REVIEW

Male Sexual Desire: An Overview of Biological, Psychological, Sexual,

Relational, and Cultural Factors Influencing Desire
Filippo Maria Nimbi, PhD,1,2 Francesca Tripodi, PsyD,2 Roberta Rossi, PsyD,2 Felipe Navarro-Cremades, PhD,3 and
Chiara Simonelli, AP1,2

ABSTRACT

Introduction: The literature showed the need for a better understanding of the male sexual response, which has
historically been considered as simpler and more mechanistic compared with that in women.
Aim: To examine the literature on biopsychosocial factors associated with the level of sexual desire in men and
discuss some interesting directions for future research.
Methods: A systematic literature review was conducted.
Main outcome measures: 169 articles published in Google Scholar, Web of Science, Scopus, EBSCO, and
Cochrane Library about male sexual desire and related biopsychosocial factors.
Results: We found a lack of multidimensional studies on male sexual desire. Most existing research has focused
on hypoactive sexual desire disorder in coupled heterosexual men. Biological factors play important roles in the
level of sexual desire, but they are insufficient to explain the male sexual response. Psychological, relational, and
sexual factors (eg depression, anxiety, emotions, attraction, conflicts, communication, sexual functioning,
distress, satisfaction) are involved in the development/maintenance of lack of sexual interest in men. Cultural
influence is also relevant, with cognitive factors linked to gender roles and sexual scripts of masculinity identified
as important predictors of low sexual desire.
Conclusion: Male sexual desire is characterized by an interplay among biological, psychological, sexual, rela-
tional, and cultural elements. This interplay merits further study to better understand how sexual desire works
and how treatments for low sexual interest could be improved. Nimbi FM,Tripodi F, Rossi R, et al. Male
Sexual Desire: An Overview of Biological, Psychological, Sexual, Relational, and Cultural Factors Influ-
encing Desire. Sex Med Rev 2018;X:XXXeXXX.
Copyright
2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Sexual Desire; Sexual Response; Man and Masculinity; Biopsychosocial Model

INTRODUCTION frequency of sexual intercourse and masturbation, sexual fanta-

There is no univocal way to describe sexual desire, as it is more
complex than any other phase of sexual response. It has unique
subjective aspects, and most attempts to measure it in research
are focused on manifestations of drive—such as hormone levels,
neuroimages, pathology of sexual desire (eg, hypoactive sexual
desire disorder [HSDD], hypersexuality), self-reports (perceived
level and intensity of sexual desire), attempts or receptivity to sex,
Received July 30, 2018. Accepted December 16, 2018.
1
Department of Dynamic and Clinical Psychology, Sapienza University of
Rome, Rome, Italy;
2
Institute of Clinical Sexology, Rome, Italy;
3
Clinical Medicine Department, Miguel Hernandez University, San Juan de
Alicante, Spain
Copyright ª 2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.sxmr.2018.12.002
sies and arousal—rather than on desire itself.1 Moreover,
expressions of desire are extremely different among individuals
and within the same person, ranging from temporary fluctuations
to broad changes in different phases of life. The enormous
variation in the reactivity of human sexual desire is a feature that
should be accommodated by any attempt to explain the foun-
dation of sexual drive.2,3
Sexual desire is commonly defined as the subjective psy-
chological status to initiate and maintain human sexual
behavior, triggered by internal and/or external stimuli.4,5 Pri-
marily, it was conceptualized by Kaplan6,7 as the first phase of
sexual response in her linear model, preceding arousal, orgasm,
and resolution. Levine8e10 highlighted 3 biopsychosocial (BPS)
components of sexual desire: drive, the biological aspect
including anatomy and physiology of the neuroendocrine sys-
tem; motivation, the psychological aspect, including mental
state, relational issues, and social context; and wish, the cultural

Sex Med Rev 2019;-:1e33 1

2 Nimbi et al
Figure 1. PRISMA Flow Diagram of the critical review.
element considering ideals, values, and rules regarding the
expression of sexuality. Stoléru11 highlighted the cognitive and
emotional components of sexual desire, stating that it involves
the mental representation of a goal regarding sexual pleasure,
which is emotionally charged. Following this line, some authors
place desire in close connection with arousal, describing the
drive as the predisposition to subjectively respond to sexual
stimuli with feelings of sexual excitement.12,13 However, these
definitions are far from adequate to describe such a complex
phenomenon; our current knowledge about sexual desire re-
mains partial and vague, with no general agreement between
scientists and clinicians.
The aim of this critical review was to discuss the literature on
BPS factors associated with the levels of sexual desire in men,
divided into biological, psychological, sexual, relational, and
cultural variables. Moreover, we wanted to suggest some inter-
esting directions for future research under the umbrella of the
BPS approach.
METHODS
This review was based on the results of a bibliographic research
in Google Scholar, Web of Science, Scopus, EBSCO, and
Cochrane Library of relevant articles. The main search terms
used, including asterisks, were “sexual desire,” “biopsychosocial”
AND “sex*,” and “desire” AND “sex*.” Additional terms
included “sex* drive,” “sex* motivation,” and “sex* interest.” The
results were reviewed as reported in Figure 1. Experimental
studies focusing on level of sexual desire and biological, psy-
chological, sexual, relational, and cultural components associated
with desire in men were selected (Table 1). Books, systematic
reviews, and meta-analyses describing models, guidelines, gold
standards, treatment algorithms, and critical issues were also
considered for a better characterization of the topic in the current
literature, but they are not included in Table 1. Excluded studies
were unrelated to sexology or were beyond the scope of this
review (eg, focusing only on women or animals). Article refer-
ences were reviewed to find additional papers. All papers selected
were published in English, and full text was accessible. When
articles were not directly available, authors were solicited by mail.
A total of 169 papers and relevant books are included in the
present review, indicating an increasing body of research on male
sexual desire adopting the BPS framework over the last several
decades.
Sexual Desire in the Models of Sexual Response
and Classifications
How to describe sexual desire and the related dysfunctions has
been debated for years in the scientific literature, especially
regarding women.85,86 From the first inclusion of desire in the
Sex Med Rev 2019;-:1e33
 Table 1. Summary of selected studies on men’s sexual desire, sorted by year of publication
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Author(s) Year Sample Methodology Main findings

Dewitte and 2018 66 monogamous heterosexual Diary study, 21 d, reporting every day on sexual
Mayer14 couples (from at least 1 year; desire, sexual activity, and relationship quality.
age 19e65 y) and living Items were selected from previous diary studies
together recruited with a and the following:
snowball method - a shortened version of the Maudsley Marital Question-
naire (MMQ)
- International Index of Erectile Function (IIEF)
- Female Sexual Function Index (FSFI)
Murray15 2018 30 men (age 30e65 y) in Interview about their experience of sexual desire
heterosexual long-term
relationships (>2 y)
Nimbi et al16 2018 298 Italian heterosexual men Paper/Web survey with snowball recruitment:
from the general population - International Index of Erectile Function (IIEF)
(age 18e72 y) - Short Form 36 for Quality of Life (SF-36)
- Beck Depression Inventory-II (BDI-II)
- Symptom Checklist 90 Revised (SCL90-R)
- Toronto Alexithymia Scale (TAS-20)
- Premature Ejaculation Severity Index (PESI)
- Sexual Distress Scale (SDS)
- Sexual Satisfaction Scale (SSS)
- Dyadic Adjustment Scale (DAS)
- Ambivalent Sexism Inventory (ASI)
- Sexual Modes Questionnaire (SMQ)
- Sexual Dysfunctional Belief Questionnaire (SDBQ)
- Questionnaire of Cognitive Schema Activation in Sexual
Context (QCSASC)
Nimbi et al17 2018 450 heterosexual Italian men Web survey with snowball recruitment:
from the general population - International Index of Erectile Function (IIEF)
(age 18e76 y) - Ambivalent Sexism Inventory (ASI)
- Sexual Modes Questionnaire (SMQ)
- Positive and Negative Affect Schedule (PANAS)
The sexual responses of women depended on the
relationship context, mainly when having children and
being in a longer relationship. Male sexual responses
depended less on contextual factors but did vary by
level of sexual functioning.
Most participants described having high and constant
levels of sexual desire, and just over one-half reported
never turning down an opportunity to engage in a
sexual encounter. However, most men also indicated
that their sexual desire was sometimes feigned to
appear more masculine or to prevent upsetting their
female partner.
Lack of erotic thoughts, fear, and desire to have a baby
were the main predictors of level of sexual desire.
Energy-fatigue, depression, premature ejaculation
severity, sexual distress, compatibility, subjective
sexual response, and sexual conservatism had weaker
effects on sexual desire. Sexual functioning (13.8%),
emotional response (12.7%), dysfunctional sexual
beliefs (12.1%), and negative automatic thoughts
(12.0%) were the areas explaining most of the variance
in sexual desire.
A model considering the interrelated role of automatic
thoughts, emotional factors, sexual function, and
sexism in influencing the levels of men’s sexual desire
was presented and tested. Path diagrams were built
including “orgasmic function,” “lack of erotic
thoughts,” “erection concerns,” “hostile sexism,” and
“positive affect” as predictors of sexual desire. Results
showed a satisfactory data fit of the model (c2 ¼
35.312; degree of freedom ¼ 34, P ¼ .406; GFI ¼ .987;
NFI ¼ .945; CFI ¼ .998; RMSEA ¼ .009; 95% CI ¼
.000e.036). All of the endogenous paths and hostile
sexism were found to be significant.
(continued)

3
 4
Table 1. Continued
Author(s) Year Sample Methodology Main findings
18
Nimbi et al 2018 450 heterosexual Italian men Web survey with snowball recruitment: “Orgasmic function,” “lack of erotic thoughts,” “erection
from the general population - International Index of Erectile Function (IIEF) concerns,” “hostile sexism,” and “positive affect” were
(age 18e76 y) - Short Form 36 for Quality of Life (SF-36) the main sexual desire predictors for men.
- Positive and Negative Affect Schedule (PANAS) “Depression,” “premature ejaculation severity,” “sexual
- Symptom Checklist 90eRevised (SCL90-R) distress,” “sexual conservatism,” and “helpless” had
- Toronto Alexithymia Scale (TAS-20)
smaller correlations with sexual desire levels.
- Premature Ejaculation Severity Index (PESI)
- Sexual Distress Scale (SDS)
- Sexual Satisfaction Scale (SSS)
- Dyadic Adjustment Scale (DAS)
- Ambivalent Sexism Inventory (ASI)
- Sexual Modes Questionnaire (SMQ)
- Sexual Dysfunctional Belief Questionnaire (SDBQ)
- Questionnaire of Cognitive Schema Activation in Sexual
Context (QCSASC)
Manuela Peixoto19 2018 142 gay and 273 heterosexual Online survey and mailing list: The main findings suggested that gay men scored
men (Portuguese speakers) - Sexual Desire Inventory-2 (SDI-2) significantly higher on both solitary sexual desire and
- Global Measure of Sexual Satisfaction (GMSEX) attractive person-related dyadic sexual desire
subscales, but not on a partner-related dyadic sexual
desire subscale, compared with heterosexual men.
Irrespective of sexual orientation, partner-related
dyadic sexual desire positively predicts sexual
satisfaction, whereas solitary and attractive person-
related dyadic sexual desire negatively predicts sexual
satisfaction in men.
Vowels et al20 2018 133 heterosexual couples (age 21 Diary study for 30 d; dyadic daily diary for perceived Men and women were found to exhibit fluctuations in
e64 y) from the general levels of sexual desire sexual desire at various frequencies, including rates of
population (nonclinical once and twice per month, and to have sexual desire
sample) that was unlikely to fluctuate over periods of 3 d or
less and thus exhibited persistence. Similar patterns of
fluctuation were exhibited within couples, and these
patterns were found to be largely synchronous.
Whereas instances of desire discrepancy may arise due
to differences in rates of sexual desire fluctuation and
random fluctuations, such instances may be normal
for romantic relationships.
Sex Med Rev 2019;-:1e33

