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Female sexual desire disorders: subtypes, classification, personality factors

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Article in World Journal of Urology · July 2002

DOI: 10.1007/s00345-002-0280-5 · Source: PubMed

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World J Urol (2002) 20: 79–88
DOI 10.1007/s00345-002-0280-5
T O P I C P A PE R
Uwe Hartmann Æ Kristina Heiser Æ Claudia Rüffer-Hesse
Gabriele Kloth
Female sexual desire disorders: subtypes, classification,
personality factors and new directions for treatment
Published online: 29 May 2002
Ó Springer-Verlag 2002
Abstract Lack of sexual interest is highly prevalent in
the general female population and, for more than two
decades, low sexual desire has been the most common
presenting problem in clinical institutions. The re-
newed interest in female sexual dysfunction has re-
cently focused on biological and classification aspects
whilst personality- and partner-related factors, as well
as theoretical concepts, have largely been neglected.
After critically reviewing the current diagnostic systems
for female desire disorders, this paper specifically ad-
dresses the issues of personality and life history fac-
tors. In two empirical studies, 50 patients with low
sexual desire were compared to a group of 100 sexu-
ally functional women by employing both semi-struc-
tured clinical interviews and a set of self-developed and
standardised questionnaires. The results of these stud-
ies indicate that women seeking help for desire dis-
orders exhibit marked signs of mood instability and a
low and fragile self-regulation and self-esteem. In ad-
dition, they tend to be more worried, anxious, intro-
verted and conventional when compared to sexually
functional women. Interestingly, no significant differ-
ences in the variables relating to partnership quality in
general could be detected. Although caution is needed
due to sample size and methodological limitations, our
results suggest a substantial level of at least subclinical
psychiatric symptoms like mood-disorders, low self-
esteem and feelings of guilt in women with sexual
desire disorders. These problems seem to be rather
deep-rooted and particularly affect the self-regulation
and the inner balance of the personality. Overall, fe-
male sexual dysfunctions and low desire, in particular,
cannot be conceptualised as discrete phase disorders,
U. Hartmann (&) Æ K. Heiser Æ C. Rüffer-Hesse Æ G. Kloth
Clinical Psychology, Department of Clinical Psychiatry
and Psychotherapy, Hanover Medical School,
Carl-Neuberg-Str. 1, 30625 Hanover, Germany
E-mail: hartmann.uwe@mh-hannover.de
Tel.: +49-511-5322488
Fax: +49-511-5322415
but rather as a global inhibition of sexual response
together with a history of mood disorder, specific
personality factors and an elevated level of psycho-
logical stress. This combination calls for broad-band
treatment approaches where individual and interper-
sonal aspects can be taken into account simulta-
neously. In addition, the ubiquitous comorbidity, both
with other sexual dysfunctions and with various per-
sonality and psychological problems, and the devel-
opmental sequence of the sexual problems must be
adequately considered.
Keywords Female sexual desire disorders Æ Female
sexual dysfunction Æ Sexual desire Æ Sexual
motivation Æ Female sexuality
For at least two decades low desire has been the most
common sexual problem of women. Most experts agree
that desire disorders confront us with many unresolved
theoretical issues surrounding female sexuality and hu-
man sexual motivation in a more general respect. They
also present us with a significant therapeutic challenge
and have recently found new interest in both basic re-
search and clinical practice. Female desire problems
comprise a broad spectrum of heterogeneous aetiologies
and constellations with the symptom low sexual desire as
only a starting point for further exploration and as-
sessment. Drawing upon a review of the recent literature
on desire problems and on empirical data from our own
female sexuality research group, this contribution will
focus specifically on issues concerned with subtyping
and personality factors relevant to low desire problems
in women. This intention is based on our belief that
more descriptive data are needed on patients with low
desire problems to refine our knowledge base and al-
lowing better theoretical concepts and treatment ap-
proaches. In a final section, some conclusions for new
directions of treatment will be drawn.
80
Classification and subtypes
General aspects
The renewed interest in female sexual dysfunction re-
vealed significant shortcomings and problems of the
current classification systems for the diagnosis of female
sexual disorders. After a period of intensive research into
male sexual dysfunction, scientific and clinical interest
has begun to focus on female sexuality with a special
emphasis on biological and pharmacological aspects.
The rapidly growing knowledge of the interplay of
mental and physiological functions and processes dem-
onstrated the need for a differentiated diagnostic and
classification system for female sexual disorders. Classi-
fication of sexual disorders is per se difficult as attitudes
concerning the appropriateness of sexual behaviour are
judged against the specific social and cultural norms of a
given epoch. Whereas, for example, 100 years ago, a
sexually interested and sensuous woman was regarded as
mentally disturbed, a lack of sexual interest is nowadays
judged as a clinical symptom requiring treatment. Fur-
ther problems arise from attempts at operationalising
sexual disorders through behavioural descriptions, as
many aspects of sexuality are essentially subjective ex-
periences not easily amenable to monitoring and as-
sessment. The need for an adequate and clearly defined
classification system is nevertheless undisputed, and re-
fining existing classification systems is an important
prerequisite for advancing knowledge of sexual disor-
ders. Further to being the common language of experts
and clinicians, broadly accepted definitions can serve as
guidelines for research and treatment and stimulate the
development of psychological and medical interventions.
