The presentations of clients with drive/desire disorders are divisible into those with primary and those with secondary problems. Primary desire disorders represent a significant challenge to psychological approaches, given that patients with these disorders lack the ability to recognize alternative states of desire due to the general absence habitually experienced. This problem of recognition can make it very difficult to find or establish a starting point from which to work. A pattern in which novelty facilitates higher levels of felt desire for a relatively brief period (possibly up to 2 years), followed by recurrence of the desire problem, leading to compensatory behavior and pretence, which then gives way to resentment and weariness, is common. Such a pattern tends to lead, ultimately, to a situation in which the relationship is threatened by conflict, thus prompting one or both partners to seek help.

Primary Hypoactive Sexual Desire

Psychological interventions for primary presentations of hypoactive sexual desire tend to commence with pathologization of an individual by a referral agent, a partner, and/or frequently the individual him- or herself. Such individuals usually report that their motivation to engage in sexual behaviors is very low and has always been so. In other words, the hypoactive sexual desire represents the individual’s “norm,” and the impetus to change the status quo is largely externally driven. The type of management originally advocated for sexual dysfunctions by Masters and Johnson was not designed to deal specifically with low sexual desire. Although many of the behavioral exercises may enhance arousal and orgasm, they often fail to increase sexual desire or motivation. Additionally, presentations are diverse in both apparent etiology and maintenance patterns. Zilbergeld and Ellison argued that each case of low desire should be assessed individually and management tailored to specific needs.

Primary hypoactive sexual desire can be managed by engaging with an individual or couple and therapeutic work done either with a single therapist or in cotherapy.

Table 63-2 presents a summary of possible management strategies for primary hypoactive sexual desire. Many patients presenting with primary hypoactive sexual desire are relatively unaware of their affective responses to situations involving sexual stimulation. Their feeling responses to sexual situations may incorporate anxiety, anger, resentment, and bewilderment, but such reactions may only be vaguely accessible to them. This lack of insight into emotional responses tends to lead to the experience of sex as somewhat neutral, when, in fact, strong negative feelings lead to active avoidance and, thus, a type of “canceling out” process. One goal of therapy in such cases is to facilitate and increase awareness of the links between physical responses and affective experiences, so as to encourage more proactive and conscious choices.

Work with individuals The existence of negative attributions to specifically sexual body parts and experiences associated with them, combined with a degree of ignorance as to what kind of sexual behaviors may be pleasurable, is an indication for the use of individually tailored sexual growth programs. One-on-one sex education, liberally scattered with permission-giving statements and encouragement, is also important in reducing the sense of sexual naivete and gaucheness common in many men and women with primary hypoactive sexual desire. Such education should also extend to building robust sexual confidence and instilling the notion that each individual is the expert in his or her own sexuality.

Explicit instruction and encouragement in the use of a variety of relaxation techniques to minimize sexual anxiety, combined with exploration of libido-enhancing strategies for increasing sexual desire in anticipation of and in preparation for lovemaking, may be used to compensate for the absence of sexual curiosity and experimentation during adolescence often reported by patients with primary hypoactive sexual desire. Depending on the treatment approach used, this may or may not be accompanied by work to promote insight into underlying personal or relationship conflicts. Reformulation of attributions about the cause of the problems in ways that are conducive to therapeutic change and resolution of interpersonal difficulties is often a key component of adapting behaviors.

Behavioral assignments used in individual programs focus on facilitating an increased familiarity and ease with sensual and sexual responses, sexual skills enhancement to empower and raise sexual confidence levels, and encouragement to learn how to use the knowledge and awareness gained from self-stimulation to enrich sexual partnerships. Also useful in both primary and secondary hypoactive sexual desire are interventions designed to induce drive, or “prime the pump.” The conscious decision to engage in sensual/sexual daydreaming, to actively use fantasy to raise levels of desire, and to generally take an active role in the anticipation of sexual contact instead of waiting to be aroused by a partner can redistribute responsibility in a way that may ultimately increase levels of desire for both partners.

Work with couples When primary hypoactive sexual desire is a component of a couple’s presentation for psychosexual therapy, a central consideration is usually to help the couple understand how low levels of desire in one partner might respond to improvement of their communication in general and of their sexual communication in particular. Learning to register the early stages of anger and anxiety in themselves by focusing on bodily sensations, and being able to alert their partner to these signs, may help prevent the partners from getting caught up in a volatile and vicious circle of action/reaction from which there seems to be no escape. Couples may additionally need very clear and specific guidance in improvement of the techniques they use for physical erotic stimulation (

see Table 63-2), especially as it is not unusual to find partnerships in which one individual has primary hypoactive sexual desire and the other is sexually inexperienced and underconfident. Such guidance must be framed in a sensitive manner by the therapist to prevent defensiveness from becoming resistance and avoidance. We all tend to be somewhat sensitive to any suggestion that we might be inadequate as lovers.

Sensate focus programs can be used both to explore and to improve communication patterns. Such programs also have diagnostic value, facilitating access to the nature of intimate interchange in the couple relationship. Isolating and pinpointing particular behaviors that carry negative significance for one or both partners and focusing on these is often the way in which blocks can be overcome. Getting couples to identify “good quality” time in relationships that have adapted to the existence of sexual difficulties and potential or real conflict by developing elaborate avoidance rituals can be problematic. Managing the demands of a multiplicity of roles may contribute to this challenge.

