Over the past 15 years, sex therapists have increasingly come to recognize and acknowledge the diversity of etiological factors implicated in sexual desire disorders. As a result, current psychological treatment approaches are varied, ranging from long-term, individual psychotherapy to short-term, problem-focused couples therapy. When working in this area, some therapists value a “toolbox” of eclectic interventions, including hypnosis, transactional analysis, systemic and feminist perspectives, Gestalt therapy, cognitive-behavior therapy, and other therapeutic techniques and frameworks.

There is increasing awareness of the possibility of organic etiologies for reduced sexual drive. Although our knowledge of how these operate has become more sophisticated, we continue to have only a rudimentary understanding of the ways in which psychological factors combine and interact to give rise to severe and long-standing difficulties with drive, desire, arousal, and orgasm in both men and women. We understand the power of these psychological forces, which extends to the capacity to overcome the action of drugs acting on sexual function, as we see them operating on a regular basis, but we have only a limited understanding as to how these forces function.

Relationship factors in absence of drive and desire are often played down by individuals, couples, and clinicians alike, because working with such factors is challenging, complex, and potentially “dangerous,” the threat of change being an extremely destabilizing force, especially in long-term partnerships.

Psychodynamically Oriented Sex Therapy

Before Masters and Johnson, such sex therapy as was available was dominated by the work of Freud and the psychoanalytic movement. Some tenets of these early approaches have now been seriously challenged and superseded. The fundamental concepts developed by early theorists, however, remain an enduring factor in therapeutic work for sexual difficulties. Kaplan’s contribution was the evolution of a sense of balance, in which the importance of psychodynamic aspects, alongside more practical behavioral programs, was highlighted. LoPiccolo reported successful outcomes for desire problems using a broad-spectrum approach.

A serious limitation in the understanding of sexual desire problems is the lack of a coherent and comprehensive theory concerning the nature of libido and the part it plays in the intrapsychic and interpersonal life of the individual. S. Levine’s model raises some critical questions regarding the distinctions between drive and desire and the importance of “self-regulation” and “partner regulation” as sources of sexual motivation.

In the work of Kaplan and others we see acknowledgement of the power of unconscious processes and defense mechanisms - along with the analysis of resistances - to diminish anxiety. Emphasis tends to be on understanding the attitudes and conflicts that impede the progress of personal relationships and on ways in which the processes of psychotherapy can remove the blocks that prevent the achievement of personal and sexual fulfillment. Psychodynamic approaches recognize and work with the influence of past and present transferential relationships as well as with current relationship conflicts and issues. The extent to which such issues underpin motivation for sexual contact, the central role of these in treatment, and the relevance of the patient’s object relations history to his or her inhibitions are topics addressed by psychodynamic perspectives.

Cognitive and Behavioral Perspectives

Management of problems of sexual desire with cognitive and behavioral techniques has become increasingly comprehensive in its approach to both assessment and treatment. LoPiccolo and Friedman postulated that the etiologies of sexual desire problems are broad and suggested that many factors may operate simultaneously to determine the relative severity of the difficulty. They and others assert that because of the complexity of these disorders, the treatment approach must be thorough and must operate from a wide base. This perspective recognizes the assessment challenge presented by disorders of desire. Reports of frequency of sexual activity can be very misleading, since, for example, some low-desire people may engage in sex more often than they wish in response to partner pressure. Additionally, acquisition of information about levels of sexual desire is problematic, given the strong social and relationship pressure to state that one does desire sexual activity. Use of questionnaires and standardized self-report inventories is one way of attempting to resolve or minimize these assessment difficulties.

The efficacy of hypnosis as a potential behavior modifier in low desire has not been fully evaluated. Although hypnosis is often regarded with suspicion by therapists and patients alike, there are those who argue strongly for its inclusion in the “treatment toolbox” for desire disorders and who believe that it may do much (in the right patients) to increase preparedness to engage sexually. Hypnosis may thus be a useful adjunct to standard sex therapy techniques, with successful outcomes depending on the therapist’s ability to carefully select and individually tailor hypnotic interventions rather than relying on more general application.