(continued)

Nimbi et al
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Table 1. Continued
Author(s) Year Sample Methodology Main findings
Werner et al21 2018 1,242 men and 1,786 women Web survey: The structure of the hypersexuality network was
from Croatia (age 18e60 y) - Ad hoc questions on sexual desire level, sexual activity, surprisingly similar in women and men, in terms of
and pornography consumption both symptom centrality and clustering of symptoms.
- Hypersexual Behavioural Consequences Scale (HBCS) Psychological distress and negative emotions triggered
- Hypersexual Disorder Screening Inventory (HDSI) by sexual fantasies and/or behaviors, together with a
loss of control over sexual feelings, occupied central
positions in the networks. Pornography use was
located peripherally in both the men’s and women’s
hypersexuality networks.
DeLamater et al22 2017 27 men and 30 women from the 10 focus groups on the meanings and connotations Participants characterized (sexual) interest as a cognitive
general U.S. population (age of multiple terms related to sexual function, phenomenon and a situational response to a specific
23e77 y) especially interest, desire, and arousal person. Similarly, they characterized (sexual) desire as
a situational person-specific experience with some
support for it as a cognitive phenomenon but more
support for it as a physical phenomenon. In contrast,
participants characterized sexual arousal as a physical
phenomenon occurring in response to physical or
visual stimulation and not related to a specific person.
Murray et al23 2017 30 men (age 30e65 y) in long- Semistructured interviews regarding participants’ A total of 14 themes and 23 subthemes were identified to
term heterosexual romantic relationships, their sexual desire, and capture men’s descriptions of eliciting and inhibiting
relationships from Canada the factors in their relationships and personal factors of sexual desire. The six most integral themes
lives that affected their sexual desire were (i) feeling desired, (ii) exciting and unexpected
sexual encounters, (iii) intimate communication, (iv)
rejection, (v) physical ailments and negative health
characteristics, and (vi) lack of emotional connection
with partner.
Pascoal et al24 2017 124 heterosexual couples from Web survey: The dyadic model had a better fit than the individual
Portugal (age 18e69 y) - International Index of Erectile Function (IIEF) model. Women’s sexual desire and orgasm and men’s
- Female Sexual Function Index (FSFI) erectile functioning were significant positive predictors
- Global Measure of Sexual Satisfaction (GMSEX) of both one’s own and partner’s sexual satisfaction.
Gender differences in sexual desire would explain why
in the present study, men’s lower sexual desire was not
associated with either personal or partner’s sexual
satisfaction: lower sexual desire in men would likely
result in a lower desire discrepancy between partners.
(continued)

5
 6
Table 1. Continued
Author(s) Year Sample Methodology Main findings
25
Dosch et al 2016 28 men and 33 women living in Laboratory session with measure of implicit Results showed higher levels of dyadic and solitary sexual
heterosexual relationships in attitudes and self-reported questionnaires: desire in men than in women. No gender differences
Switzerland (age 18e40 y) - Adapted version of the Affect Misattribution Procedure were found regarding sexual satisfaction or sexual
(AMP) attitudes. High dyadic sexual desire was associated
- Sexual Desire Inventory (SDI) with positive implicit and explicit sexual attitudes,
- Multidimensional Sexuality Questionnaire (MSQ) regardless of gender. However, solitary sexual desire
- Social Desirability Scale (DS-36)
was significantly higher in men than in women and in
women only was associated with positive implicit
sexual attitudes, suggesting that solitary sexual desire
may fulfill different functions in men and women.
Rosen et al26 2016 1,009 men (age 39e70 y) and Mixed recruitment (telephone, mail, door-to-door, Sexual problem rates of men in this survey were generally
their female partners from etc); self-reported questionnaires: similar to rates observed in previous surveys in the
Brazil, Germany, Japan, - International Survey of Relationships (ISR) general population, and similar risk factors (age,
Spain, and the U.S. - Questions adapted from the National Health and Social relationship duration, overall health) were associated
Life Survey (NHSLS) with lack of desire, anorgasmia, or erection. Men with 1
- Relationship happiness question adapted from the or more sexual problems reported decreased
Dyadic Adjustment Scale (DAS)
relationship happiness as well as decreased sexual
- Sexual satisfaction adapted from the International Index
of Erectile Function (IIEF) and the Female Sexual Func- satisfaction compared with men without sexual
tion Index (FSFI) problems.
Shrier and Blood27 2016 20 U.S. heterosexual couples Audio computer-assisted self-interview (ACASI): Sexual desire and emotional intimacy magnitude and
(age 18e25 y) in a sexual - Quality of Relationships Inventory (QRI) stability were associated with relationship quality and
relationship for at least 3 wk - Miller Social Intimacy Scale (MSIS) physical intimacy enjoyment differently in men versus
- Ad hoc items on enjoyment of physical intimacy and women. Men particularly perceived higher relationship
frequency of sexual activity, momentary sexual desire, quality and enjoyed physical intimacy more when they
and emotional intimacy
had higher and more stable sexual desire and their
female partners had more stable emotional intimacy.
28
Wu et al 2016 141 undergraduate men and 212 Cross-cultural research with either online or in vivo Men reported significantly more frequent sexual fantasy/
women from the U.S. and administration of self-report measures: arousal than women. In addition, significant
Macau - Ad hoc questions on sexual fantasy and arousal differences in the age of initial sexual arousal were
- MarloweCrowne Social Desirability Scale found. Men from the U.S. reported the earliest age of
initial arousal, followed by men from Macau, women
from the U.S., and females from Macau.
(continued)
Sex Med Rev 2019;-:1e33

Nimbi et al
Sex Med Rev 2019;-:1e33
Table 1. Continued
Author(s) Year Sample
Angst et al29 2015 292 men selected from
screening lists for military
service and 299 women
selected from the electoral
register in Switzerland
Boddi et al30 2015 3,975 men attending an Italian
outpatient clinic for sexual
problems for the first time
Carvalheira and 2015 2,968 men with an exclusive
Costa31 heterosexual behavior and
285 men with exclusive
homosexual behavior in the
previous 5 y from Portugal
and Croatia
Carvalho et al32 2015 2,000 men and 2,597 women
from Croatia (age 18e60 y)
Methodology
Structured Psychopathological Interview and Rating
of the Social Consequences of Psychological
Disturbances for Epidemiology (SPIKE)
Retrospective study based on physical examination,
blood and penile Doppler ultrasound (PDU)
examination. Questionnaires included:
- Structured Interview on Erectile Dysfunction (SIEDY)
- 2 ad hoc items to assess conflicts within the family and
within the couple
- Modified version of the Middlesex Hospital Question-
naire (MHQ)
Web survey:
- New Scale of Sexual Satisfaction (NSSS)
- 7 items from the British NATSAL 2000 study (NHSLS)
- 5-item version of the Emotional Intimacy Scale (EIS)
- Ad hoc items on number of sexual partners and fre-
quency of sexual intercourse
Web survey:
- Symptoms Checklist Depression 6 and Anxiety 4
(SCL90)
- 8-item neuroticism subscale from the Big Five Inventory
(BFI)
- Rapid Alcohol Problem Screen
- Ad hoc questions on sexual desire level, sexual activity,
and pornography consumption
- Hypersexual Behavioral Consequences Scale (HBCS)
- Ad hoc item on the inability to control one’s sexuality
Factors Influencing Male Sexual Desire
Main findings
Results showed higher lifetime risks in women than in
men for any sexual problem (women, 67.0%; men,
46.0%) and for functional problems (39.3%; 22.1%),
emotional problems (35.7%; 15.9%), and sexual desire
problems (51.6%; 33.3%). Although in general men’s
sexual problems increased with age, no such
association was observed in women. The overlap of
sexual problems were markedly different in women
and men.
Family and couple conflicts were significantly associated
with free-floating anxiety, depression symptoms, and
higher risk of subjective (self-reported) and objective
(peak systolic velocity <35 mm/s2 on penile color
Doppler ultrasound) erectile dysfunction and
hypoactive sexual desire.
Among heterosexuals, in step 1, both age and sexual
difficulties emerged as highly significant predictors,
and in step 2, the frequency of intercourse and the
number of sexual partners also emerged as significant
predictors. Finally, in the step 3, the intimacy and
duration of the relationship emerged as highly
significant predictors of sexual satisfaction.
Among homosexuals, in step 1, sexual difficulties and
country were significant predictors; in step 2, only the
frequency of sexual intercourse was a significant
predictor; and in step 3, both relational variables
(relationship duration and relationship intimacy) were
significant predictors.
Cluster analysis pointed to the existence of 2 meaningful
clusters, one representing problematic sexuality (ie,
lack of control over one’s sexuality and negative
outcomes; control/consequences cluster) and the other
reflecting high sexual desire and frequent sexual
activity (desire/activity cluster). Compared with the
desire/activity cluster, individuals from the control/
consequences cluster reported more psychopathology
and were characterized by more traditional attitudes.
(continued)
7

