For example discount finasteride 1 mg with mastercard, if the miracle happened generic 5mg finasteride otc, someone might say that they would make an appointment to get their hair cut buy discount finasteride 1mg on line. Make a list of things you might notice that were different about your life if a miracle happened and all your troubles and depression disappeared purchase 1 mg finasteride with visa. For example, if one of the things you would do if you didnt feel depressed is go for a walk, make an effort to schedule a walk tomorrow. If your list included dressing up and meeting a friend for lunch, try to schedule that. Hint: If your list includes things like My daughter and I wouldnt be arguing, schedule time for a fun activity with your daughter. People with Seasonal Affective Disorder are most prone to mood problems related to reduced sunlight. Avoid excessive alcohol or other depressants Although alcohol and other depressant drugs seem to relieve stress temporarily, they change body chemistry. However, they also can increase irritability and anxiety and disturb natural sleep-wakefulness cycles. Unless you have a disorder requiring modifcation of your food intake, adopt balanced eating habits as recommended by the Food Guide Pyramid. Most of the calories should come from complex carbohydrates, vegetables, and fruits. Drink enough water, at least 8 glasses of caffeine-free, sugar-free fuids daily, unless your doctor recommends otherwise. There is defnitely a connection between sleep problems, particularly insomnia, and depression. Take a few moments to think and write down some of the things you can do this week. Differences between Male and Female depression: Men act out their inner turmoil while women turn their feelings inward. Men were concerned that seeing a mental health professional or going to a mental health clinic would have a negative impact at work; especially if their employer or colleagues found out. Men feared a diagnosis of mental illness would cost them the respect of their family and friends, or their standing in the community. Men and Women experience depression differently and have different ways of coping with the symptoms of depression. I mean, were talking many, many beers to get to that state where you could shut your head off, but then you wake up the next day and its still there. It isnt a two-hour movie and then at the end it goes The End and you press off. I didnt care whether I lived or died and so I was going to do whatever I wanted whenever I wanted. There is a common misperception that suicide rates are highest among the young, but it is older white males who suffer the highest rate. Over 70 percent of older suicide victims visit their primary care physician within the month of their death. Suicide More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives. Many men with depression do not obtain adequate diagnosis and treatment that may be life saving. Family members, friends, and employee assistance professionals in the workplace also play important roles in recognizing depressive symptoms in men and helping them get treatment. And I remember, I never re- ally tried to commit suicide, but I came awful close, because I used to play matador with buses. Although the majority of people with depression do not die by suicide, having depression does increase suicide risk compared to people without depression. If you are thinking about suicide, get help immediately: Call your doctors offce. Diagnostic Evaluation and Treatment Your tendency is just to wait it out, you know, let it get better. If no such cause of the depres- sive symptoms is found, the physician should do a psychological evaluation or refer the patient to a mental health professional. Women are at Greater Risk for Depression than Men Major depression and dysthymia affect twice as many women as men. In fact, rates of depression were shown to be highest among unhappily married women. Reproductive Events Many women experience certain changes associated with phases of their menstrual cycles. Pregnancy (if it is desired) seldom contributes to depression, and having an abortion does not appear to lead to higher incidence of depression. In addition, motherhood may be a time of heightened risk for depression because of the stress and demands it poses. The women more vulnerable to change of life depression are those with a history of past depressive episodes. Victimization Studies show that women molested as children are more likely to have clinical depression at some time in their lives than those with no such history. In addition, several studies show a higher incidence of depression among women who have been raped as adolescents or adults. Since far more women than men were sexually abused as children, these fndings are relevant. Women who experience other commonly occurring forms of abuse, such as physical abuse and sexual harassment on the job, may also experience higher rates of depression. Abuse may lead to depression by fostering low self-esteem, a sense of helplessness, self-blame, and social isolation. Sadness and low morale are more common among persons with low incomes and those lacking social supports. Depression in Later Adulthood As with younger age groups, more elderly women than men suffer from depressive illness. Similarly, for all age groups, being unmarried (which includes widowhood) is also a risk factor for depression. Most of them are older, female, and experience varying degrees of depressive symptomatology. Most