Currently, ICD-10 [28] and DSM–IV [1] are used for
the diagnosis and classification of sexual disorders. Both
systems are founded on the conventional model of the
human sexual response cycle, pioneered by Masters and
Johnson [20] and expanded by Kaplan [17]. Both are based
on the four phases of desire, arousal, orgasm and satis-
faction. Accordingly, four main categories of disorders
are derived from these phases: desire disorders, arousal
disorders, orgasmic disorders and sexual pain disorders.
For the purpose of improving diagnostic and classi-
ficatory guidelines for female sexual dysfunction, a
multidisciplinary consensus conference was convened in
Boston in 1998 [5]. The classification system published in
the report of the Boston Group found a fair amount of
approval and consent, not only because the suggested
inclusion of psychogenic and organic aetiologies is in
keeping with today’s multi-factorial and biopsychosocial
perception of sexuality, but also because of its efforts
concerning previously neglected female sexual disorders.
On the other hand, the group of critics is spearheaded by
Bancroft et al. [4] who seriously questioned the rationale
of the new system. They criticised that the consensus
report offers few advancements compared to the existing
diagnostic systems and has only limited benefit for
future research and clinical treatment. In addition,
Bancroft et al. maintained that classification systems
should be based on a theoretical framework providing a
better understanding of the determinants of female
sexual function and dysfunction. From this theoretical
frame, a diagnostic system should be derived that could
direct research, treatment and prognosis.
The decision of the Boston conference to retain the
structure of the current diagnostic systems for reasons of
continuity was criticised by many experts. The traditional
phase-specific conceptualisation of the Masters and
Johnson and Kaplan model implies that human sexual
response follows a more or less fixed cycle of sequential
stages with the possibility of dysfunction at each of these
stages. In contrast, the more recent approaches view
sexuality as much more complex and interactive (e. g. the
mutual stimulation of desire and physical arousal). Fur-
ther criticism is related to the strong focus of the diag-
nostic system on heterosexuality and heterosexual
intercourse as the ultimate goals of sexual behaviour, as
well as to the prevailing ignorance of emotional and in-
terpersonal aspects, particularly of the context depen-
dency of female sexuality, which for many women is more
important than her genital reaction. Further criticism
from various sources is related to the following aspects:
(1) Comorbidity: the new system does not adequately
consider the frequently occurring comorbidity of sexual
disorders, i.e. the combination of different symptom
patterns in one patient and (2) Personal distress: the
standard criterion of DSM-IV (for all diseases) that the
symptom must cause ‘marked distress and interpersonal
difficulty’ has been replaced in the new classification
system by the criterion of ‘personal distress’. While this
term has the advantage of depending only on the wom-
an’s subjective experience (and not on her partner’s
feelings or some external standard), it was criticised for
raising new problems. In particular, the difficulty in as-
sessing ‘personal distress’ was pointed out as well as the
circumstance that this criterion ignores the context de-
pendency and the systemic aspect of desire disorders.
One final suggestion of the Boston report pertains
specifically to desire disorders. The DSM-IV criteria
(‘deficiency or absence of sexual fantasies and desire for
sexual activity’) were modified to include ‘lack of re-
ceptivity for sexual activity’, which, in addition, was
required to be a permanent lack of receptivity. This in-
clusion of receptivity did not remain undisputed. Critics
pointed out that there is no agreed-upon definition of
receptivity and that it remains unclear how receptivity
differs from sexual arousability. We would like to add
that the concept of receptivity might well arouse remi-
niscences to Victorian thinking – in the sense of a
resuscitation of the woman by the man.
Empirical results
In the sexual medicine outpatient unit of Hanover
Medical School, an increasing number of female patients

are seeking help for hypoactive sexual desire. In our
efforts at treating low desire problems, it became in-
creasingly clear that a more refined subtyping had to be
developed for this heterogeneous patient group, both for
diagnostic and treatment purposes.
In our research group, several assessment approaches
were developed in order to break down the individual
features of the female patient and her specific sexual
problem into meaningful subtypes [23]. First, a classifi-
cation of our patients according to phenomenological
features and the history of the dysfunction was per-
formed by means of semi-structured clinical interviews.
By this procedure, the whole patient sample was screened
for common features and differences to reach a platform
for forming possible subgroups. In a subsequent step,
personality factors and other psychological variables
were evaluated by employing a set of self-administered
questionnaires. Thus, an expert-rating was applied in the
first study part whilst the second part consisted of a self-
assessment of the patients. Patients were either self-re-
ferred or were recruited by an announcement in a local
newspaper. All patients were suffering from hypoactive
sexual desire disorder according to DSM IV-criteria.
