Female Orgasmic Disorder
Female Orgasmic Disorder (FOD) is defined in the DSM-IV-TR as a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. The inability to obtain orgasm does not always lead to sexual distress or dissatisfaction in women, and if the disorder does not cause the woman marked distress or interpersonal difficulty, a diagnosis of FOD should not be made. The diagnosis of FOD 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. Indeed, Laumann and associates3 found only the youngest group of women (18-24 years) showed rates of orgasm lower than the older groups for both orgasm with a partner and orgasm during masturbation. This is likely to be attributable to age differences in sexual experience.
Women exhibit wide variability in the type or intensity of stimulation required to attain orgasm. Research indicates orgasms in women can be induced via erotic stimulation of a number of genital sites including the clitoris and vagina (the most usual sites), the periurethral glans, breast/nipple or mons. Non-genital forms of stimulation reported to induce orgasm include mental–imagery or fantasy and hypnosis. There have also been a few isolated cases of “spontaneous orgasm” described in the psychiatric literature where no obvious sexual stimulus can be ascertained.
Most studies examining orgasmic dysfunction in women refer to orgasm problems as either “primary orgasmic dysfunction” or “secondary orgasmic dysfunction.” In general, the term primary orgasmic dysfunction is used to describe women who report never having experienced orgasm under any circumstances, including masturbation. Secondary orgasmic dysfunction relates to women who meet criteria for situational and/or acquired lack of orgasm. By definition, this encompasses a heterogeneous group of women with orgasm difficulties. For example, it could include women who were once orgasmic but are now so only infrequently, women who are able to obtain orgasm only in certain contexts, with certain types of sexual activity, or with certain partners. The DSM-IV-TR does not directly address the issue of women who can obtain orgasm during intercourse with manual stimulation but not intercourse alone. However, the generally accepted clinical consensus is that she would not meet criteria for clinical diagnosis if she is able to obtain orgasm during masturbation unless she is distressed by the frequency of her sexual response.
The Prevalence of Orgasmic Problems in Women
Based on findings from the National Health and Social Life Survey (NHSLS), orgasmic problems are the second most frequently reported sexual problem in US women. Results from this random sample of 1,749 US women (ages 18-59) indicated that 24% reported a lack of orgasm in the past year for at least several months or more. This sample also suggests that nonmarried women are at a greater risk for developing orgasm problems, as well as women who have not graduated from college. This percentage is comparable to clinic-based data.
Female Orgasmic Disorder has been treated from psychoanalytic, cognitive-behavioral, pharmacological, and systems theory perspectives. Regardless of the treatment approach used, one needs to keep in mind that relationship factors such as marital satisfaction, marital adjustment, happiness, and stability have been linked to orgasm consistency, quality, and satisfaction in women. A relation between childhood sexual abuse and various sexual difficulties has also been reported.
Cognitive-behavioral therapy for FOD focuses on promoting changes in attitudes and sexually-relevant thoughts, decreasing anxiety, increasing the link between positive emotions and sexual behavior, and increasing orgasmic ability and satisfaction. The behavioral exercises used to induce these changes traditionally include directed masturbation, sensate focus, and systematic desensitization. Sex education, communication skills training, and Kegel exercises are also often included in cognitive-behavioral treatment programs for anorgasmia.
Directed Masturbation (DM)
Directed masturbation (DM) is most frequently prescribed for women with primary anorgasmia. The successive stages of DM train a woman to locate and manually stimulate genital areas that bring her sexual pleasure. The process begins with a visual exploration of the body, using a mirror and educational material depicting female genital anatomy. Following visual and manual identification of the sensitive genital areas that elicit pleasure, a woman is instructed to apply targeted manual stimulation to these regions. Training on self-stimulation is directed toward the woman achieving orgasm alone. Once she has accomplished this, her partner is incorporated into the DM sessions. Women experiencing FOD have successfully been treated using DM in myriad therapy settings, such as group, individual, couples therapy, and bibliotherapy. A number of outcome studies and case series report DM is highly successful for treating primary anorgasmia, with success rates up to 92% of women studied. For a step by step guide to DM, see Becoming Orgasmic by Julia Heiman.
Anxiety Reduction Techniques
Anxiety could potentially impair orgasmic function in women by disrupting the processing of erotic cues and causing the woman to focus instead on performance related concerns, embarrassment, and/or guilt. This, in turn, could lead the woman to engage in self-monitoring during sexual activity, an experience Masters and Johnson referred to as “spectatoring. Anxiety reduction techniques could be beneficial for helping women attain orgasm by helping them to focus on pleasurable sexual thoughts and sensations which enhance arousal.
Systematic desensitization and sensate focus are the two most commonly used anxiety reduction techniques for treating FOD. Deep relaxation exercises in systematic desensitization enable the woman to replace fear responses with relaxation responses. A succession of anxiety-provoking stimuli is developed by the woman and the therapist to represent increasingly threatening sexual situations. The woman’s task is to alternately experience fearful and relaxed responses, resulting in a net decrease of anxiety. After the woman can successfully imagine her hierarchy of anxiety-provoking situations without anxiety, she then engages in the hierarchy of actual activities. Sensate focus is primarily a couple’s skills learning approach designed to increase communication and awareness of sexually sensitive areas between partners. Couples practicing sensate focus are instructed to first explore their partner’s nonsexual body regions without the potential for sexual activity. The couple increasingly practices sexual touching without the pressure of sexual intercourse. The sexual touching allows for a woman to eventually guide genital manual and penile stimulation to enhance her arousal.
The success of using anxiety reduction techniques for treating FOD is difficult to assess because most studies have used some combination of anxiety reduction, sexual techniques training (e.g., DM), sex education, communication training, bibliotherapy, Kegel exercises, and/or pharmacological agents, and have not systematically evaluated the independent contributions to treatment outcome. With this limitation in mind, across controlled studies, women have reported decreases in anxiety and increases in the frequency of sexual intercourse and sexual satisfaction with systematic desensitization, but substantial improvements in orgasmic ability have not been noted.
Other Behavioral Techniques
Sex education has been a hallmark of sex therapy since the days of Masters and Johnson. Education about female genital anatomy may help acquaint a woman with her body’s pleasure-producing regions and consequently help alleviate orgasm difficulties. Kegel proposed that conducting exercises that strengthen the pubococcygeous muscle could facilitate orgasm by increasing vascularity to the genitals. Treatment comparison studies have generally found no differences in orgasmic ability between women whose therapy included using Kegel exercises versus those whose therapy did not. To the extent that Kegel exercise may enhance arousal and/or help the woman become more aware and comfortable with her genitals, these exercises may enhance orgasm ability
To date, there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women with diagnosed FOD. Placebo-controlled research is needed to examine the effectiveness of agents with demonstrated success in case studies or among sexually healthy women (i.e., buproprion, granisetron, and sildenafil) on orgasmic function in women with FOD.