do not need formal treatment, but those who are moderately or severely sad appear to beneft from self-help groups or various psychosocial treatments. You should know that modern treatments for depression are shown to be effective in the process of recovery. As with many illnesses, the earlier treatment begins the more effective and the greater likelihood of preventing serious recurrences. Of course, treatment will not eliminate lifes inevitable stresses and ups and downs. The frst step in treatment for depression should be a thorough examination to rule out any physical illnesses that may cause depressive symptoms. Since certain medications can cause the same symptoms as depression, the examining physician should be made aware of any medications being used. If a physical cause for the depression is not found, a psychological evaluation should be conducted. The exam should be done by the physician or a referral made to a mental health professional. More than 80 percent of people with depressionboth men and womencan be treated successfully with antidepressant medication, psychotherapy or a combination of both. Medications There are several types of antidepressant medications used to treat depressive disorders. Usually antidepressant medications must be taken regularly for at least 4 weeks and, in some cases, as many as 8 weeks, before the full therapeutic effect occurs. The Path to Healing Reaping the benefts of treatment begins by recognizing the signs of depression. If there are no positive results after 2 to 3 months of treatment, or if symptoms worsen, discuss another treatment approach with the provider. Getting a second opinion from another health or mental health professional may also be in order.
Denition Achronic inammatory arteritis of unknown aetiology Management affecting the aorta and its main branches cheap finasteride 5 mg without prescription. Corticosteroids are the mainstay of treatment cheap finasteride 5mg free shipping, with methotrexate and azathioprine used in refractory cases generic 5mg finasteride overnight delivery. Incidence Percutaneous angioplasty or surgical bypass of affected 13 per 1 buy generic finasteride 1mg on-line,000,000 per year. Polyarteritis nodosa Denition Geography Polyarteritis nodosa is a rare intense necrotising vasculi- Largest number of cases in Asia and Africa. Aetiology/pathophysiology Associated with hepatitis B infection in 1020% be- Age cause of hepatitis B surface antigen immune complexes. Transmural neutrophil inltration of medium-sized arteries occurs, causing degeneration, weakness and microaneurysm Sex formation. Veins are also affected and the condition may M = F result in thrombosis and tissue infarction. Clinical features Aetiology/pathophysiology Polyarteritis nodosa is usually an acute illness charac- It is thought to be an autoimmune disorder. Serumconcentrations of IgA ammatory occlusion of small and medium-sized pe- are raised in approximately half of patients and IgA- ripheral arteries and veins of the upper and lower limbs. Clusters of cases have been noted with no obvious pre- Aetiology/pathophysiology cipitant. It occurs almost exclusively in heavy cigarette smokers and is therefore seen more in countries with high levels Pathophysiology of smoking. There is segmental chronic inammatory The condition results from inammation within the inltration of the vessel walls with resultant obliteration walls of small blood vessels, predominantly capillaries of the lumen and secondary thrombosis. The condition starts with digital ischaemia, ulceration The inammation of the vessels increases permeability preceded by claudication in the feet, or rest pain in the resulting in a leaking of uid and cells from the circula- ngers or toes. IgA deposition within ankle pulses are usually absent but brachial and popliteal the glomeruli of the kidney causes a focal segmental pat- pulses are present. There may be a previous history of tern of glomerulonephritis with a resultant proliferation supercial thrombophlebitis. Investigations Clinical features Arteriography shows narrowing or occlusion of small This multisystem disorder may occur with simultaneous peripheral arteries with healthy main vessels. The rash characteristically affects the lower The condition remits with quitting smoking; nicotine limbs and buttocks, but is not always conned to these replacement therapy cannot be used but bupropion areas. Prostaglandin infusions, thrombolytic puric and then goes through the classic colour changes therapy, surgical sympathectomy and revascularistion of a bruise, lesions of varying ages are present at one procedures have been tried. Oedema of the face, dorsum of the hands and feet, perineum or foreskin may occur especially in young children HenochSchonlein Purpura r Aself-limiting acute arthritis of large distal joints oc- Denition curs without articular damage with the patient com- A syndrome resulting from a vasculitis of small blood plaining of swollen, tender painful joints exacerbated vessels. Clinical features Symptoms are symmetrical with ngers affected more Complications than toes, it usually begins in a single digit and then Gastrointestinal complications include infarction and becomes more generalised. Renal failure may due to vasoconstriction progressing through cyanosis to occur in the acute phase, or may progress over many hyperaemia (white to blue to red). Investigations The diagnosis is clinical; erythrocyte sedimentation rate, Investigations white