The sample of these two studies consisted of 52 con-
secutive patients who displayed a normal state of health
and were not suffering from a severe psychiatric illness.
All women lived in stable partnerships for at least six
months prior to the first contact with our institution.
They underwent detailed clinical interviews and subse-
quently filled out a set of comprehensive questionnaires
addressing a large variety of aspects of their personal and
medical history, sexual development, partnership, phys-
ical and mental condition and various items addressing
their sexual motivation and functioning. Mean age of this
sample was 40.6 years (range 17–64 years). Of the women,
25% were suffering from primary hypoactive sexual de-
sire disorder (HSDD) and 75% from secondary HSDD.
In 79%, a generalised HSDD could be diagnosed.
The clinical interviews indicated a pronounced het-
erogeneity of most variables investigated, as well as a
Fig. 1. Comorbidity with other
sexual dysfunctions
81
frequency peak of reported desire problems around the
period of perimenopause. Therefore, in subsequent sta-
tistical analyses, age groups were formed to enable a
closer look at age-related characteristics. There were 11
women who belonged to the age group 29 years or
younger, 12 women to the group 30–39 years, 16 to the
group of 40–49 years and 13 women who were older
than 50. As Fig. 1 shows, sexual desire disorders were
often associated with arousal and orgasmic problems,
especially in women beyond the age of 40.
Data pertaining to the prevalence and severity of
psychopathological symptoms in our patients indicated
significant age differences with more depressive episodes,
more psychosomatic symptoms, a higher frequency of
psychotherapeutic treatments and a more restricted
sexual upbringing in the older women (Fig. 2).
A history of sexual abuse was reported by 10%–20%
of women and, as far as our clinical impression and the
women’s self-reports can provide a reliable measure, did
not seem to be a major factor for the desire problem. A
majority of women of all age groups estimated their
partnership as good except for the domain of sexuality,
but, interestingly, at the same time more than two-thirds
complained of partnership conflicts due to desire dis-
crepancies. Figure 3 further shows that a significantly
higher proportion of older women report a fear of losing
their partners because of sexual problems and they also
felt particularly obliged to comply with their partners’
sexual wishes.
Figure 4 indicates that both the willingness to change
and the treatment motivation were highest in the older
patient groups whilst a lack of self-esteem and feelings of
guilt towards the partner due to their sexual problem
were either more pronounced in the younger women or
equally distributed over the age groups.
The results of this study demonstrate that the ma-
jority of our patients suffered from secondary and gen-
eralised hypoactive sexual desire disorder. These findings
correspond with data provided by Kaplan [18], who, by
overlooking a large sample of patients, reported that the
82
Fig. 2. Relevant aspects of life
history and psychopathology
Fig. 3. Partnership variables
low desire was acquired in 79% while 21% had never
experienced a normal desire for sex. In most patients, it
proved to be impossible to identify clear and unambig-
uous causes for the loss of sexual desire. There were no
relevant medical illnesses or distinct mental abnormali-
ties. The women did not receive any medication with
negative influence on their sexual functions and most of
the women lived in stable and satisfactory partnerships.
In addition, significant life events or psychosocial con-
flicts that could be held responsible for losing their
sexual motivation could not be detected. Traumatic ex-
periences or a history of childhood sexual abuse were
reported by a minority of women with no, or at least no
clearly discernible, impact on the level of desire.
Looking for lifetime psychopathology, we found a
high amount of previous mood disorder in our patients,
especially in the older groups, ranging from 27% to
62%. These results are in keeping with a study by
Schreiner-Engel and Schiavi [27], who, by comparing
their patients with a group of matched controls, found a
history of major and/or intermittent depression almost
twice as often in the patient group than in the controls.
Generally, our clinical data describing the current psy-
chological profiles of the patients could be confirmed by
the results of the self-administered psychometric instru-
ments. A pronounced lack of self-esteem and feelings of
guilt were reported by more than two-thirds of all pa-
tients. Accordingly, low self-esteem and feelings of guilt
seem to be distinguished features of women presenting
with low sexual desire and deserve special consideration
in evaluation and treatment.
Personality characteristics
Empirical results
In a subsequent study [19], based on previous extensive
clinical experience with our patients and the results of
the first study, we were interested in those personality

Fig. 4. Personality characteristics
and motivation for treatment
factors associated with the organisation and regulation
of the self-system. We started from the assumption that
the specific modes of self-regulation (commonly called
narcissistic regulation) that an individual woman has at
her disposal, and which can either be adaptive or mal-
adaptive, are of pivotal importance for the degrees of
freedom she has in terms of her sexual desire. To assess
these rather complex constructs, we employed a set of
standardised self-administered instruments, including
the ‘Narcissism Inventory’ [10], the Neo FFI and other
questionnaires, together with detailed clinical interviews.
