This chapter should be cited as follows: This chapter was last updated:
Williams, N, Leiblum, S, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10432
January 2008

Human sexuality and behavioral problems

Treatment of Orgasmic Dysfunction in Women

Nina Williams, PsyD
Private Practice, Somerset, NJ; Faculty, NJ Center for Psychotherapy and Psychoanalysis; Adjunct Faculty, UMDNJ-Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
Sandra R. Leiblum, PhD
Private Practice, Bridgewater, NJ; Retired Professor and Director of the Center for Sexual and Relationship Health, UMDNJ-Robert Wood Johnson Medical School, Piscataway, New Jersey, USA

INTRODUCTION

Difficulty reaching orgasm is the second most common sexual complaint reported by women. Although this is a relatively rare condition among men, many women have difficulty reaching orgasm reliably and readily, despite the fact that there are few physical conditions that are insurmountable obstacles to orgasmic attainment.

Orgasmic disorders among women are particularly intriguing because female orgasm is so variable. Some women are promptly and reliably orgasmic with a minimum of stimulation, whereas other women require concentrated stimulation in a particular fashion for extended periods of time for orgasmic release to be triggered. The psychological and cultural valuation and 'meaning' of orgasm are complex as well, and have changed considerably over the past 50 years.

DESCRIPTION OF FEMALE ORGASMIC DYSFUNCTION IN DSM-IV AND PROPOSED CHANGES

The Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) of the American Psychiatric Association defines orgasmic dysfunction as follows1:

  1. Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis of Female Orgasmic Disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives.
  2. The disturbance causes marked distress or interpersonal difficulty.
  3. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

DSM-IV divides female orgasmic disorder into subtypes corresponding to the nature of onset (lifelong versus acquired), the context within which the dysfunction occurs (generalized versus situational), and the etiologic factors (psychological versus combined psychological, medical, and substance abuse factors).

Current empirical data led to refinement of the preceding DSM-III-R's definition in three ways. First, DSM-IV acknowledges the wide variability in orgasmic responsiveness among women, whereas the previous description of 'inhibited female orgasm' implied a normative orgasmic potential, which has not been demonstrated to exist. Second, DSM-IV does not suggest that psychological inhibitions contribute to female orgasm problems during coitus because there is no empirical validation of this theory. Finally, DSM-IV notes the importance of assessing the contribution of substance use or medical conditions to orgasmic problems, an acknowledgment indicating that sexual difficulties are often multiply determined.

Changes in DSM-IV mirrored a shift in treatment from an inhibition-focused, intrapsychic perspective toward an interpersonal, systemic approach to understanding and resolving orgasmic difficulties. However, little is known about the causes of orgasmic variability among women and how to distinguish normal variation from dysfunction. Thus, the criterion that arousal be 'adequate' to produce orgasm was often ignored.  Further, although many women with DSM-IV female orgasmic disorder were also diagnosed with female sexual arousal disorder, the DSM-IV diagnosis of orgasmic disorder precludes this second diagnosis. Because evaluation of arousal level is essential in making the diagnosis of orgasmic disorder, an international multidisciplinary group recommended the following clarification: "Despite the self-report of high sexual arousal or excitement, there is either lack of orgasm, markedly diminished intensity of orgasmic sensation or marked delay of orgasm from any kind of stimulation." 2

Nevertheless, women who have never had an orgasm can be treated with almost certain success, and the sexual satisfaction of women whose orgasmic difficulties are situational can generally be improved. Although obstetricians and gynecologists provide an expertise different from that of sex therapists, patients can benefit from the guidance of their physician in defining their orgasmic problem, providing information about treatment, and, in cases in which psychotherapy or sex therapy is indicated, making a referral to a qualified practitioner.

 

INCIDENCE

Incidence figures for sexual disorders are usually based on volunteers in surveys or on clinical populations, so they do not provide a 'true' picture of the frequency with which such problems occur in the general population. The findings of the 1994 National Social and Health Life Survey2, 3 provide the most comprehensive description of orgasmic experience in a nonclinical, representative sample of women. Twenty-four percent of female subjects reported they had experienced a lack of orgasm for at least several months or more in the previous year. 

Lifelong or primary anorgasmia was reported by 4% of all women in the survey and was highest among young, single women, in whom the prevalence was reported to be 8%; earlier estimates ranged from 6–10% or 11%.3, 4, 5, 6

Acquired, secondary, or situational anorgasmia refers to women who are able to reach orgasm in some circumstances but not in others. The most common form of female orgasmic dysfunction, anorgasmia during coitus, occurs in this category. Michael and colleagues3 found that only 25% of women always reach orgasm during intercourse, and 30% climax only sometimes or less frequently during sex with their primary partner. De Bruijn7 found that 7% of the Dutch women she surveyed had never had an orgasm during coitus, a figure that matched the incidence of situational anorgasmia in two studies of American women.8, 9 A random sample of Massachussetts women found that 10.3% reported difficulty reaching orgasm all or most of the time.10 Data from clinical populations generally indicated higher incidence. Among patients in an American outpatient gynecological clinic and a UK general practice clinic, 29% and 23% of women reported orgasmic difficulties.11, 12 

The study by Michael and associates3 provided a surprising qualitative description of the typical woman with orgasmic difficulties: she is younger and more likely to be single than women who report relative ease in reaching orgasm. In fact, monogamous married couples had more frequent and satisfying sex than did any other group surveyed in the study. The researchers found that orgasmic success among women is not related to education, religion, race, or ethnicity but does correlate with an overall sense of happiness with life.