cell count and eosinophils may be raised. Urine Primary Raynauds phenomenon must be distinguished microscopy should be performed looking for red and fromRaynaudssyndromeoccurringwithconnectivetis- white blood cells, casts and protein. In more pain and rash may be achieved with nonsteroidal anti- severe cases calcium channel blockers such as nifedipine inammatory drugs. In severe cases prostacyclin infusions may be manifestations may be improved with the prompt use of required. Complications such as acute renal failure and intussusception should be managed promptly. Behcets syndrome Prognosis Denition Inmostcasestheoverallprognosisisexcellent,thecourse Achronic,relapsingmultisystemvasculitischaracterised is variable with cases lasting between a few days and a by oral ulceration. Rarely it may continue for up to a year and there may be a course of relapse and remission. Denition An exaggerated vascular response to cold, causing a Sex spasm of the arteries supplying the ngers and toes. M > F Prevalence Geography Five to ten per cent of young women in temperate cli- Much more common in Turkey, Iran, China, Korea and mates. Patients demonstrate pathergy (a gered autoimmune reaction in a genetically susceptible papule or pustule forms at sites of skin puncture) this individual. Clinical features Management Patients have recurrent oral aphthous or herpetiform ul- Corticosteroids and immunosuppressive agents are used cers. Colchicine may be of benet for ery- ular disease (uveitis), skin lesions (erythema nodosum), thema nodosum and arthralgia. A thin section a few mil- limetres around and underneath the resulting defect Nomenclature and description is taken, divided into pieces, and cut as a fresh frozen specimen. If tumour is seen at a particular margin re- The cornerstone of dermatological diagnosis is accu- section is continued at the appropriate margin, and rate observation and description of lesions and rashes. Dermatological procedures Skin grafts r Shaveortangential excision: This procedure slices a Skin grafts are sections of skin that are completely de- surface growth off using a blade, often to remove a tached and transferred to cover large areas of skin defect. The recipient site requires a good blood supply, as the r Punch biopsy: Under local anaesthesia a full thickness graft has no supply of its own. Ifaverylargedefectneeds are scraped off with a special tool and the area is cau- covering, the graft can be meshed. Repeated treatment may be take up a blood supply more easily than full thickness required. The area heals often leaving a small hypopig- grafts, but tend to shrink and have abnormal pigmen- mented mark. Lightfreezingcausesapeeling,moderate dermis, are used mainly in reconstructive surgery. They leave a donor site, which requires closure by su- r Mohs surgery: This is a technique used in the re- tures, limiting the size of the graft. Erythroderma Intense and widespread reddening of the skin due to dilation of blood vessels, often with exfoliation. Excoriation Stripping of the skin usually by scratching as a result of intense itching of the skin. May be a primary lichenoid disease or a secondary lichenication due to repeated excoriation as seen in chronic eczema. Macule Describes a skin lesion that is at, often well circumscribed with alteration of colour. Skin aps Geography Mayoccur anywhere, but higher incidence in urban Skin aps differ from skin grafts in that they are taken areas. The coverage can thus be thicker and stronger than grafts, and can be applied to avascularareassuchasexposedbone,tendonsandjoints. Aetiology/pathophysiology Flaps may be transferred whilst maintaining their orig- The term atopy is a disease resulting from allergic inal vascular attachments (pedicle aps), or may be re- sensitisation to normal environmental constituents anastamosed to local blood supply (free aps). The underly- ing cause and mechanisms in eczema have yet to be fully elucidated; however, dry skin (xerosis) is an important Scaly lesions contributor. There appear to be genetic and immuno- logical components to allergic sensitisation (see also page 498). Offspring of one atopic parent have a 30% risk of Atopic eczema being atopic, which rises to 60% if both parents are Denition atopic. Achronic inammatory skin disorder associated with r Chromosome studies suggest that atopic tendency atopy, causing dry, scaly, itchy lesions. More common in children with peak onset usually 218 Serum IgE is elevated in 85% of individuals and higher months. It is thought that the high frequency of secondary Sex infectionisacombinationofthelossofskinintegrityand M = F deciency of local antimicrobial proteins. These are erythematous and r Antibiotics are used for secondary bacterial infection. Lesionsmayweepand r Wetwraps consist of the application of topical agents have tender tiny blisters termed vesicles especially when under bandages to facilitate absorption. The distribution is age depen- may be administered in this way or coal tar may be dent: used as a keratolytic in lichenied skin. If steroids are r Babies develop eczema predominantly on the face and appliedunderwetwrapsthedose/potencymustbede- head; this may resolve or progress by 18 months to the creased as increased absorption may result in systemic childhood/adult pattern.