The ‘Narcissism Inventory’ was designed to assess a
number of theoretically and clinically relevant aspects of
the organisation and regulation of the narcissistic per-
sonality system. It consists of 163 items belonging to 18
scales, covering a wide range of different modes of
narcissistic auto-regulation. The 18 scales are grouped
into four main dimensions according to the results of a
factor analysis. The 60-item Neo-Five Factor-Inventory
[7] measures different personality characteristics, the so-
called ‘big five’. These five dimensions are: neuroticism,
extraversion, openness to experiences, social acceptability
and conscientiousness. The NEO-FFI is a valid and
worldwide established instrument.
The sample of this study consisted of 46 female pa-
tients suffering from HSDD (hypoactive sexual desire
disorder, according to DSM IV criteria) who had
consulted our outpatient unit (ages 17–64, mean age 39;
SD=11). The patients were compared to a control
group of 100 healthy women (ages 18–54, mean 34,
SD=9). There were 38 patients (82.6%) who lived in
stable partnerships and the mean duration of the part-
nership was 13.6 years (minimum 9 months, maximum
33 years, SD= 9,44); 6 (13%) of the patients suffered
from primary HSDD; 26 (56.6%) had lost their interest
in sex; and 14 (30.4%) patients reported situation-spe-
cific low desire. In the group of women (57%) who had
lost their sexual desire, the mean duration of the disor-
der was 4.99 years (SD=4,73, range from 3 months to
20 years). In addition to their low desire, 59% of the
83
patients reported problems with sexual arousal and 52%
had never had an orgasm during intercourse.
As far as the target variables of this study are con-
cerned, significant differences between the two groups
could be detected with a higher degree of depressive
mood, emotional instability and level of anxiety in the
patient group. In particular, in our patients, the results
indicate a marked instability of the self-system with
fluent transitions between an arduously maintained and
a progressive decompensation of the mechanisms used
for self-regulation and narcissistic balance. As Fig. 5
shows, six of the eight scales for the dimension I of the
‘Narcissism Inventory’, called ‘the threatened self’, show
significant group differences. For example, the high
score for the scale social isolation (SOI) is indicative of
an inadequate mode of self-protection by withdrawing
from social contacts. Moreover, both the scales helpless
self (OHS) and derealisation/depersonalisation (DRP),
but also the scores in the two scales basic potential of
hope (BAH) and feelings of smallness (KLS) are indica-
tors of a weak or even fragile self-system. These women
have a basic feeling of being unprotected and defenceless
and exhibit substantial body image problems, as is
shown by the significantly higher scores of the scale
negative body self.
These results of the ‘Narcissism Inventory’ are con-
firmed by the findings in the NEO-FFI where significant
differences were found in three of the five scales. As
Fig. 6 shows, our patients scored significantly higher in
the scale neuroticism and lower in the scales extraversion
and openness.
Summarising the results of this study, it appears that
women seeking help for desire disorders exhibit signs of
mood instability and a low and fragile self-regulation
and self-esteem. In addition, they tend to be more
worried, anxious, introverted and conventional when
compared to sexually functional women. Interestingly,
the quality of the partnership in general as reported by
the patients was not poor, but the various markers
were, nevertheless, not as good as in our control group.
84
Fig. 5. Results of the ‘Narcissism Inventory’, dimension I, ‘the
threatened self’. **P<.00. Dimension I: Mean scores for the scales.
OHS helpless self,;AIV loss of impulse control; DRP derealisation/
depersonalisation; BAH basic potential of hope; KLS smallness
self; NEK negative body self; SOI social isolation; ARR archaic
withdrawal
Fig. 6. Results of the NEO FFI. **P<.00;*P<.05. Mean score
for the five dimensions of the NEO-FFI. Neuro neurotizism; Extra
extraversion; Openness openness for experiences; social social
acceptability; conscience conscientiousness
Although caution is needed due to the size of the
sample and methodological limitations, our results
suggest a substantial level of at least subclinical psy-
chiatric symptoms in women with sexual desire disor-
ders. These problems seem to be rather deep-rooted and
particularly affect the self-regulation or the inner bal-
ance of the personality. Pulling the results presented so
far together and given the low level of differentiation
and the weak and vulnerable self-system, one can un-
derstand that the risk of self-disclosure and intimacy
necessary for sexual arousal and desire cannot be taken
by these women.
These findings largely correspond with other studies
in this field [11, 27]. Thus, in the study of Donahey and
Carroll [12], the women with hypoactive sexual desire
reported a significantly higher level of psychological
distress in comparison to male patients and they also
showed significant elevations in depression, anxiety and
hostility, as well as higher levels of a paranoid style of
thinking.
