The characteristics of hypoactive sexual desire disorder in Korean women who visited a community-based gynaecology hospital for sexual dysfunction
Ho Ju Yun
To cite this article: Ho Ju Yun (2018): The characteristics of hypoactive sexual desire disorder in Korean  women  who  visited  a  community-based  gynaecology  hospital  for  sexual dysfunction, Journal of Obstetrics and Gynaecology, DOI: 10.1080/01443615.2017.1389866
To link to this article:  https://doi.org/10.1080/01443615.2017.1389866

The characteristics of hypoactive sexual desire disorder in Korean women who visited a community-based gynaecology hospital for sexual dysfunction
Ho Ju Yuna
a Best Skilled Gynecology Hospital, Seoul, Korea; bDepartment of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, Catholic University Medical College, Seoul, Korea

ABSTRACT
This cross-sectional study analysed the characteristics of HSDD (hypoactive sexual desire disorder) in Korean women. Two hundred and seventeen women seen for sexual dysfunction were assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DMS IV-TR) and the Female Sexual Function Index (FSFI). A diagnosis of HSDD was more common in women in their 40s (56%), who had previously undergone surgery for a feeling of ‘wide vagina’. Both too much or too little sexual activity caused HSDD. Longer physical contact and sexual foreplay duration lessened the preva- lence of HSDD. We concluded that special attention should be paid to women in their 40s, particularly those with a history of vaginal surgery as they are at risk of HSDD. Potential treatment options should include couple counselling about the optimal frequency and duration of sexual activity, as well as treat- ment specific to the disorders identified by the FSFI.

IMPACT STATEMENT
What is already known on this subject: Many socio-medical factors affect the prevalence of HSDD (Hypoactive sexual desire disorder).
Age, cultural factors, relationship status, education, religion, employment, mental distress, depression, medications, menopausal status, multiple psychiatric dis- orders and a variety of medical conditions impact on sexual function.

What do the results of this study add: A history of wide vaginal surgery (perineoplasty, vaginal rogation rejuvenation, or anterior vaginal introitoplasty) affects the incidence of HSDD (and have not been evaluated before). Both too much or too little sexual activity were found to have caused HSDD. A longer physical contact and duration of sexual foreplay lessened the prevalence of HSDD.

What are the implications of these findings for clinical practice and/or further research: We concluded that special attention should be paid to women in their 40s; particularly those with a history of wide vaginal surgery, as they are at risk of HSDD. Potential treatment options should include couple counselling about the optimal frequency and duration of sexual activity, as well as treatment specific to the disorders identified by the FSFI.

KEYWORDS
Hypoactive sexual desire disorder; Korean women; women’s sexuality; desire

Introduction
Hypoactive sexual desire disorder (HSDD) is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DSM-IV- TR) as the persistent or recurrent deficiency or absence of sexual desire which causes interpersonal distress (American Psychiatric Association 2003). Hypoactive sexual desire dis- order affects both women and men, and because it is under- diagnosed, its real incidence is unknown. Sexual activity is a private and very personal matter, so patients often do not discuss their sexual problems with a doctor.
Many socio-medical factors affect the prevalence of HSDD. Age,  cultural  factors,  relationship  status,  education,  religion, employment, mental distress, depression, medications, meno- pausal status, multiple psychiatric disorders and a variety of medical   conditions   impact   sexual   function   (Montgomery 2008). Although the partners to a relationship may have no risk factors for sexual dysfunction, unresolved differences in sexual desire can cause distress. In other words, effective communication ability is one of the most important factors in the prevention of HSDD. In Asia, because of the influences of Confucian culture, it is not easy for women to ask for sexual advice and talk about their sexual desire. Previous studies about female sexual problems have reported that orgasmic disorders are more prevalent in Asia but desire problems are more prevalent in Western countries, probably because Western women feel more comfortable to talk about sexual desire than Asian women do (Safarinejad 2006; Singh et al. 2009; Lo and Kok 2013, 2014).
In  this  study,  we  analysed  the  characteristics  of  patients who visited our community-based hospital for advice about their  sexual  problems,  in  order  to  reveal  the  incidence  of HSDD  in Korean  women and  the related  socio-medical  fac- tors. We also aimed to assist in the diagnosis of HSDD and provide some useful information for the treatment of HSDD.

