healthy men typically produce muchmore androgen than is necessary to maintain sexual function,studies that modify testosterone levels within the normal rangehave led to the general conclusion that androgens are beneficialprimarily to men whose endogenous levels are abnormally low

contracep-Depression and Hypoactive Sexual Desire Disorder

Loss of sexual desire is a classic symptom of major depressivedisorders, and therefore depression has played a prominent role

in the psychodynamics and therapeutic management of the dition Systematic studies suggest that low desire is present in up

con-to 75% of depressed patients (Rosen et al., 1997; Speccon-tor, Carey,

& Steinberg, 1996) Cause and effect are often difficult to tain: low desire may be a symptom of depression or may lead todepression as a consequence of its impact on the patient and hisrelationship On the one hand, a full assessment of patients withHSDD and erectile dysfunction often reveals mild to moderatelevels of depression (Saltzman, Guay, & Jacobson, 2004) Yet,treating the depression with antidepressant therapy is a commoncause of HSDD, erectile dysfunction, and ejaculatory problems inmen (see Case Study 1.1)

ascer-Estrogens and Sexual Desire in Men

Estradiol, the most biologically active estrogen in men, plays animportant role on bone formation and serves as the most active

Frank, a 62-year-old long-distance truck

driver, was involved in a crash late at

night when his truck jackknifed on a

frozen road The driver of an oncoming

vehicle was killed, but Frank escaped

with only cuts and grazes For 4 weeks,

he was unable to sleep but went back

to work after only a couple of days

be-cause he felt that it was the best way to

deal with his problem For the next 2

months, he experienced outbursts of

temper, poor sleep, and flashbacks of the

accident On several occasions, he had

to pull the car over because he was

shaking and feeling light-headed His

wife suggested that he see his general

practitioner, who prescribed fluoxetine

20 mg He returned after 3 weeks, and

the dosage was increased to 40 mg with

some improvement

Twelve months after the accident, he

returned to his general practitioner

complaining of erectile dysfunction and

was prescribed 50 mg of sildenafil (4

tablets); but he returned 3 months later

saying that it had not worked He and

his wife June had always enjoyed a very

active sex life right up until the

acci-dent His insurance company had

arranged a referral with a urologist to

assess the relevance of the accident, the

subsequent depression, and its

associa-tion with his erectile dysfuncassocia-tion The

urologist reported that organic erectile

dysfunction could not have been caused

by his injuries and diagnosed

“psy-chogenic erectile dysfunction,”

suggest-ing that he be referred for sex therapy

The patient requested a second opinion

because his case was soon going to

court, and he was claiming $60,000 for

erectile dysfunction as a consequence of

his accident

A second opinion confirmed that hewas in fact suffering from HSDD, sec-ondary to posttraumatic stress disorder

In fact, since the accident, he had made

no sexual attempts, avoided all possiblesexual contact with his wife, and in-creased his workload to be away fromhome Without telling June, he tooktwo doses of sildenafil 50 mg and expe-rienced no sexual stimulation His sex-ual desire was virtually nonexistentfrom the time of starting fluoxetine

Observation Points

1 A full sexual history would haveelicited the lack of sexual attemptsand stimulation

2 Do not always accept the patient’sopinion of his problem

3 HSDD is often associated with traumatic stress

post-4 This patient should have beengiven a full erectile dysfunctionassessment for cardiovascular risk,diabetes, hypogonadism, and dyslip-idaemia, despite the history Thegeneral practitioner did not put him-self in a position to diagnose the pa-tient correctly

5 The general practitioner could be able for not assessing the case ade-quately and not warning the patientabout the possible sexual side effects

li-of the fluoxetine on sexual function

6 Discontinuation of fluoxetine andrelationship therapy improved theproblem He was found to have mildType 2 diabetes, and his erectionsimproved with tadalafil 20 mg,twice weekly, under the severe dis-tress regime His testosterone andlipids were normal

Case Study 1.1

metabolite of testosterone, affecting receptors in the brain; thislatter function may underlie its possible role on sexual desire inmen Although no significant sexual dysfunction has been ob-served in men affected by congenital estrogen deficiency (Oettel,2002), Carani et al (2005), in a study on two men, observed asynergistic positive effect of estradiol and testosterone on sexualbehavior Yet, under some circumstances, estradiol may have anegative effect on sexual desire in men In males, 20% of estradiol

is formed by the Leydig cells in the testes and 80% in peripheraltissues, particularly visceral fat, from aromatization of testos-terone or from adrenal androstenedione As a result, estradiol lev-els are generally higher in men with increased visceral fat, as well

as Type 2 diabetic patients, resulting in a relative lowering of totaltestosterone As sex hormone binding globulin (SHBG) also riseswith Type 2 diabetes, free (biologically active) testosterone is fur-ther lowered, to the extent that such men may experience re-duced levels of desire Obesity and Type 2 diabetes are alsosignificant risk factors for erectile dysfunction