ETIOLOGY

One unanswered question about orgasmic disturbance in women is whether the varieties of presentation suggest one dysfunction or many. Derogatis and co-workers13 have described four subtypes of anorgasmic women based on their studies of sex clinic clients (women with reduced sexual drive; women with constitutionally weak orgasmic capacity; depressed, hostile women with poor marriages; and women with limited capacity for intimacy because of psychiatric problems). Clinicians describe a wide range of apparent sources of orgasmic difficulty, but efforts to classify them have not been empirically tested. Heiman 14 cites a variety of neuroanatomic, physiological, psychological, socio-cultural and interactional factors hypothesized to relate to orgasmic difficulties, but concludes, "... there are no consistent empirical findings that support a constellation of factors separating orgasmic from nonorgasmic women."

This uncertainty about etiology has direct implications for physicians who wish to provide useful guidance to their patients with orgasmic dysfunction. As a group, women with orgasmic difficulties differ from the clinical population seen 20 years ago in the relative proportion of presenting problems. The group that once received the most sex therapy treatment (women who had never had an orgasm because of lack of knowledge or skill) is now successfully treated with self-help books, instructional videos, and other media information. The obstetrician and gynecologist can easily provide information about these sources of help during a brief office visit. However, today's patient is more likely to present with secondary or situational anorgasmia that relates to chronic marital problems and that may be nested within concomitant desire and arousal difficulties. Teasing apart the contributions of various causes is often complex, as is determining whether the orgasmic (and arousal) problems have led to relationship conflicts, or vice versa.

Women today expect their gynecologists and obstetricians to know not only about clinical problems but also about functional sexual difficulties. Therefore, the physician requires the skills and sensitivity that are necessary to take a sexual history and provide information about sexual practices to a patient population that is likely to have higher expectations of their doctor's expertise and more complex sexual problems than in the past. The first task for the physician presented with such a patient is to differentiate between relatively clear-cut cases of primary anorgasmia and those of situational or secondary anorgasmia. The latter are more likely to require extended, psychologically based treatment and should be referred.15 The sections below outline some general causes of orgasmic dysfunction. Specific suggestions regarding sexual history taking, giving sexual advice, and deciding when a referral is needed are given later in the chapter.

The major etiologic contributions to anorgasmia can be grouped broadly under three headings: physical, psychological, and interpersonal.

Physical Causes

Orgasmic ease falls along a normal bell curve of distribution, although the physiological correlates of orgasmic capacity are not known (vaginal size and pelvic muscle strength are not predictive of orgasmic ease). About 5% of women with primary anorgasmia cannot be treated successfully; some of them likely represent the extreme low end of constitutional orgasmic capacity. At the other extreme, Whipple and colleagues16 reported on women who were able to achieve orgasms through self-induced imagery alone, an ability reported in 1% or 2% of the population.5, 6 Whipple and associates found that these imagery-induced orgasms produced “significant and substantial net sympathetic activation and concomitant significant increases in pain thresholds”, physiological correlates comparable in magnitude to those produced in the same subjects with genital self-stimulation. They concluded that defining orgasm as a reflex or as an involuntary response to a stimulus was too narrow. Therefore, they suggested that orgasm be defined as “a perceptual experience, whose occurrence is reported subjectively”.16, 17, 18

Disease-based orgasmic dysfunctions in women are uncommon. Some orgasmic problems can be attributed to a medical condition alone, particularly those that affect the nerve supply to the pelvis (such as multiple sclerosis, spinal cord tumors or trauma, and diabetic neuropathy) and circulatory disorders affecting the pelvic region.19, 20, 21 Yet Schover20 found that women can retain a normal capacity for orgasm even after the loss of genital tissue or pelvic organs, although pain, fatigue, and anxiety about physical attractiveness can certainly interfere with orgasmic functioning. In fact, most diseases that inhibit orgasm do so through the physical and emotional depletion that accompanies them. Aging, apart from health problems, does not produce a decline in orgasmic capacity.

Information about the effects of hysterectomy on orgasmic functioning in women is largely anecdotal; there are as yet no well-controlled, large-scale studies on this topic. Women who have had hysterectomies sometimes report missing the sensation of the penile thrusts against the cervix or uterine contractions. Still others note no change in orgasmic ease, or feel relief from the discomfort of cramping. Some sex therapists have heard from their clients that vaginal hysterectomies are associated with less postsurgical pain than are those done abdominally.