Treatment programs that help patients focus on bodily cues associated with feelings that result in avoidance of sex may also be of practical use. These programs incorporate remedial work to raise awareness of first sensual and then sexual pleasure. Building on such awareness, therapists then introduce cognitive interventions designed to generate alternative responses and behavioral exercises intended to provide opportunities for rehearsing these alternative responses. In this way, the restructuring of sexual behaviors helps individuals with desire disorders to learn or relearn how to be comfortably sexual and characterizes this particular approach. The multimodal emphasis of these programs is in keeping with current general psychiatric practice, in that it enhances affective experiencing and improves cognitive mastery and behavioral regulation while aiming toward specific goals and allowing for systematic evaluation.

Work with sexual scripts is an explicitly interactional approach to treatment and may be especially useful in highlighting salient features of desire discrepancy disorders in couples. Sexual behaviors can be seen as “scripted” to fit the roles, expectations, and mores of social life. Sexual scripts provide the cognitive organization of sexual interchange and focus attention on the contextual character of sexual conduct. Lack of congruence of sexual-script parameters between partners may contribute to the development of either specific dysfunctions or loss of desire. Script negotiation, with therapist support, encourages exploration of the complex motives underlying sexual behavior and allows recognition of the power and importance of context. A consideration of scripts can be useful in the assessment of desire disorders; working to modify such scripts in the treatment process allows movement away from a focus on both frequency and individual blame. Script adaptation can be usefully incorporated into both broad-spectrum cognitive-behavioral approaches and systems-interactional approaches to therapy.

Systems and Interactional Perspectives

Systemic and interactional perspectives examine the “fit” of a couple, with special emphasis on sexual communication and its rhythmicity. Three types of interaction may be particularly important with regard to desire: sensate exchange, affect-regulated interaction, and symbolic interaction. Low sexual desire, along with many other complaints that seem to fall outside the classical medical model, is a condition with different meanings. The systemic approach suggests that hypoactive sexual desire is a subjective experience of dissatisfaction, reflecting imbalance of interactions rather than any kind of “disease” process.

The more two people differ in experience, in language skills, in cultural and religious heritage, and generally in the ways they “make meaning,” the more their cognitive constructs will fail to meet. This mismatch leads to a situation in which interactional “fit” is effortful and challenging, the deficits in cognitive “kinship” raising problems for communication on all levels, including, and sometimes especially, the sexual.

When couples bond, they form implicit and explicit contracts. If these are questioned or broken, disrupting the relationship system, hypoactive sexual desire may well result. “Understandings” about the division of labor and power in the partnership are particularly prone to such disintegration and the ensuing loss of desire of one or both partners. Loss of desire may also result from confusion about the fulfillment of roles or the inability of one or both partners to express hurt, frustration, or anger. These are all systemic, transactional issues. Successful treatment may require adjustment of various aspects of the interactive system that exists between the partners. A systemic perspective allows for a movement away from “norms” and blaming of one partner; its focus is the relationship, and it is well suited to complex, multifactorial presentations.

Medical Treatments

At present, medical treatments play only a small part in the management of sexual desire disorders, except where certain treatable, organic etiological factors are confirmed. It is our concern that medical treatments designed specifically to treat hypoactive sexual desire will lead to misdiagnosis and inappropriate prescribing. Segraves and Segraves warn that the major danger of pharmacotherapy without concomitant psychotherapy is that a case will be left with incomplete resolution.

Endocrine treatment In both men and women, sexual drive appears to be androgen dependent. Biochemical evidence of androgen deficiency in patients presenting with hypoactive sexual desire requires appropriate hormone replacement, provided that contraindications are not present. Although a substantial literature exists demonstrating androgen-dose-related enhancement of sexual drive in hypogonadal men, there are few data relating to women. Kaplan and Owett reported that testosterone induced increased sexual desire in women whose pretreatment serum testosterone levels had been iatrogenically reduced. Data also support the beneficial effects on sexual desire of testosterone or androgenic progestogens in postmenopausal women. Although some clinicians prescribe androgen treatment empirically to premenopausal women with hypoactive sexual desire and claim good results, the role of such treatment has yet to be established by means of carefully controlled, well-powered clinical trials.

Pharmacological treatment Although clinicians may use drugs empirically when psychological approaches to the management of hypoactive sexual desire fail, at present there are no drugs licensed for the treatment of this condition. Individual case reports and small-scale studies have described successful outcomes, in terms of enhancement of sexual desire, with pharmacotherapy. Antidepressants and dopamine agonists are probably the classes of drugs most frequently used for this purpose. In particular, there is suggestive evidence that bupropion may enhance sexual drive.