Discussion
From the data presented here, it appears that a much
more detailed and comprehensive analysis of the
biopsychosocial determinants of functional and
dysfunctional female sexual desire is required. Only then
can a truly meaningful and real-life diagnostic system be
developed [4]. Our studies indicate that, compared to
functional women, patients with hypoactive sexual de-
sire are characterised by a vulnerable self-system with a
number of rather inadequate self-regulatory mecha-
nisms. They also report a marked lack of self-esteem and
higher levels of anxiety, feelings of guilt, negative body-
image, introversion and somatisation. However, it is
important to note that our results, as well as the findings
of other studies, do not provide evidence for serious
psychopathology in low desire women in general. To
understand the single patient and for a goal-directed,
prognosis-oriented treatment planning, personality fac-
tors and questionnaire scores have to be considered in a
strictly individual perspective. Thus, in only a few of our
patients, could a mood-disorder according to DSM-IV
criteria be diagnosed, although both mood and subjec-
tive well-being were significantly lower when compared
to the control group. The finding that older patients
showed even higher levels of depressive mood disorders
is probably associated with the sexual problem but it
may also be due to other factors, such as ageing itself
with its corresponding social and physical changes.
Whilst women in all age groups were satisfied with their
partnerships, a higher percentage of older women re-
ported that they were seeking help primarily for their
partners’ sake. This fear of losing their partners as a
consequence of low sexual motivation is obviously more
pronounced in the older age groups where it is more
difficult to find a new adequate partner.
By applying the expert rating of our first study, we
tried to understand how the specific pattern of per-
sonality characteristics found in the patient group re-
lates to other life history variables. At first glance, the
two key findings of our studies seem to be contradic-
tory as, on the one hand, more signs of mental disor-
ders or lifetime psychopathology were displayed by our
low desire patients whilst, on the other hand, our ef-
forts to classify and shape these patterns into mean-
ingful subtypes did not prove to be very successful.
This might reflect that the items and dimensions used
in the expert rating have to be critically revised al-
though these categories were either derived from ex-
tensive clinical experience or are commonly agreed to
be important markers for subgroups, such as, for ex-
ample, the quality of the partnership. Any category or
variable considered relevant for subtyping women with
hypoactive sexual desire has to be assessed for its dis-
criminative validity, preferably not only by an expert
consensus but by determining its significance in both
sexually dysfunctional and functional women through
empirical research. In our experience, the new criteria
suggested by the recent consensus conference, i.e. per-
manent lack of receptivity and personal distress, re-
quire a careful evaluation of the motivation of the
individual woman and the couple dynamics. Otherwise,
no useful inferences can be made from these criteria
regarding the treatment interventions appropriate for

the single case. In addition, our results confirm the
impression that the traditional classification system
based on the classical sexual response cycle and carried
on by the consensus conference cannot adequately take
account of the extremely high rate of comorbidity of
low desire with arousal and orgasmic disorders. Thus,
in real life, female sexual problems do not relate to a
single phase of some virtual response cycle, but are
indicative of a more or less global lack of sexual in-
terest, arousability and arousal. The following sugges-
tions for classifying hypoactive sexual desire disorders
follow the particular intention to take this comorbidity
into account and represent the constellations found in
the majority of patients:
A. Hypoactive sexual desire disorder [not otherwise
specified]
B. In combination with sexual arousal disorder
C. In combination with orgasmic disorder
D. With associated depressive symptoms
E. With associated low self-esteem
F. With associated partner conflict.
The significance of personality factors is still disputed
and was, therefore, not included in these suggestions.
Kaplan [18] contended that the human sexual motiva-
tion operates fairly independently of psychosocial pa-
rameters and her findings did not support the widely
held belief of a strong link between psychopathology
and sexual adequacy. Other studies, however, yielded
controversial results in terms of clinical abnormalities in
the personality profiles of low desire patients. Since
different assessment instruments were used in these
studies, the results can hardly be compared. The diag-
nostic instruments employed in the studies presented
here were specifically selected for addressing constant
and permanent personality features rather than more
situational characteristics.
Taken together, from the evidence available today,
one can conclude that by simply expanding and con-
tinuing DSM-IV criteria and the traditional response
cycle classification systems, it is impossible to come to
diagnostic categories and subtypes that adequately reflect
real-life female sexual problems. As mentioned before, a
new system should be able to take aetiological and com-
orbidity factors into account. But before concentrating
exclusively on classification and diagnostic issues, a better
understanding of the mechanisms responsible for causing
sexual disorders are required, which, for example, can
provide answers to the question of why one woman with
low self-esteem or depressive mood loses her sexual in-
terest and another woman does not. Thus, the biopsy-
chosocial determinants of low sexual desire represent the
real challenge for today’s research and treatment.
New directions for treatment
In the final section of this contribution we will focus
on new directions for treating female sexual desire
85
disorders. Due to the high prevalence and the marked
complexity of these problems, most experts agree that
desire disorders present us with a remarkable thera-
peutic challenge. In addition, desire disorders are often
thought to be characterised by a high resistance to
treatment, an ambivalent treatment motivation and a
rather poor outcome. There are, however, only very few
controlled studies that have recently examined the out-
come and the long-term effectiveness of sex therapy with
low desire patients. Older studies (reviews in O’Carroll
[21] and Beck [6]) have shown that desire disorders can
be successfully treated with either sex therapy alone or
with a combination of sex therapy and hormonal ther-
apy. Most of these studies, however, have serious
methodological flaws and the long-term stability of
treatment gains is obviously poor [9, 15].