Prescription medications for hypertension and psychiatric disorders have been found to contribute to orgasmic difficulties, particularly methyldopa at higher doses, fluoxetine, phenelzine, sertraline, trazodone, and clomipramine.22, 23, 24, 25 Women who abuse alcohol, crack cocaine, or other illicit drugs are at increased risk of orgasmic dysfunction; estimates of orgasmic dysfunction range from 15–60%, depending on the frequency and chronicity of abuse.19

For most women, however, the major physical contributor to orgasmic difficulty is anatomy: penile thrusting is not the most effective way of providing the sensory stimulation that triggers orgasmic release in women. Kinsey and associates5 noted more than 40 years ago that women reach orgasm more easily during masturbation than during intercourse. The vagina is not particularly sensitive to deep penile thrusting because it is the outermost third of the vagina that is most suffused with nerve endings. Furthermore, the male-superior position does not provide the right kind of stimulation to the clitoris.

Although male-active coitus is not a particularly effective way of producing female orgasm, it characterizes the way most heterosexual couples have sex. Furthermore, although clinicians have long since acknowledged that the female orgasm has both vaginal and clitoral elements, the conviction of many couples that a coital orgasm is 'superior' suggests that the debate isn't over for men and women. Masters and co-workers19 noted that although masturbatory orgasms are physiologically stronger, women report enjoying coital orgasms more. Every clinician who discusses orgasm with women will find patients still in search of this elusive prize.

Psychological Contributions

Although psychological factors seem to be implicated in most orgasmic complaints, no particular psychiatric diagnosis has been found to correlate with these difficulties. Neither depression nor a history of sexual trauma appears to directly affect orgasmic ease, although both can cause desire and arousal difficulties. Depressed women most often report a diminished desire for sex. However, as indicated above, antidepressants in the serotonin reuptake inhibitors (SRI) class have been widely reported to impede orgasmic ease.22, 23, 24, 25, 26 Sexual abuse histories contribute indirectly to orgasmic dysfunction through the impairment of both desire and arousal by post-traumatic symptoms such as flashbacks and dissociation, particularly when the sexual activity replicates the abusive situation.

Alma, a bisexual woman in her thirties, was able to reach orgasm with both male and female partners except when her lover sat next to her and looked at her genitals while penetrating her digitally. When she was given permission to ask her partners not to assume this posture, her orgasmic difficulties subsided. Subsequent psychotherapy to deal with a sexual abuse history enabled her to expand her repertoire to include this behavior with some modifications (asking her lover to look at her face rather than her genitals).

Another difficulty related to sexual abuse is some women's tendency to defend themselves against the helplessness they felt in the abusive situation by controlling their adult sexual encounters. This contributes to an overly intellectual approach to the experience, which tends to inhibit orgasmic ease by blocking attention to bodily sensations. A typical example of this complication is given later.

Finally, although studies of sexually abused women do not report a greater incidence of primary anorgasmia, the clinical literature has described two specific orgasmic patterns in women with incest histories: the ability to be orgasmic only when the sexual partner is new, and the ability to be orgasmic in the absence of sexual desires, arousal, or pleasure.27

Fisher's4 landmark study of the female orgasm found that women who have fewer orgasms are not more likely to be anxious, guilty, masculine, compulsive, angry, or repressed. Conversely, women who have orgasms easily are not more traditionally feminine, exhibitionistic, histrionic, or impulsive. Fisher's findings continue to intrigue clinicians: women who have orgasmic difficulty have significant histories of absent or undependable fathers. Fisher postulated that these women's histories of abandonment or neglect produced a premature need for emotional control and a fear of letting go in the presence of a lover, which made orgasm difficult.

Interpersonal Contributions

Theorists have increasingly noted the importance of intimate relationships for a woman's sense of self-esteem and happiness, a finding that supports current evidence that orgasmic ease correlates with a woman's overall sense of happiness in life.3, 28 Considerable research confirms that a woman's sense of safety and pleasure in her relationship is related to her orgasmic response.7, 28, 29 Blumstein and Schwartz30 refer to the “shared intimacy” women look for in sexual relationships. This demonstrates that emotions have more of an effect on orgasm during intercourse than they do on masturbation.7

Sometimes the relation between emotions and orgasm is obvious, as in the case of a patient whose husband liked to have sex on Saturday afternoon while the children played outside. The patient would rush him through sex with no attempt to experience orgasm herself because she feared her children would interrupt them or hear her. In other cases, the problem is expressed more subtly, as when a couple's apparently shared goal of helping the wife achieve a coital orgasm conceals a struggle for power and control in the marriage. In these cases, it is not clear to whom the orgasm belongs, who wants the experience, or what will be proved when the couple achieve their goal.

Cultural beliefs about female sexuality can greatly influence a woman's comfort and dissatisfaction with her orgasmic experience. Before the 1960s, many women were embarrassed and anxious about seeking sexual pleasure because of the prevailing social view that a 'good' woman simply tolerated her husband's sexual advances.

A group of women raised in the 1950s was surprised to discover that they all privately believed that good wives did not enjoy sex but that mistresses did. These women, who were in therapy to increase their sexual desire, felt like failures because they were not as interested in or gratified by sex as their female friends and relatives appeared to be. Many women with orgasmic difficulties report that they never examined their genitals, masturbated, or had a sexual fantasy because of social or religious prohibitions against these actions.

ORGASMIC DIFFICULTIES AMONG LESBIANS

If orgasmic problems are tied to heterosexual couples' unrealistic goal of coital orgasm, should one expect to find considerably less situational anorgasmia among female couples, where no such goal exists?

