Secondary hypoactive sexual desire has the advantage of comparison, in that the patient is able to contrast current levels of libido with those enjoyed at some previous time and may well have a more informed sense of what seems to enhance desire or, conversely, suppress it further. Problems of loss of desire for a specific partner, rather than a global absence of motivation for sexual contact, are more prevalent in this group and, thus, the person with lowered libido is more likely to be masturbating and aware of sexual interest in alternative circumstances, reducing the need for sexual growth work.

Work with individuals Individuals seeking therapy are often motivated more by a wish to enhance their own capacity for sexual gratification than by a desire to reduce conflict with a partner. For individuals who are not in a relationship, there is plenty of space and freedom to explore aspects of sensuality and sexuality entirely for themselves, without the pressure of pleasing someone else. For individuals who are in a relationship, therapy can be compromised by the nonpresent partner, who has an important influence on the therapy despite not always being personally influenced by the therapeutic process.

Supporting the repair of damaged sexual confidence is often a key task for the therapist. Once progress toward this goal is well established, libido enhancement, using a range of strategies, can commence (

see Table 63-2). Modification of countersexual behaviors (i.e., behaviors that reduce the likelihood of sexual engagement) may be difficult without the opportunity to work with the relationship system.

Work with couples Assessment of secondary hypoactive sexual desire requires careful consideration of the factors that may have led to the situation. It is important to consider broader sexual functioning, evaluating such features as erectile and ejaculatory adequacy and orgasmic confidence in women. Concurrent relationship assessment and psychological/psychiatric evaluation may need to be carried out. Severe relationship conflict normally necessitates couples therapy, as distinct from sexual therapy, before the latter can be of real use. It is not unusual for individuals and couples to have unrealistic expectations of what can be changed without addressing either precipitating or maintaining factors. Expectations are often of a return to previously experienced levels of desire (patients typically recall high levels of desire characterizing the early courtship stages of a relationship, when mutual idealization and a state of “limerance” tend to prevail); however, for a variety of reasons, this is not always possible. In cases of ongoing relationship conflict, raised levels of chronic stress, or a permanent change in lifestyle, a more realistic approach is to facilitate adaptation to and optimizing of sexual contact in the current circumstances. The initial work of identifying relevant factors in the reduction of experienced desire and reappraising expectations is often painful for couples and may involve issues of loss and grieving.

Secondary hypoactive sexual desire that is of specific onset - for example, following the birth of a child, an affair, an operation, job loss, or illness - tends to be identified more quickly than that of gradual onset, and the therapy may therefore adopt a damage-limitation approach, which can focus closely on the precipitating and maintaining factors. Facilitating communication about painful issues between the partners and providing a safe environment within which these can be explored may be an important precursor to the initiation of a treatment program. Secondary hypoactive sexual desire of more gradual onset may have the effect of “blurring” contributing factors. A primary discrepancy of desire between the partners, worsening over time with the loss of novelty, may be central, and negotiated reciprocity can play an important role in restoring some balance and sense of control for such couples. Conflict over the division of labor within the relationship, both practical and emotional, is common in cases of secondary hypoactive sexual desire and requires skilled therapeutic work, a degree of self-awareness and honesty on the part of each partner, and a mutual desire for change.