Materials and methods
This study was a cross-sectional study using convenience sampling of Korean women who visited our community- based gynaecology hospital for sexual dysfunction during September and October 2016. A total of 217 women were enrolled. Exclusion criteria included women under 20 years of age or over 60 years of age, with chronic disease (diabetes, hypertension, hyperlipidaemia, gout, cancer, rheumatoid dis- ease, chronic obstructive pulmonary disease, etc.), or with a history of psychiatric illness. The study protocol was approved by the Ethics and Research Committee of the Catholic University of Korea.
All  subjects  completed  a  questionnaire  designed  by  the investigators, which included questions about demographics, medical  and  surgical  history,  symptoms  of  pelvic  floor  and sexual     behaviour.     Demographic     information     collected included  age,  obstetric  history,  delivery  type,  marital  status and years of marriage. Medical and surgical history informa- tion  was  collected  included  history  of  wide  vagina  surgery (perineoplasty, vaginal rogation rejuvenation, or anterior vagi- nal  introitoplasty),  history  of  total  hysterectomy  or  other abdominal gynaecologic or cervical surgeries, history of med- ical  disease  and  medications  taken.  Pelvic  floor  information was collected included the presence of the following symp- toms: feeling of a wide vagina, vaginal flatus, feeling of pres- sure, a heavy feeling in the lower abdomen, a budging mass on   vagina,   stress   incontinence   and   urge   incontinence. Information  about  sexual  behaviour  collected  included  the frequency of sexual activity per month, the duration of each sexual  activity  in  minutes  (including  foreplay,  coitus  and after-play).
A  diagnosis  of  HDSS  was  determined  according  to  the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,  Revised  (DMS  IV-TR).  For  the  evaluation  of  sexual problems, the Female Sexual Function Index (FSFI) question- naire was used (Rosen et al. 2000). The Korean version of the FSFI contains 19 items on the following areas: sexual desire (two  questions),  arousal  (four  questions),  lubrication  (four questions), orgasm (three questions), satisfaction (three ques- tions) and dyspareunia (three questions). Investigators added one extra question about the presence or absence of distress as a result of the sexual problems (Table 1).
Question 1 of the FSFI is about the frequency of sexual desire. The question is ‘over the past 4 weeks, how often did you feel sexual desire or interest?’ The response options are: ‘almost  always  or  always’;  ‘most  times,  more  than  half  the time’; ‘sometimes, about half the time’; ‘a few times, less than half  the  time’;  and  ‘almost  never  or  never’.  Question  2  is about  the  level  of  sexual  desire.  The  question  is  ‘over  the

past 4 weeks, how would you rate your level (degree) of sex- ual desire or interest?’ The response options are ‘very high’, ‘high’, ‘moderate’, ‘low’ and ‘very low or none at all’. We cate- gorised persons according to level of sexual desire and fre- quency of sexual desire. A diagnosis of HSDD was made when the following criteria were met: a total score of less than 4 in the desire domain and the presence of distress about the sexual problems. Sixty-seven patients were diag- nosed with HSDD. An arousal disorder was defined as a total score of less than 6 in the arousal domain of the FSFI, and an orgasmic disorder was defined as a total score of less than 6 in the orgasmic domain of the FSFI.

