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Interest in male hypoactive sexual desire disorder (HSDD) is increasing as a result of a DSM5 subcommittee that is reconsidering the criteria for all sexual diagnoses just as several novel compounds are being considered for phase 2 clinical trials. The essence of HSDD-the disinclination to behave sexually- has been recognized for centuries.1 The physician is expected to respond to complaints of "low libido" by first ruling out hypogonadism before psychosocial contributants are considered.2 Table 1 summarizes the differential diagnosis of the complaint of low libido.
This article focuses on the diagnosis of this disorder and on strategies for its management.
UNCERTAIN PREVALENCE
Epidemiological studies carefully define criteria for what constitutes a "case" of HSDD and then use a specified sampling method to estimate the prevalence of the problem.3 Research findings vary because there is no clear description of what constitutes a sexual desire problem and sampling methods vary from study to study. The most widely quoted population-based study of sexuality derives from the National Health and Social Life Survey-1992.4 The respondents were aged 18 through 59 years. Of the 1511 men interviewed, 139 said they were unhappy about the frequency with which they had sex. Approximately 15% of the sample at all ages stated that they lacked interest in sex.5
Another survey of sexual behaviors of men aged 57 through 85 years demonstrated that approximately 75% of those who were reasonably physically healthy acknowledged a continuing sexual interest.6 However, sexual interest may not be synonymous with sexual desire as it is understood by clinicians and patients.
The presumed lower prevalence of HSDD among men (approximately 15%) compared with women (approximately 35%) is thought to be a consequence of men's more constant and recurring sexual interest throughout their life.7 Men far more often bring complaints about arousal difficulties (erectile dysfunction) than about their lack of sexual desire-even though the latter may be primary. The criteria for desire and arousal diagnoses are difficult to distinguish from one another in both sexes.8
When desire, arousal, and orgasmic problems coexist in the same patient, the decision about the most basic dysfunction is arbitrary. Survey research does not distinguish the 4 main types of psychogenic low desire: lifelong, acquired, situational, and generalized. To meet criteria for HSDD, the patient...