For each reporting period order 1 mg finasteride fast delivery, programs will need to review the milestones and identify those milestones that best describe a residents current performance and ultimately select a box that best represents the summary performance for that subcompetency (See the figure on page v finasteride 1mg visa. Selecting a response box in the middle of a column implies that the resident has substantially demonstrated those milestones finasteride 5mg visa, as well as those in previous columns 5mg finasteride with amex. Selecting a response box on a line in between columns indicates that milestones in the lower columns have been substantially demonstrated, as well as some milestones in the higher column. A general interpretation of each column for internal medicine is as follows: Critical Deficiencies: These learner behaviors are not within the spectrum of developing competence. Colum n 3: Describes behaviors of a resident who is advancing and demonstrating improvement in performance related to milestones. Ready for Unsupervised Practice: Describes behaviors of a resident who substantially demonstrates the milestones identified for a physician who is ready for unsupervised practice. This column is designed as the graduation target, but the resident may display these milestones at any point during residency. Aspirational: Describes behaviors of a resident who has advanced beyond those milestones that describe unsupervised practice. These milestones reflect the competence of an expert or role model and can be used by programs to facilitate further professional growth. It is expected that only a few exceptional residents will demonstrate these milestones behaviors. For each reporting period, a residents performance on the milestones for each subcompetency will be indicated by: selecting the column of milestones that best describes that residents performance or selecting the Critical Deficiencies response box Selecting a response box in the middle of a Selecting a response box on the line in between column implies milestones in that column as columns indicates that milestones in lower levels have well as those in previous columns have been been substantially demonstrated as well as some substantially demonstrated. Gathers and synthesizes essential and accurate information to define each patients clinical problem(s). Identifies forces that impact the cost of health care, and advocates for, and practices costeffective care. Has professional and respectful interactions with patients, caregivers and members of the interprofessional team (e. Comments: Professionalism The resident is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training. While medicines can help you treat your health conditions, some can create problems for your brain. This fact sheet discusses why this happens, what groups of medicines can affect your brain, and how to get help with controlling the reactions or side effects that these medicines might cause. Weight changes may affect how much supplements, natural products, alcohol, or medicine you need and how long it stays other existing health problems. So, your bodys ability to use alcohol mixed with some drugs can slow you medicines changes and so does its reactions down, cause confusion, or affect the way to them. A National Academy of Medicine report describes some In 2015, the American Geriatrics groups of medicines that may interfere with brain function Society, whose members are in older adults, including cognition. Some of these medicines are sold over-the- its list of medicines that older counter. This means you can pick them up off the shelf adults should avoid or use with without a doctors order (or prescription). This group of medicines has anticholinergic effects, and may cause older adults to experience confusion, memory loss, and other cognitive problems. You should get advice from a health care professional about your medicines, as there may be alternatives to ones that are causing problems. It is especially important to consult with your doctor before you make any changes to your medications. For free resources on medicines and older adults, please see Could this medicine affect the following websites: my brain function? Indeed, suffer treatment-caused injuries while occurin 2% to 14% of patients admitted they probably areamong the most care in the hospital. One reason injury and that 20% of those injuries sparse, in part because most studies of may be a lack of awareness of the se wereserious orfatal. Steel et al3 found iatrogenesis have focused oninjuries (eg, verity ofthe problem. Hospital-acquired that 36% of patients admitted to a uni- the Harvard Medical Practice Study). For New vention is that they have a great deal of York State, this equaled 98 609 patients Given the complex nature of medical difficulty in dealing with human error in 1984. Nearly 14% of these injuries practice and the multitude of interven when it does occur. Ifthese rates are typical of tions that each patient receives, a high to be found in the culture of medical the United States, then 180000 people errorrate is perhaps not surprising. However, a 1% fail practice, the message is equally clear: potentially preventable. Physicians in the Harvard Medical Practice Study, toleratedinindustry, particularly inhaz areexpected to function without error, 69% of injuries weredue to errors(the ardous fields such asaviation and nuclear anexpectation that physicians translate balance was unavoidable). It is the tice threat provide strong incentives currence of a similar error, often by at counterpart ofanother fundamental goal against disclosure orinvestigation ofmis tempting to prevent that