Results
Total patient data
Among 217 women, the majority (57.6%) were in their 40 s and the majority were married (86.2%). As for the age of the patients, 1.4% were in their 20 s, 24.4% were in their 30 s, 57.6% were in their 40 s and 16.6% were in their 50 s. The prevalence of HSDD was 30.9%, arousal disorder 29.0% and orgasmic disorder 23.0%.
Among  217  women  who  visited our  hospital during  the research  period,  40  women  reported  they  had  undergone wide vagina surgery before they visited the hospital. Among these  40  women,  42.5%  were  diagnosed  with  HSDD.  Only 28.2% of women who had not undergone wide vagina sur- gery were diagnosed with HSDD (Paired t-test, p < .05). A his- tory of cervical surgery or abdominal gynaecological surgery (pelvic  laparoscopic  surgery,  myomectomy  or  hysteroscopy, ovarian  surgery,  etc.)  was  not  related  to  the  prevalence  of HSDD. The relationship between the prevalence of HSDD and the number of sexual activities per month show a U shape distribution; that is, both too much and too little sexual activ- ity  caused  HSDD  (Figure  1).  The  relationship  between  the prevalence  of  HSDD  and  the  duration  of  sexual  activity showed a negative relationship; that is, longer physical con- tact and sexual foreplay duration lessened the prevalence of HSDD  (Figure  2).  Pearson’s  correlation  coefficient  (r ¼ 0.891) showed significance (p < .05).

Characteristics of HSDD patients
Fifty-six percent of women in their 40 s were diagnosed with HSDD, followed by 20% in their 50 s, 19% in their 30 s and 5% in their 20 s. In HSDD patients, 86.2% of women were married and the marriage durations were 36.3% under 10 years, 40.2% 11–20 years and 23.5% over 20 years.
The percentage of women with a history of vaginal deliv- ery who were diagnosed with HSDD was 67.1%, which was higher  than  in  women  with  a  history  of  caesarean  section (17.9%) and no history of delivery (8.9%). The surgical history and  delivery  history  of  patients  with  HSDD  is  shown  in Table 2. Parity was not correlated with the incidence of HSDD (Figure 3) (Pearson’s correlation coefficient r ¼ 0.38, p > .05).
Among the women diagnosed with HSDD, 35.8% reported no  orgasm  during  sexual  activity  and  64.8%  of  women reported no problems with achieving orgasm. Among women who  were  classified  as  having  an  orgasmic  disorder,  the prevalence  of  HSDD  was  48%;  which  was  higher  than  the prevalence in women who did not have an orgasmic disorder (27.5%).

Discussion
Hypoactive sexual desire disorder (HSDD) is defined as a per- sistent lack of sexual fantasies and lack of desire for sexual activity that causes a marked distress or interpersonal difficul- ties as measured by the DMS-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised)

(American Psychiatric Association 2003). Marked distress or interpersonal difficulties may manifest as discordance of sex- ual desire between partners, resulting in emotional discom- fort and interpersonal relationship problems. There are conflicting reports on the prevalence of low sexual desire and distressing low sexual desire in the literature (Parish and Hahn 2016). One study reported that for women in their 60 s and 70 s, the prevalence of low sexual desire was high but the prevalence of distressing low sexual desire was low (West et al. 2008). Another study reported that the prevalence of distressing low sexual desire was relatively constant for all ages, with a prevalence of 12–19% in the USA and 6–13% in Europe (Hayes et al. 2007). In our study, the prevalence of distressing, low sexual desire was highest for women in their 40 s at 56%, compared to 19% for women in their 30 s and 20% for women in their 50 s, so distressing sexual disorders were definitely more common in women in their 40 s. Our results were consistent with Berman et al. (2003) who reported the prevalence of arousal disorder in women who visited the hospital for sexual problems to be 29.0%. In our data, among women in their 40 s, 37% had an arousal dis- order, reporting the absence or the inadequacy of sexual excitement, including genital lubrication. Decreased or absence of sexual excitement caused decreased sexual inter- est and led to a sexual desire disorder or an orgasmic disorder.
The variables that affect sexual desire are a complex mix- ture of socioeconomical, psychological, physical and hormo- nal  factors.  The  working  status  of  women  and  their  sexual partner,   marital   status,   race,   menopausal   status,   general health,  disease  and  medication  history  may  affect  sexual desire. In our study, delivery mode, parity and history of cer- vical or abdominal surgery were not correlated with HSDD.
Previous studies have reported a history of delivery as a factor contributing to HSDD. In women with HSDD (De Souza et al. 2015; Kahramanoglu et al. 2017). De Souza et al. (2015) reported that all modes of delivery did equally affect postpar- tum sexual function, which returned to before pregnancy lev- els  within  12 months.  Kahramanoglu  et  al.  (2017)  reported decreased  sexual  desire,  lubrication  and  satisfaction  within 6 months of delivery, and caesarean section was not superior