Table 1. Continued
Author(s) Year Sample
33
Dosch et al 2015 178 heterosexual men and 181
women (age 25e46 y) in a
couple relationship and living
with their partner for at least
1 y, selected from the general
population living in
Switzerland
Ferreira et al34 2015 33 heterosexual couples (age 25
e78 y) from Portugal
Grøntvedt et al35 2015 331 male and 427 female
Norwegian heterosexual
university students (age 18
e44 y)
Sex Med Rev 2019;-:1e33
Methodology
Self-reported questionnaires administered at home:
- Sexual Desire Inventory (SDI)
- Multidimensional Sexuality Questionnaire (MSQ)
- 2 ad hoc items on frequency of sexual activities
- Revised Experiences in Close Relationships Question-
naire (ECR-R)
- ApproacheAvoidance Temperament Questionnaire
(ATQ)
- Mindful Attention Awareness Scale (MAAS)
- UrgencyePremeditationePerseveranceeSensation-
SeekingePositive Urgency Impulsive Behavior Scale
(UPPS-P)
Dyadic couple interviews at home with a snowball
sampling structured in 5 sections on relational
trajectories and sexual desire
Paper questionnaire:
- Mate Value Inventory (MVI)
- Top 15 most endorsed motivations for having sex, from
a previous study replicating the factor structure of
Meston and Buss to assess the reasons to have sex
- Satisfaction and commitment section of Rusbult’s In-
vestment Model
- Ad hoc items on arousal, desire, sexual behavior, and
relationships
8
Main findings
Cluster analyses, based on participants’ level of sexual
desire and sexual activity, highlighted 3 distinct profiles
for each gender related to different types of
psychological functioning: (i) participants with high
dyadic sexual desire and activity were the most
sexually satisfied, showed optimal psychological
functioning, and were characterized by a balance
between motivational tendencies to seek positive
rewards and self-control abilities (high approach
motivation, secure attachment, high self-control, high
mindfulness); (ii) participants with high dyadic and
solitary sexual desire and activity were moderately
satisfied and showed a type of psychological
functioning predominantly characterized by impulsivity
(an overly high motivation to obtain rewards in women,
and low self-control in men); and (iii) participants with
low dyadic sexual desire and activity were the least
sexually satisfied and were characterized by high
motivation to avoid negative consequences and low
self-control (high avoidance motivation, insecure
attachment, and poor mindfulness).
Factors associated with high desire were change and
autonomy, whereas conflict and children were reported
to be desire-diminishing factors. Innovation, sharing,
autonomy, and effort emerged as desire-promoting
strategies, whereas fostering personal interests,
investing in a positive connection, and enhancing
personal integrity were identified as couples’ strategies
to promote and preserve differentiation of self.
In long-term relationships, a positive partner bond
increased the initiative for sexual intercourse for
women. For men, self-perceived independence
increased the probability of taking the initiative,
whereas relationship attachment decreased the
probability. For short-term relations, the desire
component of the sociosexual orientation inventory
increased probability of initiation for both sexes,
whereas male initiative was increased by pleasure
reasons for sex.
Nimbi et al
(continued)
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Table 1. Continued
Author(s) Year Sample Methodology Main findings
Ozkan et al36 2015 56 infertile Turkish men Paper questionnaire: The scores of the infertile group were significantly lower
undergoing in vitro - International Index of Erectile Function 5 and 15 (IIEF-5 than those of the control group in orgasmic function,
fertilization therapy and 48 and IIEF-15) sexual desire, intercourse satisfaction, and overall
fertile men (age 24e45 y) - Beck Depression Inventory (BDI) satisfaction domains.
Pedersen et al37 2015 968 patients (590 men and 378 Paper questionnaire administered by physicians: The prevalence of low sexual desire was 53% (RC) and
women) with screen- - questions adapted from the National Health Interview 54% (IT) among women and 24% (RC) and 25% (IT)
detected type 2 diabetes Survey 2000 regarding sexual health among men. The prevalence of low sexual satisfaction
detected from the - 36-item Short Form Health Survey (SF36) was 23% (RC) and 18% (IT) among women and 27%
ADDITION-Denmark study at - Abbreviated International Index of Erectile Function (RC) and 37% (IT) among men. Among men, the
(IIEF-5)
6 y postdiagnosis in routine prevalence of low sexual satisfaction was significantly
care (RC) or in treatment (IT) higher in the IT group than in the RC group.
Puts et al38 2015 61 heterosexual men and 126 Testosterone level measurements in all men and in Circulating testosterone mediated the sex difference in
women from the U.S. those women taking an oral contraceptive in 3 human sociosexuality and predicted sociosexual
sessions over 1e1.5 y. The Revised Sociosexual psychology in men but not in oral contraceptiveeusing
Orientation Inventory (SOI-R) was administered women. Moreover, when sociosexual psychology was
during the third/last session. controlled, men’s sociosexual behavior (ie, number of
sexual partners) was negatively related to
testosterone, suggesting that testosterone drives
sociosexual psychology in men and is inhibited when
those desires are fulfilled.
Sutherland et al39 2015 Sample 1: 82 U.S. heterosexual Sample 1 was recruited from a larger in-person Results showed that a higher perceived, but not actual,
couples in committed long- longitudinal study with semistructured desire discrepancy was associated with lower sexual
term relationships (age 21 interviews. Sample 2 was recruited online. The satisfaction. In addition, perceived desire discrepancy
e65 y) following tools were used: outcomes differed when measured using different
Sample 2: 191 U.S. individuals (71 - Global Measure of Sexual Satisfaction (GMSEX) response scales.
men) in committed long-term - Hurlbert Index of Sexual Desire (HISD)
relationships - Perceived sexual desire discrepancy
Yıldız and 2015 127 men with diabetes from Paper questionnaire administered by a physician: The most affected domain among the cases was erectile
Bölüktaş40 Turkey - International Index of Erectile Function (IIEF) function (33.1%) and intercourse satisfaction (29.1%),
- 36-item Short Form Health Survey (SF-36) and the least affected domain was sexual desire
- Beck Depression Inventory (BDI) (6.3%). Factors affecting sexual dysfunction (SD)
- Coopersmith Self-Esteem Scale (SEI) included age, education level, obesity, hypertension,
- Body Image Scale (BIS)
retinopathy, vasculopathy, nephropathy, diabetic foot,
hemoglobin A1C and low-density lipoprotein
cholesterol levels, duration of diabetes, and drugs
used. All quality of life subgroup scores except pain
were lower in men with SD than in those without SD.
Depression and body image scores were lower in men
with SD.
(continued)

9

Table 1. Continued
Author(s) Year Sample
41
Carvalheira et al 2014 5,255 men (age 18e75 y) from
Portugal, Croatia, and
Norway
Gledhill and 2014 6 men and 2 women (age 65
Schweitzer42 e84 y) who were part of a
larger Australian study of
sexual desire in older age:
English-speaking, had
experienced erectile
dysfunction, used
pharmaceuticals for sexual
enhancement, or had
partnered men with erectile
dysfunction
Hendrickx et al43 2014 17,601 heterosexual Flemish
men and 17,531 women (age
16e74 y)
Sex Med Rev 2019;-:1e33
Methodology
Web survey:
- Symptoms Checklist Depression 6 and Anxiety 4
(SCL90)
- An item assessing lack of sexual interest from the
British NATSAL 2000
- Relationship intimacy from a 5-item version of the
Emotional Intimacy Scale (EIS)
- A 4-item version of the Sexual Boredom Scale (SBS)
- Ad hoc item on personal distress
Narratives collected from in-depth ad hoc
interviews snowball sampling
Web survey based on the Sexual Functioning Scale
(SFS)
10
Main findings
Distressing lack of sexual interest lasting at least 2 mo in
the previous year was reported by 14.4% of the
participants. The most prevalent comorbidity in these
men was erectile difficulty (48.7%). Men with low
confidence in their erectile function, lack of attraction
to their partner, and in a long-term relationship were
more likely to have a lack of sexual interest compared
with men with high confidence levels, attraction to
their partner, and in a shorter-term relationship.
Professional stress was the most frequently reported
reason for lack of sexual interest. Sexual boredom in a
long-term relationship was significantly and negatively
correlated with the level of intimacy (r ¼ 0.351; P <
0.001) and sexual satisfaction (r ¼ 0.497; P <
0.001).
Sexual desire can persist regardless of age, health, or
sexual function. Pharmaceutical therapy for sexual
enhancement can have disappointing results.
Acknowledgment of the older person as a sexual being
remains lacking in Western society.
Sexual dysfunctions were far less common than sexual
difficulties, and some uncommonly assessed sexual
problems (eg, “hyperactive sexual desire” in men) were
quite prevalent.
Even less prevalent was responsive desire as a sexual
dysfunction, with 2.3% of men classified as lacking
desire, even in response to a partner taking the
initiative, and 4% of men classified as having
hypoactive (spontaneous) sexual desire as a sexual
difficulty. Hypoactive sexual desire disorder (HSDD) as
an SD was less prevalent, with only 1.6% of men
classified with this dysfunction.
(continued)
Nimbi et al
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Table 1. Continued
Author(s) Year Sample Methodology Main findings
Mark et al5 2014 203 heterosexual couples in a Web survey: Men were significantly more likely to endorse desires for
relationship for at least 3 y - Dyadic Subscale of the Sexual Desire Inventory (SDI-D) sexual release, orgasm, and pleasing their partner.
- Ad hoc questions on the object of sexual desire Women were significantly more likely than men to
endorse desires for intimacy, emotional closeness,
love, and feeling sexually desirable. Discrepancies
within the couple with regard to object of desire were
related to their level of sexual desire for the partner,
accounting for 17% of variance in men’s desire and
37% of variance in women’s desire.
Martin et al44 2014 810 randomly selected men (age Study based on blood, physical examination, and Predictors of low dyadic sexual desire incidence included
35e80 y) from Australia who self-reported questionnaires: older age, never having been married, widowhood,
made clinical visits 5 y apart - International Index of Erectile Function (IIEF) being unemployed, being retired, insufficient physical
- Sexual Desire Inventory 2 (SDI-2) activity, and low alcohol intake. Predictors of low
- Beck Depression Inventory (BDI) dyadic sexual desire remission were being married, not
being widowed, higher income, lower abdominal fat
mass, lower obstructive sleep apnea risk, and higher
plasma testosterone level. Predictors of low solitary
SD included never having been married, being
unemployed, low alcohol intake, lower testosterone,
lower urinary tract symptoms, and hypertension.
Predictors of low solitary sexual desire remission were
being married, being employed, higher income, higher
physical activity, moderate alcohol intake, and
depression.
Mitchell et al45 2014 15 English men and 17 women Semistructured interviews on sexual desire/arousal The authors identified 3 criteria that participants used to
from clinical, subclinical, and define and distinguish between desire and arousal: the
healthy populations sequence in which they occurred; whether the mind or
the body (or both) were engaged; and the extent to
which feelings of desire or arousal were responsive (in
response to person or stimulus) and motivational
(oriented toward a goal). Most participants attempted
to distinguish between desire and arousal when
prompted, but often with difficulty; however, the
differences between terms were blurred.
(continued)

11
 12
Table 1. Continued
Author(s) Year Sample Methodology Main findings
46
Paterson et al 2014 38 men and 38 women (age 18- Experimental sessions of masturbation to orgasm In both genders, all measures increased significantly
30 y) mainly from Canada in the laboratory. Physiological sexual arousal during masturbation, with a greater buildup leading to
and the U.S. (genital temperature) and subjective sexual a more pleasurable orgasm. After orgasm, however,
arousal and desire measurements were obtained sexual arousal and desire decreased more quickly and
at baseline, after masturbation almost to consistently in men than in women. More men than
orgasm, and immediately and 15 minutes after women exhibited resolution of subjective sexual
orgasm. The following questionnaires were arousal and sexual satiation; their genital temperature
administered: also decreased to a greater degree than women’s but
- Integrated version of the Orgasm Rating Scale (ORS) did not return to baseline. Women’s orgasmic pleasure
- Ad hoc 8 items on subjective sexual arousal and desire was related to a postorgasmic decrease in genital
- Profile of Mood States (POMS) temperature but also, unexpectedly, to the
- International Index of Erectile Function (IIEF) maintenance of subjective sexual arousal and desire.
- Female Sexual Function Index (FSFI)
Peixoto and 2014 212 men (106 gay) and 192 Web survey: The principal sexual problems in the gay (33.9%) and
Nobre47 women (96 lesbian) from a - Ad hoc sexual problems questionnaire heterosexual (30.2%) men were sexual desire
wider Portuguese sample - Sexual Dysfunctional Beliefs Questionnaire (SDBQ) problems. Men with SD (regardless of sexual
orientation) reported significantly more conservative
beliefs and more erroneous beliefs related to partner’s
sexual satisfaction compared with sexually healthy
men. Also, gay men with sexual dysfunction (but not
heterosexual men) scored higher on belief in sex as an
abuse of men’s power compared with healthy controls.
In addition, heterosexual men scored higher on
“macho” beliefs, beliefs regarding partner’s sexual
satisfaction, and partner’s power, compared with gay
men.
Pexman-Fieth 2014 1053 men from 222 centers in 8 Treatment with topical AndroGel 1% T gel. Substantial improvements in hypogonadal symptoms,
et al48 countries: Canada, Russia, Assessment and routine visits (body mass index quality of life, fatigue, erectile dysfunction, and libido/
Croatia, Germany, Slovenia, [BMI] and waist circumference): sexual desire were observed. Adverse drug reactions
Saudi Arabia, Romania, and - Aging Male Symptoms (AMS) scale were experienced by 7.5% of the study population over
the United Arab Emirates - International Index of Erectile Function (IIEF) the 6-mo study period.
- Multidimensional Fatigue Inventory (MFI) scale

