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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.

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.

The disturbance causes marked distress or interpersonal difficulty. The orgasmic dysfunction is not better ed for by another Axis I disorder except another Sexual Dysfunction and is not due exclusively to the direct physiological effects of a substance e. 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.

First, DSM-IV acknowledges the wide variability in orgasmic responsiveness among women, whereas the 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.

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 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 National Social and Health Life Survey 2 , 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 year.

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. The study by Michael and associates 3 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. One unanswered question about orgasmic disturbance in women is whether the varieties of presentation suggest one dysfunction or many.

Derogatis and co-workers 13 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, " 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. 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. 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.

They concluded that defining orgasm as a reflex or as an involuntary response to a stimulus was too narrow. 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. 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.

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 associates 5 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-workers 19 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. 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. 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.

Fisher's 4 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 ificant 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.

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. This demonstrates that emotions have more of an effect on orgasm during intercourse than they do on masturbation. 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 s, 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 s 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. 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 , limited research and clinical data provide some direction.

Hurlbert and Apt 31 found no ificant 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 Lavender 32 compared sexual satisfaction among heterosexual, bisexual, and homosexual women and found no ificant difference in the of orgasms experienced. Lesbians tend to describe the difference between sex with men and sex with women in completely qualitative terms. 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. 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. 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. Masters and Johnson's 34 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. 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 ificance on the symptom of orgasmic difficulty itself than do cognitive-behavioral or psychodynamic clinicians.

Systems therapists see anorgasmia as simply the most obvious 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.

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.

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