Comparing the orgasmic experiences of heterosexual and lesbian couples provides an interesting way to study this question. Although orgasmic dysfunction in lesbian and bisexual women is even less researched than that in heterosexual women (the Sex in America survey included fewer than 30 homosexual or bisexual women in their sample of 1749), limited research and clinical data provide some direction.

Hurlbert and Apt31 found no significant difference between lesbian and heterosexual women in sexual satisfaction, but they noted dramatic differences in the role that sex played in these relationships. The lesbians demonstrated more dependency, compatibility, and intimacy in their sexual relationship, whereas the heterosexuals were more positively disposed to fantasy, were more sexually assertive, and had a stronger desire for and more frequent sexual activity.

Bressler and Lavender32 compared sexual satisfaction among heterosexual, bisexual, and homosexual women and found no significant difference in the number of orgasms experienced. They did report, however, that the homosexual and bisexual women described a higher percentage of their orgasms as “strong,” a finding they attributed to a female lover's supposed greater familiarity with and interest in giving her partner an orgasm.

Lesbians tend to describe the difference between sex with men and sex with women in completely qualitative terms.

During a group discussion with lesbian professionals, virtually all of whom had also had sexual relationships with men, one woman's opinion was typical: “I had a good sex life with my husband, with plenty of orgasms. But I would call those body-orgasms. What I have with my lover involves me on a much deeper level. I feel connected, excited, and completely released, like my whole existence is shooting out; I call these heart-orgasms.”

TREATMENT

Historical Overview

Psychological treatment for female orgasmic dysfunction has shifted from investigating the intrapsychic life of the woman to improving her relationship with her partner.

Early theorists explained female orgasmic dysfunction with the then-revolutionary view that sexual behavior was healthy insofar as it promoted the cultural and biological roles of men and women. Thus, the woman who failed to be sexually satisfied with genital intercourse, who failed to achieve a 'vaginal orgasm', was seen as the victim of her neurotic denial of her natural place as the passive receiver of the male penis. She envied her husband's genitalia. Treatment focused on working through her internal inhibitions against femininity.33

Although behavioral theorists dismissed the role of penis envy in anorgasmia, they also posited an intrafeminine locus of trouble: the orgasm was a reflex that was inhibited through a process of conditioning in response to the woman's anxiety over her loss of control during orgasm. The treatment objective was to eliminate this inhibition by learning not to divert attention when the orgasmic reflex begins.17

Masters and Johnson's34 approach to sex therapy was one of the first to incorporate both partners in treatment. They suggested that the performance pressure and anxiety that produced orgasmic difficulties could emerge from the woman's inner conflicts or from her partner's psychological needs. Whatever the source of the initial anxiety, Masters and Johnson concluded that both partners were likely to lose focus on the sensations of sexual arousal because of their preoccupation with achieving the goal of orgasm. They proposed that the goal of treatment was to teach the couple to become participants in rather than critics of their sexual lives.

There are a variety of approaches to current sex therapy for orgasmic disorders. Psychodynamic sex therapy focuses on the interpersonal relations of the couple. This is accomplished by helping each partner distinguish between the relationship he or she imagines and the realities (and possibilities) of the relationship as it exists.34 Behavioral treatment has moved beyond individual inhibition to include exploration of the unique cognitions the woman and her partner have about her orgasm: the danger of losing control over feelings and behavior along with self-blame and fears of victimization. Cognitive treatment aims to increase positive sexual experiences and to change the dysfunctional beliefs that underlie treatment failures. Hurlbert and Apt,31 for instance, emphasize that couples may be so entrenched in their resentment that each may interpret sexual overtures from the other as selfishly motivated.

Systems-based theorists place less significance on the symptom of orgasmic difficulty itself than do cognitive-behavioral or psychodynamic clinicians. Systems therapists see anorgasmia as simply the most obvious sign of larger struggles over power, control, roles, and communication within the couple's relationship. For example, female orgasmic difficulties can be related not only to female desire and arousal problems but also to male ejaculatory problems. In fact, systems theory suggests that all sexual problems are best seen as a matter of discordance between partners, not as one partner wanting too much or giving too little. Systems oriented treatment takes note of how women with orgasmic difficulties often do not ask for what they want sexually, because if they do, they may offend their male partner's wish to be the sexual authority.29

An Iranian woman who came for sex therapy requested help in achieving an orgasm but insisted that her treatment exclude her husband. She was raised in Iran until she married at age 16, and then lived in the United States for the next 20 years. She felt torn between the messages each culture gave her about her sexual life. Although her traditional upbringing had taught her to suppress her sexual urges, her western friends had piqued her interest in having an orgasm. She could not ask her husband to accompany her to sex therapy because she believed he would be offended by her request for more foreplay (which implied that he had failed to anticipate and meet her sexual needs).

Several sessions focused on her personal contributions to her orgasmic problems. Then the patient was encouraged to invite her husband to a session to describe her experiences and open the door to a discussion of their approach to sex, which limited the romantic embracing that aroused her. Her spouse, as she had predicted, expressed considerable dismay that she was dissatisfied; the patient began to retreat from her position in the session and called later to announce that the family was returning to Iran for an extended visit, terminating the treatment.