(continued)
Sex Med Rev 2019;-:1e33

Nimbi et al
 Table 1. Continued
Sex Med Rev 2019;-:1e33
Author(s) Year Sample Methodology
Sarin et al49 2014 71 men (19 controls, 52 clinical) Snowball recruitment. Participants watched two 15-
(age 18e50 y) minute film clips (neutral and erotic) while genital
arousal (GA) and subjective arousal (SA) were
measured both continuously and discretely. The
following self-report measures were assessed:
- International Index of Erectile Functioning (IIEF)
- Male Sexual Health Questionnaire (MSHQ)
- Sexual Inhibition and Sexual Excitation Scale (SIS-SES)
- Body Shape Questionnaire (BSQ)
- Body Image Self-Consciousness Scale (BISC)
- Toronto Alexithymia Scale (TAS20)
- Difficulties in Emotion Regulation Scale (DERS)
- Sexual Arousal and Desire Interview (SADI)
- Positive and Negative Affect Schedule (PANAS)
- Beck Depression Inventory (BDI)
- State-Trait Anxiety Inventory (STAI)
- Childhood Trauma Questionnaire (CTQ) - Stressful Life
Events Screening Questionnaire (SLESQ)

Stulhofer et al50 2014 506 heterosexual Croatian men Web survey:
currently living with their - Ad hoc questions on sexual desire level, sexual activity,
partners (age 21e68 y) and pornography consumption
- 12-item version of the New Scale of Sexual Satisfaction
(NSSS)
- Emotional Intimacy Scale (EIS)
Willoughby et al51 2014 1,054 heterosexual married After completing the Relationship Evaluation
couples (age 19e76 y) in the Questionnaire (RELATE), assessing the
U.S. relationship strengths and weaknesses, either on
their own or in conjunction with a third party, eg,
a clinician), all participants completed an online
survey comprising ad hoc questions on individual
and couple sexual desire discrepancy, sexual
engagement, couple satisfaction, stability, and
conflicts.
Factors Influencing Male Sexual Desire
Main findings
Genital temperature increased for all groups during the
erotic condition, yet men with erectile dysfunction (ED)
and both ED and HSDD showed less GA compared
with men without erectile difficulties. All groups
showed increased SA during the erotic condition, yet
men with ED/HSDD reported less SA than controls or
men with ED. SA and GA were highly correlated for
controls and less strongly correlated for clinical groups;
men with ED showed low agreement between SA and
GA. Groups also differed in terms of body image,
sexual inhibition/excitation, sexual attitudes, and
alexithymia.
Sexual satisfaction was dependent on both intimacy and
sexual desire. Emotional intimacy was strongly
associated with the partner-centered component of
personal sexual satisfaction, pointing to a possible
mechanism through which intimacy affects sexual
well-being. Despite the use of different analytical
approaches and controlling for age and the duration of
intimate relationship, there was no evidence of a
negative association between relationship intimacy and
male sexual desire.
Findings suggested that higher actor individual sexual
desire discrepancy (SDD) was generally associated
with negative relational outcomes, including lower
reported relationship satisfaction, less stability, and
more reported couple conflict. Marital duration did not
moderate these effects, although gender moderated
the associations between individual SDD and reported
couple communication.
(continued)
13

Table 1. Continued
Author(s) Year Sample
52
Birnbaum et al 2013 61 heterosexual couples (age 19
e38 y) from Israel in a
monogamous relationship for
3 mo or longer and currently
sexually active
Corona Et al53 2013 3,714 men attending the
outpatient clinic for sexual
dysfunction for the first time
Pastuszak Et al54 2013 186 men attending a urology
clinic in the U.S.

Stulhofer Et al55 2013 2,215 Norwegian and
Portuguese heterosexual
men (age 18e75 y) from the
Sex Med Rev 2019;-:1e33
general population
Methodology
Snowball recruitment of couples randomly assigned
to 1 of 2 conditions: discussing a relational
conflict condition (n ¼ 31) or a nonconflictual
discussion condition (daily routine; n ¼ 30). The
following questionnaires were assessed:
- Adapted Affective and Motivational Orientation Related
to Erotic Arousal Questionnaire (AMORE)
- Ad hoc sex-related motives
- Experiences in Close Relationships Scale (ECR)
All patients underwent a complete physical
examination, with measurement of blood
pressure, height, weight, body mass index, and a
penile color Doppler ultrasound examination
performed in the flaccid state and at 20 min after
an intracavernous injection of alprostadil
(prostaglandin E1, 10 mg) (dynamic evaluation).
Patients were interviewed before the start of any
treatment and before any specific diagnostic
procedures using the following:
- Structured Interview on Erectile Dysfunction (SIEDY)
- Structured interview for the screening of hypogonadism
(ANDROTEST)
A retrospective review of demographic data and
serum hormone levels. The following
questionnaires were used:
- Patient Health Questionnaire (PHQ-9)
- International Index of Erectile Function (IIEF)
- Quantitative Androgen Decline in the Aging Male
(qADAM)
Web survey:
- Ad hoc questions on sexual desire and sexual behavior
- National Survey of Sexual Attitudes and Lifestyles
- New Scale of Sexual Satisfaction (NSSS)
- Symptoms Checklist Depression 6 and Anxiety 4
(SCL90)
- Emotional Intimacy Scale (EIS)
- Multidimensional Body-Self Relations Questionnaire
- Sexual Boredom Scale (SBS)
14
Main findings
Results showed that conflict discussion inhibited
relationship-based motives and had an adverse effect
on women’s perceptions of partner’s attractiveness,
but a beneficial effect on men’s perceptions. Conflict
discussion also inhibited self-serving sexual motives,
such as having sex to obtain relief from stress in
people with avoidant partners, suggesting that people
are unlikely to turn to avoidant partners for sexual
consolation.
Reduced libido was comorbid with ED, premature
ejaculation, and delayed ejaculation in 38%, 28.2%,
and 50% of men, respectively, and was isolated in
5.1%. The prevalence of reduced libido was
substantially increased by hypogonadism, almost
doubled by psychopathology, and universally present in
men with hyperprolactinemia (secondary reduced
libido). Men with primary reduced libido were
characterized by higher postschool qualification, more
disturbances in domestic and dyadic relationships, and
an overall healthy body (lower glycemia and triglyceride
levels). Accordingly, the risk of major cardiovascular
events was lower in the patients with primary reduced
libido. Comorbidity with other sexual dysfunctions did
not affect the main characteristics of primary or
secondary reduced libido.
Negative correlations were observed between total PHQ-
9 score and sexual desire, erectile function, intercourse
satisfaction, and overall satisfaction domains of the
IIEF. Men with a PHQ-9 score 10 (mild depression or
worse) had lower sexual desire and sexual satisfaction.
Men with higher PHQ-9 score had lower qADAM
scores.
Three distinct patterns of male sexual desire were
observed: decreased (23.6%), responsive (2.5%), and
spontaneous (73.9%). Men in the more responsive and
spontaneous desire groups differed significantly from
those in the decreased desire group. The sole predictor
of the responsive sexual desire pattern was proneness
to relationship-related sexual boredom.
Nimbi et al
(continued)
 Table 1. Continued
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Author(s) Year Sample Methodology Main findings
Derogatis et al56 2012 200 U.S. men (age 25e64 y) Men completed assessments of sexual desire and There were no clinically relevant differences in age, serum
with or without symptoms of sex-related distress over 28 consecutive days testosterone, depressive symptomatology, erectile
low sexual desire and related and underwent structured clinical interviews for function, concomitant illness, or medication use
distress in a stable the diagnosis of HSDD. On days 21e27: between men with HSDD (n ¼ 109) and men without
monogamous, heterosexual - UCLA Psychosexual Diary HSDD (n ¼ 91). However, clinically meaningful
relationship of at least 1 y On day 28: differences were observed in sexual desire according to
- Sexual Desire Inventory (SDI) SDI and MDS sexual desire domain score, in sex-
- Male Desire Scale (MDS)
related distress according to SCI-M score and SDRDS
- Sexual Concerns Inventory-Male (SCI-M)
score, and in UCLA Psychosexual Diary sexual activity
- Sexual Desire Relationship Distress Scale (SDRDS)
domain score.
Mark and 2012 133 U.S.heterosexual Web survey: Higher desire discrepancy scores significantly predicted
Murray57 monogamous couples (age 18 - Sexual Desire Inventory (SDI) women’s (but not men’s) lower sexual satisfaction
e-41 y) together for least 12 - Index of Sexual Satisfaction (ISS) after controlling for relationship satisfaction. Higher
mo - Dyadic Adjustment Scale (DAS) desire discrepancy scores significantly predicted men’s
(but not women’s) lower relationship satisfaction after
controlling for sexual satisfaction.
Mark58 2012 133 U.S.heterosexual Web survey: Individual sexual desire for one’s partner significantly
monogamous couples (age 18 - Sexual Desire Inventory (SDI) predicted sexual satisfaction for women and men,
e-41 y) together for least 12 - Index of Sexual Satisfaction (ISS) whereas sexual desire discrepancy significantly
mo - Dyadic Adjustment Scale (DAS) predicted sexual satisfaction for men only. However, in
predicting relationship satisfaction, individual sexual
desire for the partner is significantly related to
women’s relationship satisfaction, whereas sexual
desire discrepancy is significantly related to men’s
relationship satisfaction.
Murray and 2012 170 undergraduates (91 women Paper survey: Women’s sexual desire was significantly and negatively
Milhausen59 and 79 men) in Canada (age - Desire domain from the Female Sexual Function Index predicted by relationship duration after controlling for
18e25 y) (FSFI) age, relationship satisfaction, and sexual satisfaction.
- Male Sexual Function Index (MSFI) Men’s sexual desire was not significantly affected by
- Index of Sexual Satisfaction (ISS) the duration of their romantic relationships, however.
- 7 items from the Dyadic Adjustment Scale (DAS)
Willoughby and 2012 8,096 heterosexual dating Individuals completed the Relationship Evaluation A greater discrepancy between sexual desire and
Vitas60 couples (age 18e58 y) from Questionnaire (RELATE) online assessing the frequency was associated with higher relationship
the U.S. relationship strengths and weaknesses, either on satisfaction and lower relationship stability. These
their own or in conjunction with a third party, eg, associations were moderated by gender and
a clinician), after being exposed to the relationship length. Women’s sexual desire discrepancy
instrument through a variety of settings. had a particularly strong effect on relationship
satisfaction.
(continued)