individual from of medical education: developing the takes. It is For example, ifa nursegives a medi everything that happens to the patient, hardly surprising that aphysician might cation to the wrong patient, a typical it follows that you are responsible for hesitate to reveal an errorto either the response would be exhortation ortrain any errors that occur. While the logic patient orhospital authorities orto ex ing in double-checking the identity of may be sound, the conclusion is absurd, pose a colleague to similar devastation both patient and drug before adminis because physicians do not have the for a single mistake. Although itmight be noted that power to control all aspects of patient The paradoxis thatalthough the stan the nursewas distracted because of an care. Authorities arenot supposed leagues and patients when they make system for dispensing medications in to err. Yet, they are denied both in which safety is contingent oninspection need to be infallible creates a strong sight and support by misguided concepts by an individual at the end point of use. Training is directed change the way they think about errors astated by serious mistakes that harm toward teaching people to do the right and why they occur. In nursing, rigid adherence topro deal has been learned about errorpre sician who cares for patients has had tocols is emphasized. In medicine, the vention in other disciplines, information that experience, usually morethan once. Systems that rely oner as airplane cockpits and nuclear power Hilfiker19 points out, "We see the horror ror-free performance aredoomed to fail. Cognitive psycholo of our own mistakes, yet we are given The medical approach to error pre gists concentrated on developing mod no permission to deal with their enor vention is also reactive. Errors areusu els of human cognition that they sub mousemotional impactThe medical ally discovered only when there is an jected toempirical testing. Lessons from profession simply has no place for its incidentan untoward effect or injury both spheres ofobservation have greatly mistakes. All these factors lead to stand why errors occur we must first simultaneously, with increasing exper preoccupations that divert attention. Environmen theory and is consistent with empirical areformulated at am oreabstract level. Slips areerrorsof is strong (frequently used), that seems gon, that are "expert" on some minute action. A knowledge or misinterpretation of the In addition to this automatic uncon slip occurs when there is a break in the problem. Pattern matching is preferred scious processing, called the "schematic routine while attention is diverted. The to calculation, but sometimes wematch control mode," cognitive activities can actor possesses the requisite routines; the wrong patterns. This "at- errorsoccurbecause ofalack ofatimely thought have been identified that alter tentional control mode" or conscious attentional check. Inbrief, slips aremoni pattern matching orcalculation and lead thought is used for problem solving as toringfailures. A commonmechanism of a slip is cap pletely understood and areseldom rec The attentional control mode is called ture, in which a more frequently used ognized by the actor. One such process into play when we confront a problem, schema takes over from a similar but is biased memory. For example, if the on what is in ourmemory, but memory of the schematic control mode. An everyday example is depart doxically, memory is also biased toward Rasmussen and Jensen27 describe a ing ona trip in which the first part ofthe overemphasis on the discrepant. A con model ofperformance based onthis con journey is the same as a familiar com tradictory experience may leave an ex cept ofcognition that is particularly well muting path and driving to work instead aggerated impression far outweighing suited for error analysis.
Sex therapists are also equipped to help resolve the intrapsychic and inter- personal blocks (resistance) to restoring sexual health (20 buy generic finasteride 1 mg on line,42) discount finasteride 1mg with amex. Some clinicians are uncomfortable discussing sex cheap finasteride 5mg otc, and many important issues remain unexplored because of clinician anxiety and time constraints purchase 5mg finasteride fast delivery. They are trained to manage the most difcult cases involving process-based trauma that are replicated in the current relationship. Sex therapists can enhance hope, facilitate optimism and maxi- mize placebo response. There can be an increased individualization of treatment format, by ne-tuning therapeutic suggestions, as well as improving response to medication by optimizing timing and titration of dose. Finally, sex therapists are skilled in using cognitive-behavioral techniques for relapse prevention. All of these issues impact potential and capacity for success- ful restoration of sexual health. Delineating all permutations, of multidisciplinary team approaches likely to be utilized for the next decade, is beyond the scope of this chapter. Case Study: Jon and Linda Jon and Linda were referred to the author by Jons current psychopharmacolo- gist. Jon is a 62 years old nancier who has been married to Linda (53 years old) for over 20 years. Their marriage was marked by periods of disharmony secondary to multiple etiologies. Jon and Linda had a symbiotic relationship where she dominated much of their daily life. She tended to be explicitly critical of him, which he resented but managed passive-aggressively. Linda