In retrospect, this case is an example of the risks involved in underestimating systemic contributions to sexual problems; specifically, the need to respect cultural sex roles that were more entrenched and connected to marital roles than the therapist had anticipated.

Assessment

Gynecologists and obstetricians practicing today are expected to be informed about and skilled in sexual matters. One way to express this expertise is to take a sexual history from any patient who:

Is new to the practice

Is sexually active

Presents with concerns about sexually transmitted diseases (STDs)

Presents with a chronic illness

Is experiencing a major life-cycle event (puberty, pregnancy, menopause), which is likely to raise questions about altered sexual response in this new phase

Presents for a postsurgical consultation

In the managed care environment, when physician time is at a premium, a well-trained nurse, physician's assistant, or social worker can take a sexual history. An alternative is to amend a questionnaire covering pertinent medical history to include questions about contraception, STDs, type of condoms used, sexual orientation, and difficulties with arousal, orgasm, or pain during sex. The physician can gain much valuable information, however, by asking two simple questions in a relaxed, matter-of-fact manner: (1) "Are you sexually active, and, if so, with whom and under what circumstances?" (2) "What questions, concerns, or difficulties are you having at the present time?"15

Treatment of orgasmic difficulties in women must begin with a thorough assessment of the relative roles psychological, physical, and interpersonal issues play in each case. In a medical setting, evaluation of the physical contributions to the difficulty should be made, with particular attention given to undiagnosed sexual pain and the impact of prescription or recreational drug use.

Most orgasmic disorders in women, however, are predominantly psychological in nature, and it is this variable that needs the most extensive evaluation. Topics that should be covered in a thorough assessment of sexual difficulty include a review of all current sexual functioning and a problem-focused follow-up when a problem is presented.

Current Sexual Functioning

This information is needed to determine whether the orgasmic dysfunction is life-long, generalized, or situational. Clients tend to have unspoken beliefs regarding the source and cause of their difficulties, and these beliefs do not have to be valid to have a powerful influence on the outcome of treatment. Thus, the physician's ability to elicit the patient's own (and her partner's) theories about the problem will define the relationship as one in which these concerns are valid and welcome. In fact, patients often have an initial surge of hopefulness in response to the questioner's interest and acceptance of what may be shame-ridden material. Areas of inquiry in a general sexual history should include the following:

1.   Current sexual activity

            With partner(s)

            Sexual orientation

            Number of partners in the previous year

            Contraceptive use

            Sexual pain

            STDs

            During masturbation

            Satisfaction

            Specific problems or questions

 

2.   Adequacy of sexual responses

            Desire (is there too much, too little, or is the level too different from partner's?)

            Arousal (adequacy of lubrication, subjective excitement)
            Orgasm (frequency, ease of attainment)

 

3.   History of sexual abuse now and in the past

 

4.   Medical conditions that may affect sexual functioning

(pregnancy, menopause, surgery, cancer, arthritis, medications)

 

Gathering information about orgasmic dysfunction

When the patient presents with an orgasmic dysfunction or when the sexual history reveals a concern, the physician should follow up with questions about the particular difficulty. The goal is to obtain specific information from the patient (and her partner if he or she is available) about the following:35, 36, 37

How she defines the orgasmic problem (to determine that the physician and patient share a definition)

When the problem began (to differentiate between primary and secondary anorgasmia and to identify any related trauma or illness)

Whether the dysfunction occurs all the time or only during particular activities or with particular partners (to distinguish between primary, secondary, and situational dysfunction)

How the problem has changed her life, feelings, and relationships (to assess the severity of the dysfunction to the patient and to her partner[s])

How she has tried to solve the problem and how her solutions have worked (so that the physician doesn't inadvertently suggest an approach that has already failed)

Whether she wants treatment for the problem (so that an approach can be planned)

One problem the physician is likely to encounter in assessing orgasmic dysfunction is the likelihood that only the woman will be available for the interview. In a case of primary orgasmic difficulty, interviewing the couple is less crucial because treatment will focus on teaching the woman to bring herself to orgasm. With secondary or situational anorgasmia, however, it is important to assess the sexual satisfaction of the couple as well as the number of orgasms achieved. It is also important to determine whether the cause is attitude, behavior, communication about sexual needs, or larger problems in the couple's relationship that are being expressed in the sexual sphere.

Some patients are able to provide information about a partner's perspective on the problem, but successful treatment of secondary orgasmic difficulty is often the result of improved communication between the partners. In these cases, a joint interview can be suggested. The inquiry should elicit the opinions of both partners about the woman's orgasmic difficulties as well as their feelings about the problem. (Is he or she ashamed, disinterested, ignorant, angry, or oblivious? Does either think orgasmic ease relates to morality? Do they view the orgasmic difficulty as her, his, or their problem?)

The physician treating the patient with orgasmic dysfunction also needs to evaluate the psychological health of the individual and the couple. Does the woman have an untreated depression that has lowered her sexual arousal? Is she so troubled by the recollection of a traumatic sexual experience that she is unable to experience current sexual activity as pleasurable? Is her worry about a job, an ill family member, or a financial problem distracting her? Is one partner worried that the other is having an affair or will have one if the problem is not resolved?