From this, one must conclude that new approaches
and strategies for treating female desire disorders have to
be developed. The theoretical and practical framework of
first-generation sex therapy established through the
landmark works of Masters and Johnson and Kaplan
has never been quite suitable for the complexities, para-
doxes and conflicts surrounding sexual desire and its
problems. More distinctly than is the case for other
sexual dysfunctions, the therapeutic experience with de-
sire disorders is indicative of the limitations of central
ideas and basic concepts of traditional sex therapy. Based
on the empirical results and clinical experience presented
in this paper, as well as on a couple of new approaches
that have recently been put forward, some implications
for new treatment models shall be discussed here.
Conceptual and theoretical issues
The two most salient points to be drawn from our data
and from our clinical experience refer to the remarkable
comorbidity and the high rate of personality and mental
health problems like deficits in self-regulation, mood
disorders and lack of self-esteem. Our results are con-
sistent with earlier studies where high levels of comor-
bidity and psychological distress together with a higher
lifetime prevalence of mood disorder were reported by
the female patients. It is important to note in this con-
text that personality variables seem to be more predic-
tive of sexual satisfaction in women than sexuality
variables alone.
In keeping with other recent publications, our results
highlight that female sexual dysfunctions and low desire
in particular are not discrete phase disorders, but rather
a global inhibition of sexual response together with a
history of mood disorder, specific personality factors
and an elevated level of psychological stress. This com-
bination calls for broadband treatment approaches
where individual and interpersonal aspects can be taken
into account simultaneously. In addition, the ubiquitous
comorbidity, both with other sexual dysfunctions and
with various personality and psychological problems,
and the developmental sequence of the sexual problems
86
must be adequately considered. For scientific reasons
and clinical studies, it might be useful to define criteria
for discrete dysfunctions like ‘‘pure’’ arousal disorders
but, in real life, comorbidity and blurred transitions are
the rule. The considerable proportion of women with
subclinical or clinical psychiatric problems requires
special knowledge and skills in this sector. It also re-
quires a double strategy; on the one hand, treatment has
to focus on the history of the individual woman’s
problem, on the constellation of personality, social and
mental health factors associated with the sexual symp-
tom and on the point she presents for help but, on the
other hand, it has to adopt a relationship perspective
right from the start. This requires the therapist to re-
structure and redesignate the problem to make the in-
dividual low desire a couple issue and any treatment a
joint project in which both partners are involved [22].
Since the reward expectation towards sexual activity
tends to be low or submerged in these patients, it is
important to instill a sense of hope and some sort of
anticipated personal gain early in the treatment process.
From a more theoretical vantage point, future treat-
ment strategies should be based on response rates and
prognosis on the one hand (what works for what kind of
problem) and on a better theoretical understanding of
female sexuality and its disorders on the other hand. As
a matter of fact, new approaches are emerging that seem
appropriate to provide a theoretical framework for the
understanding of inhibited sexual desire and arousal.
The dual-control model of sexual excitation and inhi-
bition by Bancroft and Janssen [2, 3] is one the most
promising concepts, especially in terms of treatment
aspects. The model proposes that the sexual response is
based on the balance of centrally acting excitation and
inhibition processes. Individuals vary in their tendency
towards sexual inhibition and excitation and a high in-
hibitory tone is associated with an increased vulnera-
bility to sexual dysfunction. This individual inhibition
proneness will very likely prove to be a central param-
eter in future research and we have included this
parameter in our routine diagnostic assessment.
Looking at sexual desire from an information pro-
cessing standpoint [8, 13, 16], a given stimulus must first
be perceived as sexual (which is mostly the result of
emotional learning and the establishment of a consistent
reward expectation), before unconscious and then con-
scious attention sets in which leads to sexual arousal.
The early stages of this process may reflect the subjective
feeling of desire. Thus, arousal and desire center on
meaning and attention and are always reactive since they
require (internal or external) stimuli. Accordingly, in
considering treatment strategies, we have to look at the
stimulus-side, the attention-side, the reward-expectation
and the actual reward side of sexual desire and arousal.
Typically, patients already avoid the initial awareness of
sexually relevant cues, which prevents the ignition of the
following stages of the arousal-desire-process.
In this view, desire and arousal are processes about
the constitution of meaning, the processing of external
and internal stimuli, about erotic codification. This
codification process is blocked in our patients with the
result that without desire, subjective arousal is low –
without subjective arousal, the incentive or desire for sex
is minimal [12]. Finally, it is often ignored that sexual
desire represents a complex manifestation of sexual
motivation. Therefore, a better understanding of the
neurobiological and psychological underpinnings of
human sexual motivation is urgently needed to advance
treatment approaches [4, 8, 14].