15
 16
Table 1. Continued
Author(s) Year Sample Methodology Main findings
Carvalho and 2011 205 heterosexual men (age 18 Paper survey: Regarding cognitive and emotional factors, restrictive
Nobre61 e72 y) from the general - International Index of Erectile Function (IIEF) attitudes toward sexuality, lack of erotic thoughts
Portuguese population - Brief Symptom Inventory (BSI) during sexual activity, concerns about erections,
- Sexual Dysfunctional Belief Questionnaire (SDBQ) emotions of sadness, and shame in a sexual context
- Sexual Modes Questionnaire (SMQ) were significant predictors of sexual desire. Dyadic
- Dyadic Adjustment Scale (DAS)
adjustment and the presence of medical conditions
- Medical History Formulation (MHF)
were not significant predictors of male sexual desire. A
multiple regression analysis including all these
variables, in addition to age, indicated that lack of
erotic thoughts during sexual activity was the sole
significant predictor of sexual desire.
Carvalho and 2011 205 heterosexual men (age 18 Paper survey: Results showed that beliefs related to restrictive attitudes
Nobre62 e72 y) from the general - International Index of Erectile Function (IIEF) toward sexuality, erection concerns, and lack of erotic
Portuguese population - Brief Symptom Inventory (BSI) thoughts in sexual context had a significant direct
- Sexual Dysfunctional Belief Questionnaire (SDBQ) effect on reduced sexual desire. Moreover, this set of
- Sexual Modes Questionnaire (SMQ) cognitive-emotional factors also mediated the
- Dyadic Adjustment Scale (DAS)
relationships among medical problems, age, and sexual
- Medical History Formulation (MHF)
desire.
Træen and 2010 1,671 people (age 18e67 y) from Mixed sampling (open web survey and drawn from The highest expected prevalence of manifest problems
Stigum63 a web survey and 12,000 the Population Register of Norway). Ad hoc was found in the following groups: reduced sexual
(age 18e59 y) randomly questions were assessed. desire problems in 60- to 67-y-old women with
extracted from a national university education (52%); orgasm problems in 18- to
register in Norway 29-y-old women with less than a university education
(32%); genital pain in 18- to 29-y old women with less
than a university education (19%); premature
ejaculation problems in 18- to 29-y-old men with less
than a university education (27%); delayed ejaculation
problems in men with less than university education
(12%); ED in 60- to 67-y-old men (34%); and
lubrication problems in 60- to 67-y-old women living in
southeast Norway (29%). Sexual problems correlated
negatively with sexual well-being. In men, reduced
sexual desire correlated positively and moderately with
orgasm problems and ED.
Winters et al64 2010 6,458 men and 7,938 women Web survey: Men and women who reported having sought treatment
Sex Med Rev 2019;-:1e33

mainly from the U.S. and
Canada (age 18e94 y)
- Sexual Compulsivity Scale (SCS)
- Sexual Inhibition/Sexual Excitation Scales (SIS/SES)
- Sexual Desire Inventory-2 (SDI-2)
- Total Sexual Outlet taken from the Sexual Outlet In-
ventory (SOI)
scored significantly higher on measures of
dysregulated sexuality and sexual desire. Dysregulated
sexuality was associated with increased sexual desire.
Confirmatory factor analysis supported a 1-factor
model, indicating that in both male and female

Nimbi et al
- Survey of Sexual Behaviours (SSB)
- Derogatis Sexual Functioning Inventory (DSFI) participants, dysregulated sexuality and sexual desire
- Balanced Inventory of Desirable Responding (BIDR) variables loaded onto a single underlying factor.

(continued)
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Table 1. Continued
Author(s) Year Sample Methodology Main findings
Emmelot-Vonk 2009 237 men (age 60e80 y) with a Double-blind, randomized, placebo-controlled trial. After treatment, there were no differences in scores on
et al65 testosterone level 13.7 nmol Participants were randomly assigned to receive sexual function between the groups. Subanalysis
L-1 randomly selected by the oral testosterone undecanoate or a placebo for 6 showed that although a baseline testosterone level in
municipal register of Utrecht, months. the lowest tertile was associated with significantly
The Netherlands The Eleven Questions on Sexual Functioning (ESF) lower scores for sexual fantasies, desire for sexual
was administered. contact, and frequency of sexual contact, testosterone
supplementation did not result in improvement in any
of these items in this group.
Gades et al66 2008 414 men (age 40e79 y) residing Longitudinal study at the 14th year of follow-up. Out of 414 men, 294 had a regular sexual partner and
in the U.S. Measurements of testosterone, bioavailable androgen measurements at the 14th year of follow-up.
testosterone, and estradiol and the following Total testosterone and erectile function were
self-report surveys: significantly correlated even after adjustment for age
- Brief Male Sexual Function Inventory (BMSFI) (r ¼ 0.12; P ¼ 0.04). Conversely, total testosterone
- 36-Item Short-Form Health Survey (SF-36) was not significantly correlated with sex drive (r ¼
0.08; P ¼ 0.17). Bioavailable testosterone was
significantly correlated with both erectile function and
sex drive (r ¼ 0.16; P ¼ 0.01 and r ¼ 0.20; P ¼ 0.001,
respectively); however, these associations disappeared
after adjustment for age (r ¼ 0.04 and 0.09,
respectively).
Janssen et al12 2008 50 U.S. men (age 18e70 y) Qualitative analysis of 6 focus groups homogenous Men described a wide range of physical (genital as well as
prevalently heterosexual, but in terms of age (18e24 y, 25e45 y, and 46þ y) nongenital) and cognitive/affective cues for sexual
also with bisexual and arousal. Also, men described the relationship between
homosexual men sexual desire and arousal as variable and complex, had
a wide range of factors that increased or decreased
sexual arousal, and showed substantial variability in
both the importance and direction of their effects.
Prause et al13 2008 36 women and 33 men Completion of a dot detection task measuring Participants with high levels of sexual desire were slower
attention capture by sexual stimuli and a startle to detect targets in the dot detection task that
eyeblink modulation task indexing the valence of replaced sexual images but did not differ in startle
emotional response to affective stimuli, along eyeblink responses to sexual stimuli. The results
with the following self-report questionnaires: suggest that the amount of attention captured by
- Sexual Desire Inventory (SDI) sexual stimuli is a stronger predictor of a person’s
- Sexual Inhibition/Excitation Scales (SIS/SES) sexual desire level than the valence of the emotional
responses elicited by such stimuli.
Fenigstein and 2007 Study 1: 75 undergraduate Study 1: Paper survey with ad hoc questions Typically, men desired multiple sex partners, whereas
Preston67 women and 54 men Study 2: Paper survey with ad hoc questions women were consistently interested in a single sex
Study 2: 36 romantically partner, regardless of the risks or opportunities
uncommitted heterosexual involved.
men and 52 women
(continued)

17
 18
Table 1. Continued
Author(s) Year Sample Methodology Main findings
68
Richardson et al 2007 13 U.K. men who have sex with The men were allocated at random to receive either Inventory data showed a rise in dyadic desire in both
men HIV-positive on highly parenteral testosterone (Sustanon 250 treatment arms. Mean actual sexual acts rose from
active antiretroviral therapy intramuscular injection) (n ¼ 6) or letrozole 2.5 0.33 to 1.5 in the testosterone group and from 0.43 to
(HAART) with low sexual mg orally daily (n ¼ 7) for 6 wk. Sex steroid 1.29 in the letrozole group. Serum luteinizing hormone
desire as well as an elevated hormone assays, sex hormone-binding globulin, and testosterone levels increased in every man
estradiol level (>120 pmol/L) virologic, hematologic, biochemical parameters, receiving letrozole. There were no adverse events from
and frequency of sexual intercourse were either medication.
measured before and after treatment, and the
following surveys were completed:
- Sexual Desire Inventory-2 (SDI-2)
- Depression Anxiety Stress Scale-21 (DASS-21)
Træen et al69 2007 399 Norwegian heterosexual Self-administered postal questionnaires, adapted Most of the couples (59%) did not report distressing
couples (age 22e67 y) from other tools related to social background, problems related to a loss of sexual desire. In 26% of
communication with the partner, sexual behavior, the couples, the female partner had experienced a
the relationship to one’s partner, and living distressing loss of sexual desire; in 8% of the couples,
together the male partner did, and in 8% of the couples, both
partners did. Most of the men and women who had
sexual desire problems believed their loss of sexual
desire was related to stress, disease, or “other”
factors. Reduced capacity for sexual arousal was the
best predictor of loss of desire in both genders.
Lachtar et al70 2006 77 married heterosexual men Ad hoc self-report paper questionnaire on sexual Conjugal sexual desire was good in 76.5% of cases, and
and 43 women from Tunisia desire and satisfaction after marriage conjugal sexual satisfaction was usually present for
80%. Factors favouring the maintaining of sexual
desire in couples were: positive sentiments,
confidence, intimacy, and communication. Sexual
desire of men seems to be maintained by sexual
satisfaction, and sexual desire of women appears to be
maintained by couple stability and marriage duration.
Sexual desire of men seemed unaltered by conjugal
conflicts.
Lykins et al71 2006 663 heterosexual female and Paper questionnaires administrated in university Most women reported decreased sexual interest and
399 male college students classrooms: response when feeling depressed or anxious; however,
- Mood and Sexuality Questionnaire (MSQ) a minority (approximately 10%) of women reported
- Zemore Depression Proneness Ratings (ZDPR) increased sexual interest/response during periods of
- Spielberger Trait Anxiety Inventory (STAI) anxious and depressed mood. This sample of women
Sex Med Rev 2019;-:1e33

- Sexual Inhibition/Sexual Excitation Scale (SIS/SES) was compared with a sample of 399 college-aged
men. In general, men were more likely than women to
report increased sexual interest during negative mood
states.