Different life stages involve the adoption, prioritization, and re-prioritization of different roles. Men and women may have a professional/worker role, a domestic role, and a parental, filial, friendship, and community role in addition to the role of lover. The lover role tends to be the one that most often and easily falls off the agenda as the demands of others increase or as stress levels rise and fatigue sets in. Early partnerships and the sexual relationships accompanying them tend to involve only two or three of these roles, whereas during a couple’s 30s and 40s, the number of roles and demands of juggling them are often at their peak. The introduction of timetables can be revealing in providing a structured process that encourages couples to reflect upon their individual and joint distribution of time among the variety of roles and activities that make up their lives. This process almost always reveals deficits in personal and relationship time that tend to be clarified through juxtaposition with periods in the couple’s life when they were more physically intimate and more mutually attentive.

The following case example illustrates the management of a couple in which the female partner experienced primary sexual desire disorder.

Mrs. P was referred to the clinic with a presenting problem of loss of desire. She and her husband, both in their 30s, had relatively demanding careers. They had been married for over 10 years and had one son, age 6. Mrs. P had a recent history of depression, which was currently being controlled through medication. She reported that her depression first started after the birth of their child. Neither spouse expressed much emotion, although they were comfortable and forthcoming in talking about their difficulties. Mrs. P’s level of desire seemed to have become further inhibited since the birth of their son; however, it had never been very high, and neither partner could remember a time when she had initiated sexual contact.

Currently the frequency of sexual activity between the couple was once every 4-6 months. Mr. P described his sexual desire as “normal,” but he had reached the stage where he very rarely tried to initiate anything, as he felt that refusal and rejection were inevitable. The couple had discussed Mrs. P’s generally low level of desire, and it was reported that both her sister and her brother experienced very similar levels of desire.

A cotherapy team consisting of a male and a female therapist worked with the couple. In initial sessions, Mr. and Mrs. P were split up and given individual time to explore their own separate issues. Mrs. P looked at her attitudes toward sex and experiences of sexual contact, trying to identify what factors made things better or worse. Mr. P discussed the frustration and rejection that he experienced within the relationship and his feelings of impotence regarding his ability to change the situation. The couple was instructed to carry out sensate focus, stage 1. There was a ban on intercourse, and they were advised to try to incorporate considerable buildup to when they were going to carry out the program. Mrs. P felt that when there was a long buildup, she was more able to respond. Strategies for her self-management of this process were introduced. The couple reported some limited success at both tasks, although initiation had been mostly from Mr. P, who felt that if he had not mentioned doing the tasks, Mrs. P would have avoided them.

During sessions, further factors were identified that optimized Mrs. P’s level of desire. These included choosing the time of week or day that they could carry out tasks and monitoring her level of desire in relation to her menstrual cycle. Mrs. P felt that she was most likely to be interested in sexual activity during the time leading up to ovulation. Some individual work was suggested for Mrs. P around fantasy, and it was suggested that she find herself some acceptable erotic fiction to read to help her frame her fantasy. Mr. P found the ban on intercourse quite frustrating, especially since there had been an increase in nonsexual physical contact. Various coping strategies were discussed with Mr. P and the couple together, such as the acceptability of his engaging in self-stimulation. This discussion resulted in his decision not to use self-stimulation for the time being and to reassure Mrs. P more about his support of the program, as he felt that, long term, this combination of abstinence and reassurance would help the situation more. Individual work was commenced with Mr. P on how he might be able to enhance physical erotic stimulation for his partner in the most “romantic,” least-threatening/demanding way possible, as Mrs. P had identified waning romance in the relationship as a compounding factor for her.

The ban on intercourse was broken on a few occasions during the treatment. On one particular occasion, Mrs. P had actively wanted to be sexual after a meal out together to celebrate a friend’s wedding. This experience of desire had been characterized by considerable anticipation of the event for a number of days beforehand, coupled with the increased contact and communication they had been working on. Both partners had enjoyed intercourse on this occasion, and there was an associated increase in confidence for the couple. The behavioral program was amended to allow for intercourse on occasions when both partners wished it and at Mrs. P’s initiation. It was recommended that nonsexual contact continue on a more regular basis and that its initiation should be shared between them as much as possible, even if this meant longer gaps when Mrs. P was initiating.

The frequency of appointments was reduced, as Mr. and Mrs. P were satisfied with the progress they were making. At their final appointment, they felt that there had been significant improvement in their situation, even though their frequency of intercourse was not as high as Mr. P had originally suggested. Both had revised their expectations of how desire should operate within the relationship. The changes made in their behavior had led a to sustainable improvement, and Mrs. P reported enjoying sex more and feeling more confident and motivated to initiate it. Her level of desire had increased during the program, and she now spontaneously engaged in sexual “daydreaming,” which had not previously been a familiar activity for her. The couple were offered suggestions and strategies for monitoring the situation for themselves on an ongoing basis, with plans for remedial action should things begin to revert to their former pattern, and discharged.