Hypoactive Sexual Desire Disorder (HSDD)

What makes low desire a disorder

Desire varies widely between people and over a lifetime. Lower interest in sex is not a disorder in itself. Clinicians diagnose HSDD when:

• Sexual thoughts, fantasies and desire for sex are persistently reduced or absent
• This has lasted at least 6 months
• It causes personal distress, not just a partner's frustration
• It is not better explained by another mental health condition, severe relationship problems or violence, other major stressors, or the effects of a medicine or medical condition alone

In the DSM-5-TR, the psychiatric diagnostic manual, women's low desire is grouped with arousal problems as female sexual interest/arousal disorder, while men's is called male hypoactive sexual desire disorder. Gynecology and sexual medicine societies still use HSDD for women. People who identify as asexual and are not distressed do not have a disorder.

Low desire is one of several sexual dysfunctions and often overlaps with arousal problems, pain or difficulty reaching orgasm (anorgasmia). For a broader look at everyday reasons sex drive falls, see low libido.

Spontaneous vs responsive desire

Many people, especially in long relationships, rarely feel desire "out of the blue" (spontaneous desire) but do feel it once touching or intimacy begins (responsive desire). This is normal. HSDD involves little desire of either kind. Understanding this difference alone helps many couples.

Causes and risk factors

Medical and hormonal

• Menopause, especially surgical menopause with removal of both ovaries
• Low testosterone in men (hypogonadism)
• High prolactin and thyroid disease
• Diabetes, heart disease, multiple sclerosis, cancer and its treatment, chronic pain
• Pain during sex, vaginal dryness and erectile dysfunction, which make sex unrewarding

Medicines

• SSRIs and SNRIs (the commonest medication cause)
• Hormonal contraception in some women
• Opioids, some blood pressure medicines, antipsychotics, anti-androgens and finasteride

Psychological and relationship

• Depression and anxiety
• Stress, exhaustion and caregiving, including after childbirth
• Relationship conflict, poor communication or lack of trust
• Negative body image, past sexual trauma, or restrictive beliefs about sex

How HSDD is diagnosed

A doctor, gynecologist, urologist or sex therapist will ask:

• When desire changed and whether it is lifelong or acquired, general or only with one partner
• How much it bothers you and your relationship
• About mood, stress, sleep, relationship and past experiences
• About pain, arousal, lubrication, erections and orgasm
• What medicines and substances you take

Short questionnaires such as the Decreased Sexual Desire Screener are sometimes used. Examination and blood tests are guided by the history: prolactin, thyroid function, and in men a morning testosterone level. In women, testosterone levels do not reliably diagnose HSDD and are not used for that purpose.

Treatment

Psychological and couple approaches

• Sex therapy and couple therapy: improve communication, reduce performance pressure and use structured exercises such as sensate focus.
• Cognitive behavioral therapy and mindfulness-based therapy: have good evidence for women's low desire.
• Education about responsive desire, scheduling intimacy and reducing distractions.

Addressing medical causes

• Changing or adjusting an antidepressant. Bupropion is less likely to lower desire. Never stop an antidepressant suddenly without medical advice.
• Treating vaginal dryness after menopause with lubricants, moisturizers or low-dose vaginal estrogen.
• Treating depression, thyroid disease, high prolactin or erectile dysfunction.

Medicines for HSDD

These medicines produce modest average improvements, and combining them with therapy usually works best.

Outlook

Acquired HSDD with a clear cause, such as a medicine, often improves when that cause is treated. Lifelong low desire tends to be more persistent, but therapy can still reduce distress and improve satisfaction. Many people find that easing the pressure around sex and addressing the relationship makes the largest difference.

Frequently asked questions

What is hypoactive sexual desire disorder?

It is a persistent, distressing lack of sexual desire, thoughts or fantasies lasting 6 months or more, not fully explained by another mental health condition, relationship crisis, medicine or illness. It is diagnosed only when the low desire bothers the person, not because it differs from a partner's level.

What is the best treatment for HSDD?

There is no single best treatment. Most people do well with a combination: treating medical and medication causes, sex therapy or CBT, and relationship work. For premenopausal women, flibanserin or bremelanotide may be added, and postmenopausal women may benefit from carefully monitored testosterone.

Can antidepressants cause HSDD?

Yes. SSRIs and SNRIs commonly reduce desire and delay orgasm. Options include lowering the dose, switching to bupropion or another medicine, or adding treatment, all under medical supervision. Depression itself also lowers desire, so treating it well remains important.

Is HSDD the same as low libido?

Low libido is a general description of reduced sexual interest, which is often temporary and may not be a problem. HSDD is a clinical diagnosis requiring at least 6 months of low desire and personal distress, after other explanations have been considered.

Do men get hypoactive sexual desire disorder?

Yes. Men can have persistent, distressing low desire, from low testosterone, depression, medicines, relationship problems, stress or erectile dysfunction. Testing a morning testosterone level is part of the assessment, but most men with low desire have normal testosterone.