Nimbi et al
(continued)
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Table 1. Continued
Author(s) Year Sample Methodology Main findings
Ridley et al72 2006 24 U.S. married couples who Diary study examining daily fluctuations in marital Daily affect was generally related to lust both within
were in a waiting-list control lust over a 56-d period. The diary comprised a 12- partners and between partners. In addition, spouses’
group for a communication item report of daily levels of lust, positive and relational states (ie, closeness and equality of power)
skills program negative affect toward their partners, feelings of moderated several of these intrapersonal and
closeness, and power relative to the spouse interpersonal associations. In general, the affectelust
link was strengthened by closeness and equality of
power, whereas the lustelust link between spouses
was often conditioned by both relationship affect and
relational states.
Laumann et al73 2005 13,882 women and 13,618 men Ad hoc questionnaire about health, relationships, The estimates of prevalence of sexual problems are
(age 40e80 y) in 29 and general satisfaction, individual behavior, comparable with published values. Several factors
countries, who had had practices, attitudes, and beliefs regarding consistently elevated the likelihood of sexual problems.
intercourse at least once in sexuality Age was an important correlate of lubrication
the last year. difficulties among women and of several sexual
problems, including a lack of interest in sex, inability to
reach orgasm, and erectile difficulties in men. Sexual
problems tend to be more closely associated with
physical health and aging in men than in women.
Corona et al74 2004 428 men with erectile A complete physical examination and a series of Among the patients studied, 22.8% reported mild, 12.9%
dysfunction attending for the biochemical, hormonal, and penile vascular tests, moderate, and 4.6% complete loss of sexual interest.
first time an outpatient clinic as well as the following self-report Patients reporting HSDD showed significantly lower
in Italy questionnaires: testosterone (T) levels than the rest of the sample,
- Structured Interview on Erectile Dysfunction (SIEDY) although the prevalence of hypogonadism (T <10 nM)
- Modified Middlesex Hospital Questionnaire (MHQ) was comparable in the 2 groups. Only a minority
(<2%) had severe hyperprolactinemia (4,700 mU/L),
which nonetheless was closely associated with a
relevant HSDD. Both mental disorders and use of
medication interfering with sexual function were
significantly associated with HSDD, as were depressive
and anxiety symptoms. Persons with HSDD showed
significantly higher scores on the SIEDY Scale-2, which
explores the relational components of ED. In particular,
perceived partner libido and climax were crucially
associated with impaired sexual desire.
(continued)

19

Table 1. Continued
Author(s) Year Sample
75
Bancroft et al 2003 919 white heterosexual men
(age 16-84 y) from the U.S.
for the paper questionnaire,
of whom 43 men agreed to
participate in the interview
Bancroft et al76 2003 662 white gay men (age 18e80
y) for the paper
questionnaire, of whom 51
agreed to participate in the
interview
Sex Med Rev 2019;-:1e33
Methodology
Paper questionnaires:
- Mood and Sexuality Questionnaire (MSQ)
- Zemore Depression Proneness Ratings (ZDPR)
- Spielberger Trait Anxiety Inventory (STAI)
- Sexual Inhibition/Sexual Excitation Scale (SIS/SES)
- Sensation Seeking Scales (Form V)
Interview study to obtain qualitative data mainly
relevant to sexual satisfaction, behaviors, and
relationships
Paper questionnaires:
- Mood and Sexuality Questionnaire (MSQ)
- Zemore Depression Proneness Ratings (ZDPR)
- Spielberger Trait Anxiety Inventory (STAI)
- Sexual Inhibition/Sexual Excitation Scale (SIS/SES)
- Sensation-Seeking Scales (Form V)
Interview study to obtain qualitative data mainly
relevant to sexual risk taking, but also including
questions relating to mood and sexuality
20
Main findings
Among those reporting the experience of depression,
9.4% indicated increased sexual interest and 42%
reported decreased sexual interest when depressed;
for anxiety/stress, these percentages were 20.6% and
28.3%, respectively. Increased sexual interest during
negative mood states was negatively related to age
and trait measures of sexual inhibition and positively
related to proneness to depression and sexual
excitation. Sex when depressed can serve needs for
intimacy and self-validation as well as sexual pleasure.
Sex when anxious appears to be more simply related
to the calming effect of sexual release, plus a possible
“excitation transfer” effect of anxious arousal.
Sixteen percent of men reported that when depressed,
they typically experienced increased sexual interest,
with 7% reporting increased capacity for erectile
response. 47% and 37% reported a decrease,
respectively; the remainder reported no change. When
experiencing anxiety, 24% reported that they typically
experienced increased sexual interest, 14% reported
increased responsiveness, and 39% and 31% reported
a decrease. Forty-three men were interviewed in depth.
The resulting qualitative data showed depression to
have a more complex relationship to sexual interest
than to anxiety; other mediating mechanisms, such as
the need for intimacy and self-validation, were
sometimes involved. Fourteen percent of those
interviewed reported reduced concerns about sexual
risk when depressed. A paradoxical increase in sexual
interest or activity during negative mood states is
relevant to high-risk sexual behavior among gay men
and merits closer study.
(continued)
Nimbi et al
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Table 1. Continued
Author(s) Year Sample Methodology Main findings
McNicholas 2003 208 men (age 31e80 y) who Comparing pharmacokinetics and treatment Testim produced dose-dependent improvements in all
et al 77 were randomized and treated effectiveness in 90 d of Testim in 2 doses and pharmacokinetic variables compared with Andropatch.
in 29 centers in Denmark, Andropatch. Pharmacokinetic profiles were The mean increases from baseline to 90 days in
Germany, The Netherlands, obtained, body composition was measured, and testosterone were 12.41, 6.54, and 3.82 nmol/L for
Sweden, and the U.K. mood and sexual function data were recorded. Testim 100 mg/d and 50 mg/d and the Andropatch,
The questionnaires used were not specified. respectively. Both doses of Testim significantly
improved positive and negative mood over baseline,
but Andropatch did not. All 3 treatments increased
lean body mass, and the higher dose of Testim
produced a significant decrease in body fat percentage.
At all sampling times, both doses of Testim
significantly improved sexual performance, sexual
motivation, sexual desire, and spontaneous erections.
Andropatch provided insignificant improvements from
baseline at all sample times for sexual desire, an
inconsistent improvement in sexual motivation, but no
effect on spontaneous erections. These results are
similar to those previously reported for testosterone
replacement therapy in hypogonadal men, suggesting
that normalization of serum testosterone restores
sexual function. However, the present data suggest
that higher serum testosterone levels may further
improve sexual function. Gel treatment was well
tolerated, while patch treatment produced higher rates
of application site reactions and study discontinuation.
Mercer et al78 2003 11,161 men and women (age 16 Computer-assisted self-interviews asking In this group, 34.8% of men and 53.8% of women
e44 y) in the U.K. participants about their sexual lifestyles and reported at least 1 sexual problem lasting at least 1
attitudes. Included were questions about their month. The most common problems among men were
experience with sexual problems based on those lack of interest in sex, premature orgasm, and
used in the U.S. National Health and Social Life performance anxiety, and those in women were
Survey, which assessed the main dimensions of inability to experience orgasm and painful intercourse.
sexual dysfunction, as defined in ICD-10. Among people who had sexual problems, 32.5% (95%
CI ¼ 29.7%e35.3%) of men and 62.4% (95% CI ¼
60.4%e64.3%) of women avoided sex because of
their problems. Only 10.5% (95% CI ¼ 8.8%e12.4%)
of men and 21.0% (95% CI ¼ 19.3%e22.7%) of
women with problems in the previous year sought
help.
(continued)

21
 22
Table 1. Continued
Author(s) Year Sample Methodology Main findings
Nobre and Pinto- 2003 201 women and 255 men (age Validation study of the Sexual Modes Questionnaire Results show statistically significant negative correlations
Gouveia79 18e67 y) from Portugal (SMQ), assessed in paper version together with among all dimensions of the automatic thought
the following: subscale and the sexual response index. Correlations
- International Index of Erectile Function (IIEF) between the emotions experienced during sexual
- Female Sexual Function Index (FSFI) activity and the intensity of sexual response indicate a
link between some emotional responses and behavioral
dimensions in sexual expression. Emotions of sadness,
disillusionment, guilt, shame, anger, and hurt were
inversely related to sexual response intensity, whereas
pleasure and satisfaction feelings were correlated
positively and significantly with sexual response
indices. In particular, the following were related to
lower male desire: failure anticipation thoughts,
sadness, disillusion, and satisfaction.
Klusmann80 2002 1,865 heterosexual university An ad hoc questionnaire sent to university students Sexual activity and sexual satisfaction decline in women
students (19-32 years old) assessing sexual behavior, satisfaction, and and men as the duration of partnership increases.
currently committed to a desire Sexual desire declines only in women, and desire for
steady partner from Germany tenderness declines in men and rises in women.
Ansong and 1999 108 men (33-79 years old) who A retrospective medical record review including the 55 men (50.9%) had a low sex drive, 38 (35.2%) had a
Punwaney81 attended a hospital based Brief Sexual Function Inventory questionnaire moderate sex drive, and 15 (13.9%) had a high sex
erectile dysfunction clinic (BSFI) and serum total and free testosterone drive. Mean sex drive, bothersomeness, and total
from USA measurements. sexual function scores were significantly different
among the groups (P < 0.001). Mean serum total
testosterone levels among men with low, moderate,
and high sex drive were 2.8, 3.2 and 3.4 mg/mL,
respectively (normal, 2.8e8.81 mg/mL), respectively,
and mean free testosterone levels were 9.1, 9.5 and 11.4
pg./mL, respectively (normal, 8.7e54.7 pg/mL).
Differences among means were not statistically
significant. As a screening test for low sexual drive,
low total testosterone had a positive predictive value of
59.2%, negative predictive value of 55.9%, and yield of
26.9%.
(continued)
Sex Med Rev 2019;-:1e33

Nimbi et al
Sex Med Rev 2019;-:1e33

Factors Influencing Male Sexual Desire

Table 1. Continued
Author(s) Year Sample Methodology Main findings
Laumann et al82 1999 1,749 women and 1,410 men Interviews regarding lack of desire for sex, arousal Sexual dysfunction is more prevalent in women (43%)
(18-59 years old) in USA difficulties, inability achieving climax or than in men (31%) and is associated with various
ejaculation, anxiety about sexual performance, demographic characteristics, including age and
climaxing or ejaculating too rapidly, physical pain educational attainment. Experience of SD is more likely
during intercourse, and not finding sex among people with poor physical and emotional health.
pleasurable Moreover, SD is highly associated with negative
experiences in sexual relationships and overall well-
being. Men reporting any same-sex activity are more
than twice as likely to experience premature ejaculation
(95% CI ¼ 1.2e3.9) and low sexual desire (95% CI ¼ 1.1
e5.7) compared with men who do not. This also holds
for male victims of adultechild contact.
Angst83 1998 591 young men and women 5 interviews over a 15-y period about Sexual desire problems seem to be the main problem
(28-35 y) from the general psychosomatic and psychiatric problems, sleep, overlapping with other sexual problems. Sexual
Swiss population sexuality, pregnancy, contraception, and problems are greater in depressed people in treatment
homosexuality. The Symptom Checklist 90 (with either drugs or psychotherapy).
eRevised (SCL90-R) was also assessed.
Beck and 1995 24 men and 24 women (age 18 Laboratory experimental session with 6 audiotapes; The results indicated that in women, both anger and
Bozman84 e35 y) from the U.S. each subject was asked to move a subjective anxiety significantly reduced desire relative to the
rating dial for his or her sexual desire. The Profile control condition, with anger showing a more marked
of Mood States (POMS) was completed after effect. For men, similar results were noted, although
each stimulus. fewer differences were observed between the anxiety
and anger conditions. Significantly more women (79%)
than men (21%) indicated that they would have
terminated the encounter during the anger condition.