After the assessment, a decision is made regarding the appropriate treatment. Depending on the chronicity of the problem and the distress it has caused, the obstetrician or gynecologist may elect to provide treatment in the office. In more complicated cases or when the physician is uncertain about the results of the assessment, he or she may refer the patient to another medical specialist (for concomitant physical problems or consultation about medications chosen), to a psychotherapist (for psychiatric problems or traumatic history), to a sex therapist (for long-standing sexual difficulties, sexual pain, or treatment across the sexual response cycle of desire, arousal, and orgasm), or to a couples therapist (for marital or communication problems).

Although orgasmic disorders can be treated in a variety of ways, certain guidelines will assist the physician in making the referral and in explaining his or her reasoning to the patient. When sex therapy is indicated for single women, individual and group treatment are both effective. Group therapy offers a powerful source of support and encouragement and reduces the sense of isolation these women often feel.38, 39 If the patient is part of a stable relationship or marriage, the outcome is generally better when the couple is treated together. If the assessment reveals serious problems with the psychological stability of either partner, or if it reveals an abusive relationship, individual or marital therapy should be undertaken before couples sex therapy.

Treatment for Primary Orgasmic Dysfunction

Treatment can be quite straightforward for primary anorgasmia. Directed masturbation (DM) is the treatment of choice.40 Bibliotherapy is often sufficient to help the preorgasmic woman achieve her first climax.28 Heiman and LoPiccolo's41 book Becoming Orgasmic and Barbach's38 For Yourself offer women a private and comprehensive introduction to masturbation and the use of vibrators. If the physician has established a safe, trusting environment within which to discuss the problem, instruction in DM can be provided within the medical setting.  Heiman 14 outlines four stages of DM:  (1) Reviewing the background, context, and meaning of previous sexual experiences; (2) Exploring one's emotional and physical relationship with the body through private, non-sensual exploration of the genitals; (3) Discovering one's individual arousal patterns through thoughts, touch, and imagery; and (4) Learning to include a partner in the changed sexual approach.  The physician's familiarity with the DM approach will enable her or him to tailor the exercises to the individual patient's needs. 

The goal of DM is to gradually introduce the woman to the pleasurable exploration of her own body. The physician can initiate this process by providing an educational pelvic examination to help the patient identify her genitalia and visualize her anatomy. He or she can then provide the patient with a summary of the process of DM, to which she will be introduced in her reading. She will be instructed to devote two or three short sessions (in a private setting away from distractions) to practicing different types of touch (light versus hard, fast versus slow, and so forth) on the nongenital parts of her body. Once the patient has established a pattern of relaxed exploration, she begins sessions of genital exploration in which the focus is on attending to the sensations themselves rather than on building arousal; maintaining this exploratory stance helps the patient avoid judging herself or becoming discouraged when she does not feel immediate arousal. Finally, the use of a vibrator is suggested. By the time the DM program is complete, 95% of the patients will have had an orgasm. If prolonged vibrator use does not produce orgasm in a motivated preorgasmic woman, more extensive medical assessment is warranted.29 A follow-up appointment should be scheduled within 2–3 months to determine progress and to keep the avenues of physician-patient communication open.

May was a single, 36-year-old academic whose decade-long relationship with her boyfriend ended the year before when he jilted her for a woman who, he said, was more sexually responsive. May had never liked sex and never had an orgasm. She entered individual sex therapy and a concurrent group to address these issues. May said that she became sexually aroused when she fantasized alone but that she lost this ability with a partner. During these “aroused” times she says she felt “as if I wasn't even in my body".

Treatment focused first on helping May distinguish between the sense of failure she had about her sexual experiences with her boyfriend and the pleasure she was able to feel in a peak experience that occurred in a “lover's hideaway” motel, where she was free of the inhibitions she felt at home. May reported a dream in which she was seducing a married man away from his unattractive, passive wife, with whom she felt great empathy. May felt profoundly aroused and driven to seduce this man, even though she knew this was wrong. The group's discussion of the dream led to May's disclosure that her own father had been an openly unfaithful husband who had failed to communicate to May any sense that she was an attractive or interesting young woman. Her mother had been outraged but passively tolerant of her husband's abandonment. As other group members revealed similar histories, May connected her own feeling of danger at being fully sexual with her mother's misery over the affairs.

As the treatment moved into directed masturbation, May revealed her naiveté about her own body and sexuality, which she attempted to cover up by pretending to be more sophisticated than she actually was. May had deliberately lost her virginity in her late twenties because she was tired of pretending to be sexually active. She was not alone in the group in feeling more firmly grounded in a childhood body image and identity than in adult womanhood; this led to her reluctance to do homework assignments that involved looking at her naked body and sleeping in the nude. She admitted not ever having masturbated and related it to her boyfriend's persistent and coercive sexual pressure. May expressed concern that her progress would be slowed because of her lack of a partner; the group's expression of envy that she could focus on her own pleasure instead of a partner's needs was a pleasant surprise.