was particularly sensitive to rejection, and was considerably upset when Jon withdrew from her in response to her criticism. He even- tually responded, becoming loud and aggressive, which initially dissipated his tension. This pushpull process would begin anew, characterizing the rhythm of their marriage. Jon and Linda enjoyed high frequency successful coital activity with mutually enjoyable coital orgasms, despite their intermittent marital disharmony over a 15-year period. They both wanted Jon on the antidepressant medications, yet their marital conict increased. He needed to move to a different city in order to nd work, uprooting Linda and the kids. This left her slightly depressed, but predominantly, critical of him and doubting the viability of their marriage. She was helped to reframe his withdrawal, as insecurity, not rejection or abandonment of her. Her criticalness was reduced, which led to a reduction in his passive-aggressive behavior. Although not resolving the individual and marital dynamics, these insights increased harmony enough, for a sexual pharmaceutical to become effective. The drugs longer duration of action allowed him to respond to her receptivity cues, which she dropped like a hankie. However, if only due to pharmaceutical advertising, most patients will rst consult with a physician who will hopefully possess sex counseling expertise, as well as a prescription pad. This physician would adjust treatment according to the individual and couples history, sexual script, and intra and interpersonal dynamics. All clinicians want to optimize the patients response to appropriate medical intervention. However, it is equally important to not collude with the patients unrealistic expectations of either his or her own idealized capacities, or an idealization of the treating clinicians abilities. These fantasies are based on ignorance and may reect unresolved psychological concerns. There are situ- ations when it is appropriate to either make a referral within a team approach or to decline to treat a patient. Signicant, process based, developmental predisposing factors, usually speak to the need for resolution of psychic wounds prior to the introduction of the sexual pharmaceutical. Sexuality is a complex interaction of biology, culture, developmental, and current intra and interpersonal psychology. Restoration of lasting and satisfying sexual function requires a multidimensional understanding of all of the forces that created the problem, whether a solo physician or multidisciplinary team approach is used. Psychotherapy: Special Issue: Empirically Supported Therapy Relationships: Summary Report of the Division 29 Task Force. Vardenal: a new approach to the treatment of erectile dysfunction, Curr Urol Rep, Curr Sci Inc 2003; 4:479487 14. Efcacy and safety of tadalal for the treatment of erectile dysfunction: results of integrated analyses. Drivers and barriers to seeking treatment for erectile dysfunction: a comparison of six countries. A comparison of nefazodone, the cognitive-behavioral analysis system of psychotherapy, and their combination for the treatment of chronic depression. The Management of Benign Prostatic Hyperplasia, Amer- ican Urological Association Education and Research, Inc. Self-injection of papaverine and phentolamine in the treatment of psychogenic impotence. The combined use of sex therapy and intra-penile injections in the treatment of impotence. Combination of psychosexual therapy and intra-penile injections in the treatment of erectile dysfunctions: rationale and predictors of outcome. Intracavernous injections and overall treatment of erectile disorders: a retrospective study. Evaluation and treatment of ejaculatory disorders, in atlas of male sexual dysfunction [Ed: Lue, T. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenal citrate. Presented at 6th Congress of the European Society for Sexual Medicine, Istanbul, Turkey, 2003. Cognitive and social science aspects of sexual dysfunction: sexual scripts in therapy. Successful Salvage of Sildenal (Sildenal) Failures: Benets of Patient Education and Re-Challenge with Sildenal. Presented at the 4th Congress of the European Society for Sexual and Impotence Research, Sept. Sildenal failures may be due to inadequate instructions and follow-up: a study of 100 non-responders. It encourages the belief that sexually healthy women agree to sex or initiate it mostly because they are aware of sexual desirebefore any sexual stimulation begins. Indeed, this is in accordance with the traditional model of human sexual responding of Masters, Johnson, and Kaplan. As we will see, this conceptualization contradicts both clinical and empirical evidencewomen in established relationships infrequently engage in sex for reasons of sexual desire (16). That sense of desire, or need, or hunger is nevertheless felt once subjectively aroused/excited. When that arousal is insuf- cient or not enjoyed, motivation to be sexual typically fades. In other words, although not usually the prime reason for engaging in sex, enjoyable subjective arousal is necessary to maintain the original motivation. So, lack of subjective arousal is key to womens complaints of disinterest in sex. This imprecision presents a major dilemma to both clin- icians and the women requesting their help. Any formulation of a hypoactive sexual desire/interest disorder must take into account the normative range of womens sexual desire across cultures (7), age, and life cycle stage (8).