23
24
Diagnostic and Statistical Manual of Mental Disorders, Third Edi-
tion (DSM-III)87 based on Kaplan’s model,6,7 the following
statements had different paths for the 2 genders. Basson88 pre-
sented a circular model of sexual function that included over-
lapping phases of response in a variable temporal sequence. In
contrast to the previous focus on spontaneous sexual desire, Bas-
son’s circular model featured a responsive form of desire, which can
be accessed once sexual arousal has been experienced. This model
has been largely accepted for women, influencing the subsequent
years of research and practice. However, it should be noted that
although this circular model was originally designed for both
women and men, but found infertile soil in the latter.89,90 The
debate in the scientific literature regarding female desire85,86,91 led
to the incentive-motivation model,3,92e94 in which sexual desire
results from the awareness of sexual arousal. Sexual excitement
occurs in response to sexual stimuli, even when a woman is un-
aware of encountering such stimuli. Sexual desire may feel spon-
taneous to the perceiver, but sexual stimuli are previously
unconsciously processed. Another example of an approach
recognizing the strict connection between desire and arousal in
both genders is the dual control model,95 which has been applied
in many studies on desire, addiction, and sexual orientations. The
overlap between desire and arousal in women resulted in the
acknowledgment of a unique phase of sexual response in the DSM-
V,96e98 although many authors strongly disagreed with this
combination.49,99e101 Data on incidence, prevalence, and risk
factors for related sexual dysfunctions seem to support the strong
link between the 2 phases and at the same time, the separation of
desire and arousal-related disorders. Thus, further studies are
needed to determine the extent to which these 2 phases overlap or
are distinct entities.
On the male side, most of the scientific attention has been focused
on the arousal and plateau phases rather than on desire. For example,
in 2004, Lue et al102 described the problems of sexual desire in a few
lines, highlighting the absence of psychological treatment protocols
for sexual desire claims and focusing on the erection process. Previ-
ously, the only medical treatment available for low sexual desire was
the use of testosterone, which proved effective mainly in men with
hypogonadal conditions.56,65,103 Currently, the classification of male
sexual dysfunctions in the DSM-V96 is still based on Kaplan’s linear
model,6,7 keeping desire and excitement clearly separate, thanks to the
visibility and significance given to the erection phenomenon; how-
ever, some authors have reported that both patients and clinicians
remain confused regarding the evaluation of desire and subjective
arousal.22,45,104,105 Therefore, how sexual desire problems are often
confused with erection complaints is a prominent issue that should be
explored in more depth in future studies with practitioners. Critics of
the Kaplan model6,7 complain that it is related to a mechanistic and
biomedical view of male sexuality, as it does not consider responsivity
and psychosocial factors.53,55,90,98,106 Future research should attempt
to overcome these limits, including examining different facets of
sexual desire (spontaneous, responsive, solitary, and dyadic) and the
role of psychosocial factors.
Nimbi et al
From Gender Differences to Intergender Studies
and Couple Discrepancy
For years, a principal area of interest in sexology has been the
exploration of differences between men and women in terms of
desire for sexual variety, casual and indiscriminate sexual
behavior, and pornography use.3 A prominent gender stereo-
type holds that men are more interested in sex than women
purely for physical reasons. Studies of the dual control model
have revealed evidence supporting this view from a neurobio-
logical and evolutionary perspective.107 According to the meta-
analysis by Baumeister et al,108 men typically report a higher
sexual drive, a greater number of sexual thoughts and fantasies,
an increased desired frequency of sex, and a higher desired
number of sexual partners compared with women. Significant
gender differences in sexual desire also have been reported5;
men are significantly more likely to endorse a desire for sexual
release, orgasm, and making a good impression than women,
who usually are more used to having a desire for intimacy,
emotional closeness, love, and feeling sexually attractive. An
important element for better comprehending these data should
be noted; these studies are based mainly on self-reported mea-
sures of sexual desire, which are often influenced by sexual
stereotypes and social desirability. Thus, men could easily
overestimate their drive, whereas women could undervalue their
sexual desire to present a better image of themselves, more in
line with the sexual script.
Evolutionary sociobiologists have suggested that the differ-
ences in sexual tactics are biologically determined and reflect an
optimal “spreading genes” strategy. In contrast to this position,
many sociologists and anthropologists have argued that this
variance is mostly culturally determined.28 For example, a cross-
cultural study of the general population in 29 countries showed
that gender differences in desire and sexual interest were uni-
versal, but that the gap between men and women was larger in
male-dominated cultures than in liberal Western societies.109
Other studies have highlighted how differences in desire and
mating strategies are more influenced by gender identity than by
sexual orientation.67,110 However, the natural fluctuation of
physiological (eg, hormonal variation in different periods such as
in pregnancy, ovulatory period, puberty) and psychological states
(eg, reaction to a stressful moment, such as a mourning, abor-
tion, being fired) should be recognized, avoiding an over-
simplification of sexual desire in both men and women.111,112
The nature or nurture debate regarding sexual interest has
been ongoing without resolution.109,113 Today, the focus is
slowly moving toward a holistic understanding of sexual function
in men and women, recognizing the importance of similarities
between genders and contemplating the context of intimate
relationships.114 Current research should overcome the stereo-
typical significance placed on male and female differences in
sexual behavior toward an in-depth analysis of interindividual
variance within genders and inside the couple.
Sex Med Rev 2019;-:1e33
Factors Influencing Male Sexual Desire
The relationship is the “place” in which the differences in
variance of sexual desire are primarily experienced and con-
fronted. The “couple discrepancy” is one of the crucial issues
contributing to increasing the relational distress of a couple
facing sexual desire problems. Sexual desire discrepancy can be
defined as the point at which 2 partners in an intimate rela-
tionship have considerably different levels of desire or frequency
of sexual activity.115 Desire discrepancy can arise for various
reasons, including lifestyle patterns (eg, preferred time for
sleeping, work schedule conflicts, medical issues, hormone levels,
relationship factors) and represents the most common women’s
sexual complaint.116,117 Inside the couple, the individual who
reports lower sexual desire compared with the partner is often led
to believe that he or she is the one “with a problem.” This usually
happens when he or she is using his or her partner’s level of
sexual desire as the benchmark for what should be “normal.”118
Sexual desire discrepancy has received relatively little empirical
attention, despite many studies showing that higher perceived
(not real) desire discrepancy was associated with lower sexual and
relational satisfaction in both men and women.39,51,57,58,60
Future studies inquiring about the levels of sexual desire or the
clinical disorders (hypoactive sexual desire disorder [HSDD] and
hypersexuality) should focus on discrepancies, including both
partners’ perspectives.
BPS Determinants of Male Sexual Desire
The literature lacks studies on male sexual desire and focuses
primarily on HSDD, mainly in heterosexual men involved in an
intimate relationship.12,55,98,119e122 Fewer studies have investi-
gated high levels of sexual desire in different pop-
ulations.21,32,41,64,123 The use of different methodologies across
studies also has made it difficult to describe sexual desire in men.
For example, in line with the DSM diagnostic criteria, some
studies have included the assessment of perceived
distress,41,43,63,69,73,78,124,125 whereas other studies have consid-
ered only the level of perceived desire in various time ranges (from
1 month to 24 months).47,61,62,82,126,127
Understanding sexual desire requires an approach that gathers
together the influences of biology, psychology, sociology, and
culture. In this complex scenario, clinicians and researchers have
recognized the BPS model as the leading framework for sexology
and sexual medicine studies.101,102,128e131 This framework de-
scribes a complex network of direct effects and interactions
among biological, psychological, and sociocultural variables
characterizing human phenomena.
In the following sections, we summarize the most influential
studies of BPS factors associated with male sexual desire, dividing
the variables into biological, psychological, sexual, relational, and
cultural. This partition is sometimes mechanical and arbitrary,
because some factors can be attributed to more than 1 category,
in line with the BPS concept of health.
Sex Med Rev 2019;-:1e33
25
Biological Factors
Early studies attempted to identify some physiological predictors
of sex drive based on hormonal levels.48,65,66,68,74,77,81,132e135
Androgens, such as testosterone, are essential for male sexual
desire. It has been shown that a minimum level of androgens is
required to experience sexual desire, but this relationship is not
linear; elevated levels of free androgens do not directly correlate with
high levels of sexual desire.136 In men with hypogonadism, testos-
terone therapy has been shown to have a direct effect on sexual
interest.66 Moreover, testosterone has been shown to increase the
desire for uncommitted sex and hence for greater numbers of sexual
partners. The satisfaction of these urges usually lowers the levels of
free testosterone in the blood after the intercourse, but not the level
of perceived desire.38 Recent guidelines103 indicate that several
hormones can modulate or promote human sexual behavior,
including drive and arousal. Although the literature corroborates the
crucial roles of testosterone (increasing) and prolactin (reducing) on
desire, the effects of other hormones are less clear. Hypothalamic
neurohormones, such as oxytocin and a-melanocyteestimulating
hormone, are currently under active research for therapeutic pur-
poses. Hormonal treatment can improve libido in hypogonadal and
hyperprolactinemic men. Other evidence indicates that androgen
deprivation therapy, which may be used as a curative or palliative
treatment in men with advanced prostate cancer, lowers libido.137
Further research is needed on hormones and related therapies,
focusing on how they interact with psychological and relational
elements in affecting the level of sexual desire.
Animal and human neurobiology typically confine the control of
sexual responsiveness in the hypothalamus, brainstem, and spinal
cord. However, human sexuality is more complex and versatile,
involving other cerebral areas.138e140 Neuroimaging studies have
found that significant activation of the medial orbitofrontal cortex
region occurs in subjects with HSDD. The inhibitory role of this
area results in a devaluation of sexual stimuli, which may be related
to continued activation of the ventromedial prefrontal cortex, a
region that includes the medial orbitofrontal cortex, in response to
visual sexual stimuli. Sexual desire corresponds to the dorsal caudal
anterior cingulate cortexe ventral striataleamygdala functional
network. Higher subjective scores of sexual desire to explicit cues are
associated with greater activity and enhanced functional connec-
tivity among these areas.141 Neuroimaging could have a key role in
future studies on differentiating sexual desire from arousal/orgasm
and exploring different manifestation of sexual desire (eg, sponta-
neous, responsive, solitary, coupled).
Aging and the presence of organic diseases have clear negative
effects on overall sexual response.26,29,53,142e145 The recognized
conditions associated with low sexual desire level
include36,37,40,136,146:
 Androgen deficiency
 Antidepressant therapy
 Anxiety conditions
26
 Bodybuilding and eating disorders
 Cancer
 Coronary disease and heart failure
 Depression
 Diabetes and obesity
 Elevated dopamine level
 Epilepsy
 HIV
 Hyperprolactinemia
 Infertility
 Posttraumatic stress disorder
 Prostatitis/chronic pelvic pain syndrome
 Renal failure
 Sexual dysfunction
 Stroke.
The relationships between drive and each of the foregoing
conditions are univocal and should be explored in more depth to
tailor specific holistic interventions.
It is clear that biological factors play a central role in sexuality,
but they are not sufficient to explain human sexual response.36
According to the perspective advanced here, any psychological
changes correspond to variations in the brain. Sex hormones are
released into the blood by the glands and travel to the brain,
where they sensitize specific regions, making them more
responsive to sexual stimuli and thoughts. Reciprocally, events
described as “psychological” affect the body; for example, having
a new romantic partner might increase sexual motivation, with
effects on hormone levels and the brain.3 This relationship has
been explained using the terms “psychosomatic” and “soma-
topsychic,” underscoring the continuous interaction between
body and mind in producing health or illness status.144,147
Psychological Factors
Among psychological factors, specific mood states can promote
or inhibit sexual desire. Depression and anxiety have been asso-
ciated mainly with low levels of desire41,54,71,148e150; however,
some studies have found an increase in sexual desire level associated
with altered mood.75,76,83,123,151,152 In a study of 919 heterosex-
ual men, Bancroft et al75 found that 9% of those with elevated