Elements of individual therapy
As mentioned above, our empirical results highlight the
importance of individual factors in low desire patients
like narcissistic deficits, mood disorders and lack of self-
esteem. Insight and understanding, both by the therapist
and the patient, of the multiple and highly individual
causes behind the surface of low desire are crucial steps
in every therapy. Low desire is not an isolated symptom,
instead, it is intimately associated with biographical and
developmental issues, personality factors, but also with
the present partnership and social situation of the
woman. As Pridal and LoPiccolo [22] point out, there
are always ‘‘reasons’’ for a given desire disorder and
there is no such thing as bland indifference since, under
the umbrella of low desire, there are always negative
emotions (anxiety, anger, disgust, hostility) or some kind
of traumatic experience that are blocking sexual moti-
vation. One of the central goals of treatment is to in-
crease the awareness of the connection between these
past and present influences and the actual feelings about
sexuality. The woman should be able to experience, both
emotionally and cognitively, that her old coping strategy
of low desire that served as a protection from frustration
and disappointment in interpersonal relations is no
longer adaptive. Instead, it has become a serious ob-
stacle to becoming a grown-up sexual person. In order
to take the responsibility for her own sexual feelings and
desires, old scripts have to be rewritten during the course
of the treatment process, which, in turn, improves the
reward expectation associated with sexual experience.
Some more practical aspects of individual therapy
refer to the patient’s basic conditions and the basic needs
required for sexual desire. As sexual motivation does not
exist in a vacuum, therapy often entails some sort of
social work or social education to identify these basic
conditions and to search for solutions to realise them. In
many cases, these real-world matters are no less im-
portant than the above-mentioned intrapsychic issues
and should be seriously targeted by the therapist.
Elements of interpersonal therapy
Although it is evident that individual and developmental
aspects, as well as the reasons and the meanings of low
sexual desire, are highly important and have to be

adequately considered, there is a strong need for an in-
terpersonal, systemic perspective in therapy. Essentially,
sexual desire is, in most instances, the desire for a spe-
cific person rather than the desire for sexual behaviour
per se. The basic needs that sexual desire is able to realise
and fulfil and the corresponding rewards that it offers to
the individual depend heavily on this interpersonal as-
pect. From a therapeutic standpoint, treatment cannot
be successful if it is focused mainly on ‘‘curing’’ the low
desire partner [22]. Instead, the low desire problem must
be redesignated as a couple problem and treated ac-
cordingly as a couple project where both partners have
equal responsibilities.
In terms of the interpersonal treatment aspects, both
our theoretical understanding and the structure of our
practical approach has been profoundly influenced by
the work of Schnarch [24, 25, 26], who has proposed a
new paradigm for treating desire disorders that has
advanced and expanded traditional sex therapy. In his
systemic perspective, desire problems are a form of
personal communication and sexual desire represents
an interpersonal process that influences, and is influ-
enced by, the relationship dynamics. He also claims
that a given sexual desire problem is not a symptom of
problems elsewhere in the relationship but reflects the
relationship itself and is, perhaps, the best window into
the functioning of the individual woman and her
partnership. Schnarch’s systemic concept is based on
the concepts of personal growth, differentiation and
self-validation, as opposed to emotional fusion and the
tendency to validate oneself through the partner. He
emphasises that sexual desire is connected to intimacy
but proposes a different notion of intimacy that is not
simply closeness without separateness but rather
self-disclosure to one’s partner while maintaining a
clear sense of oneself as a person. In contrast to more
traditional approaches, this treatment model of desire
problems is not aimed at improving couple communi-
cation or negotiation but at personal growth and
development as the key variables for mutual desire,
especially in long-term relationships. In addition, it
tries to tap into the previously unexploited sexual
potentials of both partners.
Concluding remarks
Due to the complexity and the biopsychosocial nature
of female sexual desire disorders, a comprehensive,
broad-spectrum treatment approach is needed. The
various components of the treatment concept have to be
tailored to the individual case after performing a careful
assessment procedure. For a successful treatment of low
desire, interventions addressing individual (intrapsy-
chic) and relationship (systemic) aspects are equally
important. The significance of developmental issues and
personality factors, together with the specific function
and meaning of low desire, has to be taken into
account, but this should happen within a systemic
87
framework. Thus, couple therapy for female desire
problems can be a very effective form of individual
therapy allowing personal growth for both partners and
the relationship. In view of the many unresolved issues
and intricate questions, the challenge that sexual desire
and its disorders present to us has not subsided. As
much remains to be learned, it seems important that
researchers and clinicians do not yield to the temptation
to concentrate only on endpoints, criteria, markers or
outcomes. Instead, let us first talk to these women and
their partners, let them tell us their individual stories
and let us listen carefully.