After several weeks of hesitation and self-doubt, May achieved her first orgasm during masturbation with a vibrator. The experience relieved her sense of being physically defective, a fear she had never shared. It also led to a reappraisal of her boyfriend's rejection of her as May distinguished between the glorified version of orgasmic sex he had given her and the actual pleasure she experienced. May described a richer acceptance of herself as a woman who could make a choice to achieve sexual pleasure and left the group announcing her intention to do so.

Treatment for Secondary or Situational Orgasmic Difficulty

The treatment strategy is not as straightforward for cases in which the patient was able to have orgasms with one partner but does not have this ability with the current partner (secondary), or for cases in which the goal is coital orgasm (situational). The treatment approach should be based on the relative roles of physical, psychological, and interpersonal factors. For example, when a couple's problem is the belief that coital orgasms are the only real orgasms, the physician can provide education on this topic and can confront and challenge this erroneous belief, encouraging the couple to expand their sexual script to include options that place less pressure on both partners to achieve.

When more guidance is needed, treatment for situational anorgasmia should include training in DM so that the woman learns how to bring herself to climax and what positions, touches, and movements are most helpful. She and her partner can next be taught the bridge maneuver, in which the woman is brought to the point of orgasm through masturbation or through manual and oral stimulation by her lover. The couple then shifts to coitus with concurrent clitoral stimulation until an orgasm is reached. It is helpful to have the couple expand their sexual script to include more time with highly arousing techniques. If a woman has a preference for a specific masturbatory technique, this should be incorporated into the couples' sexual script.

Both secondary and situational orgasmic difficulties can be treated with sensate focus exercises.19, 34 Referring a patient to one of the many popular books describing sensate focus can be helpful, as is describing the process to the patient and allowing her to react to the recommendations.35

Sensate focus shares with DM the goal of teaching the couple to stop 'spectatoring' and begin focusing on the actual sensation of sexual exchange. The exercises involve each partner taking turns being caressed by the other. The couple negotiates who initiates the first session, and then they take turns being responsible for initiation. The initial sessions are limited to nongenital touching. The patient is told to focus on his or her own sensations in a nonevaluative way. The couple is instructed not to escalate sensate focus into genital sex.

The sessions then progress to genital touching (with intercourse still prohibited). The technique of 'hand-riding' is introduced, in which the woman places her hand on top of the man's as he touches her. This conveys nonverbally how, where, and for how long she wants to be touched. Either partner is permitted to reach orgasm during this phase, although they are cautioned not to make orgasm the goal.

The couple then progresses to mutual touching sessions with variations such as oral-genital contact and the use of oils or lotions to add sensual variety. Many couples spontaneously progress to intercourse at this point. If not, they are taught to practice sensual intercourse. Sensual intercourse will probably differ considerably from the coital techniques the couple previously practiced because of the emphasis placed on nongenital touching, hand-riding, and the recommended female-astride position. The couple is encouraged to practice shallow penetration without vigorous thrusting, combined with direct clitoral stimulation, fantasy, and vibrator play.

Eichel and colleagues42 introduced an adjustment in coital technique designed to improve the ability of male-superior coitus to produce female orgasm. Called the Coital Alignment Technique (CAT), the position combines the intimacy of face-to-face contact with a repositioning of the male (the so-called 'riding high' variation) so that there is greater contact of the penile shaft with the clitoris and a mutual rocking (rather than thrusting) motion. Fig. 1 and Fig. 2 illustrate the CAT technique.

Fig. 1. The position of coital alignment. (Reprinted with permission from Eichel E, Eichel J, Kule S: The technique of coital alignment and its relation to female orgasmic response and simultaneous orgasm. J Sex Marital Ther 14:131, 1988)

Fig. 2. Position of male and female genitalia in coital alignment technique. (Reprinted with permission from Eichel E, Eichel J, Kule S: The technique of coital alignment and its relation to female orgasmic response and simultaneous orgasm. J Sex Marital Ther 14:133, 1988)

The CAT's early promise has not been replicated in terms of its capacity to increase female orgasms, but some couples report liking its more intimate coital style.43 Eichel and Nobile published a popular book on the technique that can be recommended to patients.44

An interesting example of a comprehensive treatment for situational anorgasmia is called orgasmic consistency training.37 The program, originally designed for women with low sexual desire, has also been successful for women who have infrequent orgasms. It includes DM and couples sensate focus, as well as CAT and techniques to increase male self-control and timing of orgasm. This latter element addresses Hurlbert's belief that women whose male partners delay orgasm until after she climaxes will be more interested in having sex. The strategy of 'ladies come first' theoretically increases communication, affection, and sexual awareness.

Danielle, 39, was a married executive with no children who was accustomed to high levels of achievement in her business and social life. She had set herself the goal of reaching coital orgasm but had been unsuccessful to date. She and her husband entered sex therapy, although her husband said he was satisfied with the status quo. Danielle's continued striving for coital orgasm led to a reduction in sexual desire. When she entered group therapy she announced, “I would be happy if I never had to have sex again”.

