Female Orgasmic Disorder

Persistent or recurrent delay or absence of orgasm after a normal excitement phase of sexual activity that is assessed as adequate in focus, intensity, and duration.

Most patients have a disturbance of both sexual excitement and orgasm; in such cases, the diagnosis is not orgasmic disorder. Orgasmic disorder is diagnosed only when there is no or slight difficulty with arousal (excitement).

Orgasmic disorder may be lifelong or acquired, general or situational. About 10% of women never attain orgasm regardless of stimulation or situation. Most women can attain orgasm with clitoral stimulation, but only about 50% of women regularly attain orgasm during coitus. When a woman responds to noncoital clitoral stimulation but cannot attain coital orgasm, a thorough sexual examination, sometimes with a trial of psychotherapy (individual or couple), is required to judge whether the inability to attain coital orgasm is a normal variation of response or is due to individual or interpersonal psychopathology.

Once a woman learns how to reach orgasm, she generally does not lose that capacity unless poor sexual communication, conflict in a relationship, a traumatic experience, a mood disorder, or a physical disorder intervenes.

Etiology

Etiology is similar to that of sexual arousal disorder (see above). In addition, lovemaking that consistently ends before the aroused woman reaches climax (eg, due to inadequate foreplay, ignorance of clitoral/vaginal anatomy and function, or premature ejaculation) and produces frustration may result in resentment and dysfunction or even sexual aversion. Some women who develop adequate vasocongestion may fear "letting go," especially during intercourse. This fear may be due to guilt after a pleasurable experience, fear of abandoning oneself to pleasure that depends on the partner, or fear of losing control.

Drugs, particularly selective serotonin reuptake inhibitors, may inhibit orgasm. Depression is a leading cause of decreased sexual arousal and orgasm, so the patient's mood must be evaluated.

Treatment

Physical disorders should be treated. When psychologic factors predominate, counseling to remove or reduce the causes helps; usually both partners should attend.

The Masters and Johnson 3-stage sensate focus exercises, in which the couple moves stepwise from nongenital pleasuring to genital pleasuring to nondemanding coitus, generally benefit women regardless of the level of sexual inhibition. Individual psychotherapy or group therapy is sometimes useful.

A woman should understand the function of her sexual organs and her responses, including the best methods of stimulating the clitoris and enhancing vaginal sensations. Kegel's exercises strengthen voluntary control of the pubococcygeus muscle. The muscle is contracted 10 to 15 times tid. In 2 to 3 mo, perivaginal muscle tone improves, as does the woman's sense of control and the quality of orgasm.

Women with lifelong orgasmic disorder should be referred to a psychiatrist. With any patient, the nonspecialist should limit the number of counseling sessions to about six, referring complex cases to a sex therapist or a psychiatrist.

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