References
1. American Psychiatric Association (1994) Diagnostic and sta-
tistical manual of mental disorders, 4th edn. American Psychi-
atric Association, Washington, DC
2. Bancroft J (1999) Central inhibition of sexual response in the
male: a theoretical perspective. Neurosci Biobehav Rev 23:763–
784
3. Bancroft J, Janssen E (2000) The dual control model of male
sexual response: a theoretical approach to centrally mediated
erectile dysfunction. Neurosci Biobehav Rev 24:571–579
4. Bancroft J, Graham CA, McCord C (2001) Conceptualizing
women’s sexual problems. J Sex Marital Ther 27:95–103
5. Basson R, Berman J, Burnett A, Derogatis L, Ferguson D,
Fourcroy, Goldstein I, Graziottin A, Heiman J, Laan E,
Leiblum S, Padma-Nathan H, Rosen R, Segraves K,
Segraves RT, Shabsigh R, Sipski M, Wagner G, Whipple B
(2000) Report of the international consensus development
conference on female sexual dysfunction: definitions and
classifications. J Urol 163:888–893
6. Beck JG (1995) Hypoactive sexual desire disorder: an overview.
J Consult Clin Psychol 63:919–927
7. Borkenau P, Ostendorf F (1993) NEO-Fünf-Faktoren-Inventar
(NEO-FFI). Hogrefe, Göttingen
8. Both S, Everaerd W (2002) Comment on ‘‘the female sexual
response: a different model.’’ J Sex Marital Ther 28:11–16
9. De Amicis LA, Goldberg DC, LoPiccolo J, Friedman J, Davies
L (1985) Clinical follow-up of couples treated for sexual dys-
function. Arch Sex Behav 14(6):467–489
10. Deneke FW, Hilgenstock B (1989) Das Narzissmus-Inventar.
Hans Huber, Bern
11. Derogatis LR, Meyer JK, King KM (1981) Psychopathology in
individuals with sexual dysfunction. Am J Psychiatry
138(6):757–763
12. Donahey KM, Carroll RA (1993) Gender differences in factors
associated with hypoactive sexual desire. J Sex Material Ther
19(1):25–40
13. Everaerd W, Both S (2001) Ideal female sexual function. J Sex
Marital Ther 27:137–139
14. Hartmann U (2001) Gegenwart und Zukunft der Lust. Ein
Beitrag zu biopsychologischen und klinischen Aspekten sexu-
eller Motivation. (Present and future of desire. A contribution
to bio-psychological and clinical aspects of sexual motivation).
Sexuologie 8:191–204
15. Hawton, K, Catalan J, Martin P, Fagg J (1986) Long-term
outcome of sex therapy. Behav Res Ther 24(6):665–575
16. Janssen E, Everaerd W, Spiering M, Janssen J (2000) Auto-
matic processes and the appraisal of sexual stimuli: toward an
information processing model of sexual arousal. J Sex Res
37:8–23
17. Kaplan HS (1979) Disorders of sexual desire. Brunner & Ma-
zel, New York
18. Kaplan HS (1995) The sexual desire disorders. Brunner &
Mazel, New York
88
19. Kloth G, Heiser K, Rüffer-Hesse C, Hartmann U (2001) Per-
sonality characteristics and narcissistic self-regulation in
women with hypoactive sexual desire disorders. Poster pre-
sented at 4th Congress of the European Society for Sexual and
Impotence Research (ESSIR), Rome, Italy, 30 September–3
October, 2001
20. Masters WH, Johnson VE (1966) Human sexual response.
Little, Brown, Boston (dt.: Die sexuelle Reaktion. Reinbek:
Rowohlt 1970).
21. O’Carroll R (1991) Sexual desire disorders: a review of con-
trolled treatment studies. J Sex Res 28:607–624
22. Pridal CG, LoPiccolo J (2000) Multielement treatment of sex-
ual desire disorders: integration of cognitive, behavioral and
systemic therapy. In: Leiblum SR, Rosen RC (eds) Principles
and practice of sex therapy, 3rd edn. Guildford Press, New
York, pp 58–59
23. Rüffer-Hesse C, Heiser K, Kloth G, Hartmann U (2001) Fe-
male sexual desire disorders: are there subtypes of women
View publication stats
suggesting specific treatment strategies? Poster presented at 4th
Congress of the European Society for Sexual and Impotence
Research (ESSIR), Rome, Italy, 30 September–3 October, 2001
24. Schnarch D (1991) Constructing the sexual crucible. W.W.
Norton, New York
25. Schnarch D (1997) Passionate marriage. W.W. Norton, New
York
26. Schnarch D (2000) Desire problems: a systemic perspective. In:
Leiblum SR, Rosen RC (eds) Principles and practice of sex
therapy, 3rd edn. Guildford Press, New York
27. Schreiner-Engel P, Schiavi RC (1986) Lifetime psychopathol-
ogy in individuals with low sexual desire. J Nerv Ment Dis
174(11):646–651
28. WHO (1991) Tenth revision of the International Classification
of Diseases, ch V(F). World Health Organization