to vaginal birth in terms of the preservation of sexual func- tion. Although, some researchers have reported that higher degree perineal tears or episiotomy during vaginal delivery and the scarring after vaginal surgery negatively affected sex- ual function, because of dyspareunia (Tunuguntla and Gousse 2006; Boran et al. 2013; Sayed Ahmed et al. 2017). Among the 217 patients, 8.8% had no delivery history, 18.4% had delivered once and 58.1% had delivered twice. Correlation analysis showed no meaningful correlation between parity and HSDD.
In  this  study,  researchers  asked  patients  ‘Have  you  ever had  surgery  for  wide  vagina  sensation?’  Surgery  for  wide vagina   sensation   includes   perineoplasty,   vaginal   rogation rejuvenation,  or  anterior  vaginal  introitoplasty  (Ostrzenski 2012;  Ostrzenski  2014;  Ulubay  et  al.  2016).  Ulubay  et  al. reported  that  among  38  patients  who  underwent  perineo- plasty for wide vagina sensation, 10% of patients experienced dyspareunia  during  sexual  intercourse  after  surgery  (Ulubay et al. 2016). Fibrosis and scarring after surgery results in dys- pareunia, and could be a cause of decreased sexual desire. In this paper, the percentage of patients diagnosed with HSDD who  had  previously  undergone  wide  vagina  surgery  was 25.3%. Although, among the 40 women who had previously had wide vagina surgery, 42.5% were diagnosed with HSDD. Only 28.2% of women with no vaginal surgery history were diagnosed with HSDD.
In previous studies on Asian women (Lo et al. 2014; Nagao et  al.  2014),  the  desired  duration,  and  frequency  of  sexual activities was different to the actual duration and frequency of  sexual  activities.  Unidirectional  coitus  initiation  and  low foreplay enjoyment were correlated with desire, arousal and orgasmic  problems.  In  our  report,  the  relationship  between HSDD and number of sexual activities per month showed a U-shape distribution. Both too much or too little sexual activ- ity  caused  HSDD.  Montgomery  reported  that  differences  in sexual desire between partners created discrepancies and this distress  led  to  HSDD  (Montgomery  2008).  To  evaluate  this factor, separate interviews of each partner would be needed.
The relationship between HSDD and the duration of sexual activity showed an inverse relationship; that is, longer phys- ical contact  and  sexual  foreplay  duration  lessened  the  inci- dence   of   HSDD.   These   results   suggest   that   adequate frequency of sexual activity and adequate duration of each sexual activity lessens HSDD. Miller and Byers (2004) studied the actual and desired duration of foreplay and intercourse, and   revealed   a   discrepancy   between   men   and   women. Women  significantly  underestimated  their  partner’s  desired duration of foreplay and intercourse, and both partners dem- onstrated   incorrect   stereotyped   ideas   about   what   men desired.  The  reported  ideal  duration  of  foreplay  and  inter- course was found to be more strongly-related to their own sexual stereotypes than to their partner’s self-reported sexual desires. The ideal frequency and duration of sexual activities differed among couples, and the best way to lessen female HSDD  is  to  resolve  any  discrepancies  between  actual  and ideal sexual activities.
In the clinical setting, special attention should be paid to women in their 40 s, particularly those with a history of vagi- nal surgery as they are at risk of HSDD. Ultimately, the key to reducing the under-diagnosis of HSDD is to encourage women to talk about their sexual issues and to seek help. Potential treatment options should include couple counsel- ling about the optimal frequency and duration of sexual activity, as well as treatment specific to the disorders identi- fied by the FSFI.

Disclosure statement
The authors declare no conflicts of interest.

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