Other evidence delineating a relationship between estrogenand male sexual response has been reported, but most is circum-stantial to human response or correlational in nature For example,experiments in male rats (e.g., Srilatha & Adiakan, 2004) haveshown that increases in estrogen, including phytoestrogen (i.e., es-trogens derived from plant sources), are associated with a reduc-tion in circulating testosterone and erectile insufficiency in rats due

to cavernal hypoplasia In men, a link has been found between ual dysfunction and exposure to pesticides with estrogenic or an-tiandrogenic properties (Oliva, Giami, & Multigner, 2002) Elevatedestradiol levels have been observed in erectile dysfunction patientswith veno-occlusive dysfunction (Mancini, Milardi, Bianchi, Sum-maria, & DeMarinis, 2005) Despite such associations, evidence isnot yet sufficient to justify routine screening for estradiol in menwith sexual desire problems or erectile dysfunction

sex-Dehydroepiandrosterone

Dehydroepiandrosterone (DHEA) is synthesized by the zona laris of the adrenal gland DHEA is a weak androgen (see Table 1.3),available over the counter in many countries, having been reclassi-fied in 1994 as a food supplement DHEA is converted peripherally

reticu-to tesreticu-tosterone by 17-beta hydroxysteroid dehydogenase (Siiteri,2005) Although doses of 50 to 100 mg DHEA have been reported toimprove sexual desire in men and women—with a slightly greatereffect in women—a recent analysis of all published studies on theeffect of DHEA indicates, at best, inconsistent results in men

Hyperprolactinemia

Increased secretion of prolactin (PRL) may have negative effects onsexual desire by impairing the pulsatile release of luteinizing hor-mone (LH) and subsequently testosterone (Buvat, 2003) Schwartz,

Table 1.4 Drugs Likely to Increase Serum Prolactin and Interfere with Sexual Function

Methadone

Psychotropic drugs especially phenothiazines and tricyclic antidepressants Anti-emetics, especially metoclopramide

H2 blockers, especially cimetidine at high dose

Antihypertensives, especially Reserpine, methyldopa

Estrogens

Based on “The Neurology of Sexual Function,” by C M Meston and P E.

Frohlich, 2000, Archives of General Psychiatry, 57, 1012–1030.

Bauman, and Masters (1982) reported on a series of patients withhyperprolactinemia (HPL) and isolated HSDD and anorgasmia Pa-tients with HPL commonly have low or low-normal levels of testos-terone, but improvement in sexual function by treatment with thePRL-lowering agent bromocryptine more closely mirrors the lower-ing of prolactin than the rise in testosterone (T) HPL is also associ-ated with decreased 5-alpha reduction of T to DHT, the more activemetabolite, especially on central T receptors This effect on sexualdesire is consistent with that of 5-alpha reductase inhibitors such asFinasteride (Buvat & Bou Jaoude, 2005) The effect HPL has on sex-ual desire may be mediated by the down regulation of centraldopamine receptors; hypothalamic dopamine has been consistentlyimplicated in human sexual desire Not surprisingly, commonlyused drugs that interfere with the prolactin-dopamine pathway mayaffect sexual desire and erectile function (see Table 1.4) Currentrecommendations call for the measurement of prolactin levels inconjunction with testosterone therapy in men with HSDD with orwithout associated erectile dysfunction

Alcohol

At small doses, alcohol is widely used to relieve inhibitions and toovercome negative influences on sexual desire At higher doses, al-cohol acts as an inhibitor of desire predominantly through effects

on the central nervous system and by inducing hepatic conversion

of testosterone to estradiol, particularly as hepatic function orates as the result of prolonged alcohol use Gynaecomastia, tes-ticular atrophy, and visceral obesity are associated with prolongedalcohol use

deteri-Pheromones

Interest in the relationship between chemosensory cues and maledesire, arousal, and behavior has developed recently (Cutler,Friedmann, & McCoy, 1998) Although such suppositions arebased mostly on animal experimentation, human studies haveindicated that, at high concentrations, pheromonal compoundsare consciously detected and perceived as body scents and odors