levels of depression reported an increase in sexual interest and 42%
reported a decrease. Among the men with significant anxiety, 21%
reported an increase in sexual desire and 28% reported a decrease.
These results have been replicated in a study on gay men.76 A
significant percentage of these men reported an increased interest
in sex at times of depression or anxiety episodes, reporting that sex,
particularly masturbation, helped lower their level of negative
emotions.153 In some recent studies,16e18,41,61 anxiety was not
identified as a predictor of male desire level. Therefore, the
mechanisms underlying the relationships between anxiety/
depression and sexual interest remain unclear, and future studies
should explore nonlinear associations, especially between desire
and anxiety, in more depth.
Nimbi et al
Regarding emotions, studies have reported conflicting results.
Portuguese researchers have emphasized the centrality of emo-
tions in male sexual response.79,154,155 In an early study, Beck
and Bozman84 showed that HSDD was strongly associated with
feelings of anger and anxiety, whereas a more recent study found
an association with sadness and shame.61 Low levels of desire
have been more closely associated with a lack of positive affects
related to sexuality than with the presence of more negative
emotions.17,18 In general, emotions have been strictly connected
with cognitive factors (such as automatic thoughts during sexual
activity) in 2 models.17,62 These models revealed emotions
mediating the cognitive distraction effect on male sexual desire.
The validity of these models depends on their replicability in
other studies and applicability in clinical practice. Therefore, it is
important to study the cognitive-emotional association with
sexual desire in more depth, both for theoretical purposes and for
possible clinical implications.
Ferreira et al34 found a positive effect on sexual desire in a
group of men who felt their partners were attracted to them.
Attraction, self-esteem, and body image have been less well
studied in men, although they are known relevant predictors of
female sexual interest.114 Future research is needed to investigate
these links and evaluate whether they might have the same
impact on drive in men.
Adult attachment styles have been examined in several studies,
which have provided mixed results regarding how they influence
sexual desire. For example, men with higher anxious attachment
reported greater sexual drive with their partners in an effort to
reestablish emotional closeness.52 Attachment theory has been
mainly linked to sexual satisfaction.156,157 New studies are
needed to better explore the involvement of attachment and
personality traits in the experience of sexual desire.114
Sexual Factors
Distress and satisfaction about sexual activity are recognized as
central elements connected to sexual functioning.25,31,33,124 As
described in Basson’s model,88 positive and negative past expe-
riences have direct effects on sexual interest and behavior.
Distress can differentiate between clinical and nonclinical levels
of low sexual desire,56 whereas sexual desire was found to predict
sexual satisfaction.57,58 The link with desire and satisfaction was
not confirmed in a recent study,24 whereas in a newly published
study,19 partner-related dyadic sexual desire seemed to positively
predict sexual satisfaction in men. These conflicting results
highlight the need to examine the role of sexual desire in both
personal and couple satisfaction in more depth.
Regarding sexual response, the level of desire usually increases
during any sexual experience (eg, masturbation, intercourse)
until orgasm, and it seems to predict the quality of and satis-
faction with the orgasmic phase.46 In line with this study, Nimbi
et al17,18 found a strong association between level of desire and
orgasmic function, stronger than that with arousal. This link
Sex Med Rev 2019;-:1e33
Factors Influencing Male Sexual Desire
should be better evaluated, perhaps in the light of a reexamina-
tion of Basson’s model88 for men.
The presence of sexual problems in other phases of sexual
response could also have a negative effect on interest and the
overall sexual function.26,144,158 For example, erectile dysfunc-
tion (ED) and premature ejaculation (PE) have been reported as
the most prevalent comorbidity among men with low levels of
sexual desire.41 In a retrospective study, Corona et al53 reported
that reduced libido was comorbid in 38% of men claiming ED,
in 28.2% of those with PE, and in 50% of those with delayed
ejaculation, whereas it was isolated in only 5.1%. In contrast,
good sexual function can increase sexual and relational satisfac-
tion and the level of sexual desire. Research is needed to better
explore the associations between sexual desire problems and
comorbidities in men, both when desire is the triggering problem
and when it is influenced by other difficulties (in either them-
selves or the partner), to improve therapeutic actions under a
BPS approach.
Relational Factors
The association with relational factors is not clearly defined in
the literature. Sexual interest in men has been considered quite
independent of couple dynamics,14 especially familiar and dyadic
conflicts,70 and more closely related to individual psychological
factors.30 As monogamous heterosexual relationships progress,
men’s desire for tenderness and closeness with the partner seems
to decrease with an increasing duration of the relationship, but
sexual desire does not.44,59,80 Thus, although a couple may seem
well matched in sexual desire early in the relationship, over time
this compatibility might decrease, causing tension (ie, desire
discrepancy). Some studies have shown that realistic expectations
of sexual desire shifts during a relationship have a favorable
impact on sexual interest and behavior in long-term relation-
ships.20,34,39,159,160 A recent study of men’s experience of sexual
desire in long-term relationships23 found that regardless of age or
relationship duration, such factors such as “feeling desired,”
“exciting and unexpected sexual encounters,” and “intimate
communication” were the most important factors eliciting sexual
desire, and that “rejection,” “physical ailments and negative
health characteristics,” and “lack of emotional connection with
partner” were the main inhibiting factors. Ridley et al72 reported
that positive feelings, such as trust, intimacy, and good
communication, can increase sexual desire. Ferreira et al34
identified “breaking the routine,” “new positive experiences,”
and “excluding the partner” as factors associated with greater
desire, and “stress,” “couple conflicts,” and “having children” as
desire-diminishing factors. “Innovation,” “sharing,” “autonomy,”
and “effort” emerged as desire-promoting strategies, whereas
“fostering personal interests,” “investing in a positive connec-
tion,” and “enhancing personal integrity” were identified as
couples’ strategies to promote autonomy and preserve differen-
tiation of the self. Intimacy has an important positive role in male
Sex Med Rev 2019;-:1e33
27
sexuality; a recent study found a strong association with sexual
satisfaction and no evidence of a negative association between
relationship intimacy and male sexual desire.50 Shrier and
Blood27 focused on the importance given to physical intimacy
and showed a strong link with greater male drive. To a greater
degree than relationship duration, dyadic satisfaction and soci-
osexuality (ie, individual willingness to engage in sexual activity
outside of a committed relationship) may have a role in deter-
mining sexual interest35,161; however, more studies focusing on
both individual and couple characteristics are needed to confirm
this direction. In addition, Mark and Lasslo114 have suggested
the need for further studies to better explore the feeling of
attraction to one’s partner, which has been investigated mainly in
women but could have an important impact in men as well.
Cultural Factors
The impact of cultural factors has been less well studied
compared with physiological and psychological variables, but it
should be recognized that research on sexuality has been guided
in large part by gender and sexual stereotypes. For example, the
focus of previous studies on gender differences was on uncov-
ering empirical evidence to confirm stereotypical male and female
roles. Regarding sexual function and behavior, men’s health
research has been strongly influenced by cultural messages on
masculinity, resulting in “erection-centered” rather than “desire-
centered” studies.114 Thus, cultural dimensions in forms of
myths related to male sexual performance and sexual scripts have
been examined primarily in relation to ED42,79,162e167 and only
recently in relation to sexual desire.16e18,61,62 The most repre-
sentative factors associated with low desire have been identified as
“lack of erotic thoughts” (ie, absence of thoughts like “I like this
feeling.”) and “erection concerns thoughts” (eg, “I am not
getting an erection”) during sexual activity.16e18,47,61,155 Rigid
thoughts about virility, focus on erection, and focus on sexual
performance might foster an unrealistic expectation of sexuality
and reduce erectile confidence.41 Social pressure and expectations
of gender roles and masculine sexual scripts have been identified
as risk factors for sexual desire levels,15 and stigmatization of
reduced male libido might negatively influence sexual satisfac-
tion.121 Men may feel that they should constantly report high
levels of drive even if it is not real and actually might “simulate”
desire to fit this script.15,114 This is an important issue that
should be considered as a methodological bias in all studies based
on self-reported measures.
The influence of cultural aspects is extensive and often invis-
ible, because clinicians and researchers are born and raised in
their cultural contexts, being influenced by their own internal
messages and scripts on gender and sexuality. Practitioners
should examine the real weight of cultural factors and deal with
them in their clinical work. There is a need for more multi-
centered and multicultural studies, which may better explain the
role of cultural messages, stereotypes, and scripts.
28
CONCLUSION
In this review, we have summarized the current scientific
knowledge of the variables associated with male sex drive.
However, the list of studies examined is arbitrary and not
comprehensive. How the factors highlighted herein are associated
with desire remains an open question. Given the current state of
the art, it is difficult to establish whether factors are influenced by
or influence sexual interest. Causality and the direction of asso-
ciations are usually determined theoretically (referring to a
model/approach). The 2 models briefly introduced herein17,62
attempt to interpret how some BPS factors interact with one
another in influencing sexual desire, but additional studies are
needed to increase the reliability of the models and to verify them
in other populations.
Future studies should assess the interplay of biological, psy-
chological, sexual, relational, and cultural factors in sexual drive.
The need for improvements in measures and questionnaires on
desire has been highlighted. Most of the available studies are
retrospective and self-reported; more longitudinal studies (using
daily reports, diaries, etc) on both single and dyadic desire are
needed. Sexual desire can be best understood by examining both
objective and subjective perspectives; some features of desire are
open to scientific investigation, whereas others are best explored
by qualitative first-person insights.3
Another important point is to extend the research to different
populations, such as other sexual orientations (eg, gay, bisexual,
and asexual men) and specific clinical groups (eg, obesity, cancer,
sexual dysfunction).168,169 Regarding sexual orientation, the
possible effect of minority stress and internalized homophobia on
sexual function should be explored. Moreover, a wider discussion
of sexual desire should include important relational elements,
such as monogamy, adultery, open couples, polygamy, and
polyamory. Research on these topics remains very limited.
Whatever the situation, health care professionals and therapists
are in a unique position to address desire-related problems when
approached by men experiencing sexual problems. Not only
might they in a noncastigating and supportive manner point out
the biological, psychological, and sociocultural effects affecting
the desire for sexual engagement and sexual response. Moreover,
they are also well positioned to discuss other health-related
complications, simultaneously acknowledging and incorpo-
rating the patient’s and couple’s desires and functional
goals.168,169
The variables presented and discussed herein might be useful
not only to deepen the research on understanding male sexual
response, but also in clinical practice. During the assessment
phase, it could be useful to explore the factors highlighted here
(eg, medical history, emotions, sexual problems, distress,
depression, stereotypical beliefs about masculinity and erection).
These factors should be analyzed and considered as predisposing,
precipitating, maintaining, contextual, and protective factors. In
sexual therapy, psychosexologists should include tools and
Nimbi et al
strategies for exploring these factors, such as reflecting on erotic
imagery and stimulating critical thinking and discussion about
sexuality in the couple. Counteracting dysfunctional sexual be-
liefs and thoughts with sexual education may expand con-
sciousness regarding self-attitudes and limitations on sexuality,
but further studies are needed on the efficacy of sexual education
on restrictive thoughts and beliefs.114 Our findings show that
male sexual desire is characterized by complex interactions
among physiological, psychological, sexual, relational, and cul-
tural elements that a wise clinician should bear in mind while
working toward quality of life of patients with sexual desire
problems.
Corresponding Author: Filippo Maria Nimbi, PhD, Universita
degli Studi di Roma La Sapienza Facolta di Medicina e Psico-
logia, Via dei Marsi 78, 00185 Roma, Italy. Tel: 393405006643;
E-mail: filipponimbi@hotmail.it
Conflicts of interest: None to report.
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