Danielle approached the group treatment with the same high motivation and enthusiasm she demonstrated throughout her life. She assumed the role of assistant leader and took lengthy notes during each session. After several weeks of intellectualized participation, Danielle announced that she had taken a long, sensuous bath the previous week and had rubbed lotion all over herself. The guilt she experienced as she did this led her to connect her sense of shame about her sexual feelings and her need to control sexual encounters to her experience of sexual abuse in childhood (when she told her parents about a neighbor's molestation of her, they angrily blamed her). The group's empathic support seemed to break down Danielle's defensive barriers, and she began to discuss her increasing awareness and acceptance of her body in subsequent sessions. Her husband's interest increased when Danielle informed him that she wanted to focus on her own sensual awakening rather than on intercourse. This led to the exploration of the subtle power dynamic of being the sexual distancer rather than the pursuer. In a subsequent session, Danielle reported that she had had sex with her husband and had enjoyed it tremendously. By the end of the group sessions, Danielle had achieved her coital orgasm. As pleased as she was with this accomplishment, Danielle and her husband both reported a broader sexual repertoire that had become possible only after Danielle's orgasm no longer was the goal of each sexual encounter.

Although the straightforward nature of these techniques may make this approach to treatment seem simple, Kelly and colleagues45 point out that couples need to find ways of communicating the woman's most intimate sexual preferences if they are to be successful in eventually achieving orgasm.37 A woman's preference for any particular sexual activity is not necessarily based on empirical evidence that the activity is likely to produce orgasm. For instance, prolonged cunnilingus when the woman finds such activity demeaning is bound to frustrate the couple and result in treatment failure. The physician needs to help the couple answer such questions as: "Is the woman interested in having an orgasm? Does she engage in the kind of sex play she finds exciting? If she enjoys the sex play, does it continue long enough to maximize arousal? Does intense arousal or the sensation of an impending orgasm result in fear of losing control?"

When the orgasmic problem does not respond to these techniques, the probability increases that it is connected to other problems in the individual or in the relationship. In these cases, referral to a couples or sex therapist is indicated. These treatments assume a dual focus, in which the therapist balances symptom reduction techniques with treatment of the underlying problems in communication, conflict resolution, power, trust, and control.

Gina, a married, 40-year-old professional, had secondary orgasmic dysfunction. Able to feel aroused and orgasmic in her first marriage, her second husband's sexual approaches left her feeling “utterly revolted” and “incapable of feeling like a woman.” Couples and group treatment were successful only to the degree that they exposed the essential difficulty. Gina portrayed her husband as verbally abusive and sexually manipulative. He enjoyed a range of sexual activities that she regarded as kinky, including light bondage and dominance as well as cunnilingus. Gina, meanwhile, described her sexual peak as moments of emotional merger and regarded cunnilingus as demeaning.

As Gina became increasingly comfortable with her own sexual feelings, she gradually became convinced that her husband's continued insistence that she participate in sexual activities she did not enjoy was evidence of his need for power and control. She became a skilled and secretive masturbator who concealed her reawakened sexuality from her partner. The group's insistence that she confront her husband with her feelings led to Gina's realization that couples therapy was essential. She recognized that the battle for control over virtually every aspect of their marriage was contaminating her sexual relationship with her husband.

OUTCOME

Women with primary orgasmic dysfunction who are treated with DM have an 80–90% success rate.39 Therapy for secondary anorgasmia has been only moderately successful, with success rates ranging from 10–75% after sex education, communication training, marital therapy, anxiety reduction, and sensate focus.4, 45, 46 One study demonstrated high rates of orgasm among couples treated with a combination of sexual skills training and communication training in groups when compared with wait-listed controls and structured-lecture controls, but the research design lacked sufficient power to demonstrate a significant effect.46 The clinical utility of the existing research is limited by its failure to identify the specific contributions of each component of treatment to success or failure.

CONCLUSIONS

The outcome of sex therapy for female orgasmic problems is quite positive. Women benefit from permission and encouragement to masturbate, and from suggestions on how to masturbate; they also benefit from validation of the fact that they are entitled to sexual pleasure. Couples' therapy for situational and/or secondary anorgasmia is generally helpful in improving the relationship and enhancing communication, although it does not always result in coital orgasm.47

Some basic issues regarding orgasmic dysfunction have yet to be resolved. Transfer of orgasms to coitus is often low, and it must be asked whether coital orgasms are realistic or necessary for all women. Without carefully conducted studies using validated outcome measures and attention-placebo groups, the key components in the treatment of anorgasmia cannot always be determined.

The range and variety of women presenting with orgasmic complaints are so great that it is not always clear from the outset what treatment intervention will be most useful. However, couples' therapy is often helpful either as an adjunct or as a primary means of treating situational or secondary anorgasmia. For gynecologists and obstetricians who want to provide counseling on sexual issues, this differential diagnosis serves as the basis for the decision to provide brief educational guidance or to refer the patient and her partner to a sex therapist.

Although orgasm is not the sine qua non of sexual exchange for most women, the ability to have one is often reassuring and self-validating. Fortunately, there is a plethora of treatment options available for female orgasmic problems. The treating physician who develops the assurance that is necessary to explore sexual difficulties in the medical setting, who is skilled at history-taking and assessment, who has knowledge of treatment options, and who has a referral network may be fully certain that he or she can help patients with these difficulties.

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