Low Sexual Desire (HSDD) in Women and Men: Causes and Care

"Doctor, my girlfriend says I'm not the same any more," or "I love him, but I just don't want to." I hear these two sentences about equally often. Reduced sexual desire can happen to anyone of any gender, and it does not mean love has gone. It is a signal that something in the body, the mind or the relationship deserves attention.

What kind of drop counts as HSDD?

Sexual desire (libido) naturally goes up and down with stress, work, sleep, having young children, or simply being together a long time. There is no number for "how many times a week you should want it".

Hypoactive sexual desire disorder (HSDD) is used when:

• sexual thoughts, fantasies or desire are persistently reduced or absent
• this has lasted at least about 6 months
• it causes the person distress, which is the most important point
• it is not fully explained by medicines, a physical illness or severe conflict in the relationship

The names differ slightly. In DSM-5-TR (2022), the term for men is male hypoactive sexual desire disorder, while for women desire and arousal are combined as FSIAD. ICD-11 and ISSWSH still use the term HSDD for women. In practice the idea is similar: whether reduced desire has reached the point of causing distress.

Understanding women's desire correctly

The work of Rosemary Basson explains that many women, especially in long-term relationships, do not always feel desire "out of the blue" first. Instead, desire follows closeness, relaxation and the right kind of stimulation. This is called responsive desire.

So if you never feel sudden, spontaneous desire but enjoy it once things begin, that is a normal pattern, not a disorder. What helps is creating a context in which desire has a chance to appear: time that is not rushed, not being exhausted, and feeling safe with your partner.

1. 1
   Safe contextNot rushed, not tired, feeling safe with partner
2. 2
   Open to touchYou can start even without feeling desire first
3. 3
   ArousalBody and mind begin to respond
4. 4
   Desire followsDesire appears after arousal
5. 5
   SatisfactionMakes you want closeness again

Rosemary Basson's model: not wanting it first but enjoying it once started is a normal pattern.

Common causes

In men, if reduced desire comes with tiredness, loss of muscle or poor erections, testosterone should be checked; read symptoms of low testosterone, and rule out depression as well; see depression or low testosterone?

Medicines

• SSRI/SNRI antidepressants
• Some contraceptives, some blood pressure drugs

Hormones and illness

• Menopause, postpartum
• Thyroid, prolactin, diabetes
• Low testosterone in men

General health

• Sleep loss, chronic pain
• Heavy alcohol use

Mind

• Depression, anxiety
• Body image

Relationship

• Built-up conflict, unequal load
• Sex that is painful or unsatisfying

HSDD applies when it lasts about 6 months or more and causes distress.

How a doctor assesses it

1. A detailed, private history: when it started, whether it is reduced in every situation or only with a partner, and whether there is also pain, dryness or poor erections.
2. A review of all medicines, including supplements.
3. Screening for mood problems such as depression and anxiety.
4. Examination and blood tests as appropriate, such as thyroid, blood sugar and prolactin; in men, a morning testosterone test. In women, blood testosterone levels are not recommended for diagnosing HSDD.

Evidence-based treatments

• Fix what can be fixed first: adjust medicines that reduce desire, and treat vaginal dryness or pain, because while sex still hurts, desire is hard to bring back.
• Sex therapy and psychological therapy: research in women shows that CBT and mindfulness help increase desire and reduce distress. Read mindfulness and sex.
• Working with the couple: sensate focus exercises help reduce pressure and build new closeness.
• Low-dose testosterone for postmenopausal women: the 2019 global consensus and the 2021 ISSWSH guideline state there is evidence for HSDD in postmenopausal women. It must only be used under a doctor's care. Read testosterone in women.
• Specific medicines for HSDD: flibanserin and bremelanotide are approved in the US for premenopausal women. They have a moderate effect and are not generally available in Thailand.
• In men with genuinely low testosterone: testosterone replacement helps desire, but the deficiency must be confirmed first.

When to see a doctor

• Desire has been low for several months and you are unhappy about it
• It started after a change of medicine, childbirth, surgery or menopause
• There is also pain, dryness or poor erections
• You feel low, have lost interest in many things, or have thoughts of harming yourself: call 1323, Thailand's free mental-health hotline (Thai language; ask for English support)

At Dr. Kris Clinic, we assess this fully: body, mind and relationship. You can come alone or bring your partner, and English-speaking consultations are available in person or online.