First of all, what is it? Women, particularly those in long-term monogamous relationships, may lose sexual desire and/or the ability to become sexually aroused or have orgasms. By itself, this is not a disorder even if her partner has significantly greater or more frequent desire; that is merely “desire disparity.” Nor is it a disorder if the partner is sexually frustrated, unless the affected woman feels marked distress about this loss. A dysfunctional loss or decrease in one of the main phases of sexual function, ie, desire, arousal, or orgasm, or in some form of pain with sexual activity, defines individual sexual dysfunctions, but sexual distress is what defines sexual dysfunction as a sexual disorder according to the standard manual of sexual diagnostics, the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM). If the phase of the sexual cycle (see Male HSDD) that is impaired is desire, the disorder is called Hypoactive Sexual Desire Disorder (HSDD).

A new fifth version of the DSM took effect in May, 2013. It merges disorders of desire and arousal into one diagnosis called “Sexual Desire/Arousal Disorder” (SI/AD; see below). Evidence for and against this is still forthcoming, but many clinical trials and various surveys have shown that far more women, over two-fold, have distressing loss of sexual desire than of any other of the kinds of sexual dysfunction (of arousal or orgasm, or sexual pain) [Shifren 2008; see Problems with Arousal and Orgasm].

Overlap of desire and arousal difficulties has been estimated at 25-50%. For SI/AD , three desire symptoms are to be considered: loss of desire for sex, loss of sexual thoughts, and (new vs DSM-IV Hypoactive Sexual Desire Disorder, HSDD) loss of receptivity to sex. Three arousal problems are to be considered: loss of the sensation or the genital swelling/lubrication associated with arousability, loss of pleasure/satisfaction with sex, and (new vs DSM-IV Female Sexual Arousal Disorder, FSAD) failure to become interested in sex from any stimulus.

Sexual dysfunction with related distress is frequent and chronic. The largest cross-sectional epidemiology study yet conducted, the PRESIDE study of over 30,000 US women of all ages, determined that the incidence of desire disorder with marked sexual distress was about 10%. [Shifren 2008]. This and other surveys have reached similar findings, and that the main differences among age groups were that postmenopausal women tend to have lower levels of sexual distress and were more likely to have simultaneous difficulties with desire and arousal. HSDD can drag on for years—the average duration was five years in the pre-menopausal women studied in recent clinical studies to validate measures of female sexual dysfunction and in interventional trials [Goldfischer 2011, Derogatis et al, 2012b].

So why aren’t women—or doctors—talking about this? Despite greater awareness and openness about sexual problems among women, many patients can’t discuss such problems with their doctor. Compounding the silence, clinicians are often reluctant to ask about sexual dysfunction. A study was published recently about doctors and patients to learn how they can communicate more effectively together about hypoactive sexual desire disorder (HSDD). The study explored the language used by 95 women with HSDD and 127 clinicians in the United States, France, and Germany to describe HSDD. Clinicians and patients alike found FSD difficult to discuss. HSDD was not a familiar term; “decrease in sexual desire” was preferred. Distress, though integral to the diagnosis of HSDD, was an unpopular term. To patients it implied 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 is why they were reluctant to open the topic of sexual health with patients. It became clear that simpler, patient-friendly terms, based on the common language between clinicians and patients, would improve doctor-patient communications and set expectations for treatment of HSDD. (Goldstein, 2009)

No approved treatment is available in the US for female sexual dysfunction disorders despite four large-scale development programs. This includes testosterone patches and gels, and a serotonergic agent, flibanserin, that was rejected by the FDA Advisory Committee in 2010 because of a failure to show significant efficacy over placebo on a daily intensity measure of desire, because of its modest margin of efficacy over placebo on increasing satisfying sexual events, and because of questions about safety, especially sedative reports including potentially problematic interaction with alcohol or certain other drugs, especially for a non-life-threatening indication. For female sexual arousal dysfunction, sildenafil was found ineffective, particularly in women with concomitant desire difficulties. [Basson 2002]