What are the diagnostic criteria for Hypoactive Sexual Desire Disorder (HSDD)?

Diagnostic Criteria for Hypoactive Sexual Desire Disorder (HSDD)

HSDD is defined as persistent deficient sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty, with symptoms lasting at least 6 months and not better explained by another condition or medication. 1

Core Diagnostic Criteria

HSDD diagnosis requires the following elements:

1. Persistent or recurrent deficiency or absence of:

   • Sexual fantasies/thoughts
   • Desire for sexual activity
   • Receptivity to sexual activity 2

2. Duration: Symptoms must persist for at least 6 months

3. Distress: The condition must cause personal distress or interpersonal difficulties 1, 3

4. Exclusion criteria: The symptoms cannot be better attributed to:

   • Another primary disorder
   • Medication effects
   • General medical conditions 3

Clinical Assessment Components

Validated Diagnostic Tools

• Decreased Sexual Desire Screener (DSDS): Specifically validated for use in general practice to detect and diagnose HSDD 1, 4
• Yale-Brown Obsessive-Compulsive Scale (Y-BOCS): For differential diagnosis when considering obsessive sexual thoughts versus desire disorders 5

Key Differential Diagnosis Considerations

1. Sexual Orientation Obsessive-Compulsive Disorder (SO-OCD)

   • Involves intrusive thoughts about sexual orientation
   • Features anxiety and distress about these thoughts
   • Includes compulsive behaviors to reduce anxiety 6
   • Unlike HSDD, SO-OCD involves unwanted intrusive thoughts rather than decreased desire

2. Other conditions to rule out:

   • Depression
   • Anxiety disorders
   • Medication side effects (particularly SSRIs)
   • Relationship problems
   • Hormonal imbalances 2

Classification Differences

It's important to note that in DSM-5, HSDD has been subsumed under Female Sexual Interest/Arousal Disorder for women, while remaining a separate diagnosis for men. However, decades of research based on the DSM-IV-TR HSDD criteria form the foundation of our understanding of distressing low sexual desire. 1

Biopsychosocial Factors

HSDD etiology is multifactorial and includes:

1. Biological factors:

   • Hormonal imbalances
   • Medical conditions
   • Medication effects 2

2. Psychological factors:

   • Life events
   • Sexual history
   • Affective state 2

3. Interpersonal factors:

   • Partner satisfaction
   • Communication
   • Relationship duration 2

4. Sociocultural factors:

   • Cultural expectations
   • Religious beliefs 2

Treatment Options

For premenopausal women with HSDD, FDA-approved medications include:

1. Flibanserin: First FDA-approved medication for HSDD in premenopausal women 6, 3

   • Efficacy: Approximately 1 additional satisfying sexual event every 2 months

2. Bremelanotide: FDA-approved for acquired, generalized HSDD in premenopausal women 6, 3

   • Shown to increase sexual desire and reduce distress related to low sexual desire

3. Off-label options (when FDA-approved treatments aren't appropriate):

   • Bupropion
   • Buspirone 6

Common Pitfalls in Diagnosis

1. Underdetection: Less than half of patients with sexual problems seek help or initiate discussions with physicians 1

2. Misdiagnosis: Confusing HSDD with other conditions like depression or relationship problems 5

3. Inadequate assessment: Failing to use validated screening tools like the DSDS 1, 4

4. Overlooking comorbidities: HSDD often coexists with other conditions that require concurrent treatment 5

5. Cultural insensitivity: Not accounting for cultural variations in sexual expression and norms 5

By using these diagnostic criteria and assessment approaches, clinicians can accurately identify HSDD and develop appropriate treatment plans to improve patients' quality of life and relationship satisfaction.