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Psychosexual issues are more frequently a cause in life-long orgasmic dif culties, while biologic etiology should be considered with gradual or rapid onset of anorgasmia If the history and physical assessment has ruled out any hormonal, neurophysiologic, or pharmacologic-related causes, the treatment of orgasmic disorders should then focus on an assessment of knowledge Teaching women and their partners about appropriate arousal techniques may be all that is needed In addition, sociocultural factors need to be considered; that is, there may be inhibitions about receiving pleasurable sexual stimuli (usually in generalized primary anorgasmia, but not always) Education can be given about how women become aroused, the amount of time needed for arousal, and the types of stimulation commonly needed for orgasm to be experienced Information that most women are not able to experience orgasm from vaginal intercourse, and that extended clitoral or vaginal (G spot) stimulation may be needed, is also important information to disseminate [33,34] Referral of the woman and/or couple to a certi ed sex therapist is helpful here (see wwwaasectorg for a certi ed sex therapist in your geographic area) The treatment of anorgasmia has been based on psychoanalytic, cognitive-behavioral, systems theory, and pharmacologic approaches [35] According to Meston and colleagues, cognitive behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually-relevant thoughts,
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decreasing anxiety, and increasing orgasmic ability and satisfaction [6, p 67] In the 1970s the small-group format was suggested and a number of books and videos were developed to give women permission to experience orgasm and to share ways in small pre-orgasmic groups that they found helpful to experience sensual and sexual pleasure [36] Behavioral exercises include directed masturbation, with and without vibrators, which has been shown to be effective in groups and individually If a woman is able to experience orgasm through masturbation, but not with a partner (if this is her desire), then couple therapy may be recommended, once issues of anxiety, communication, trust, and past history have been addressed Another behavioral approach often suggested is Kegel exercises Graber and Kline-Graber found a positive correlation between the strength of a woman s pelvic muscles and her orgasmic response The women with very weak muscles were anorgasmic in their retrospective study [37] Perry and Whipple found that women who experienced female ejaculation have signi cantly stronger pelvic muscles than women who did not experience this phenomenon [38,39] Sensate focus exercises were developed by Masters and Johnson to reduce anxiety by using a series of body touching exercises, moving from sensual to increasingly sexual [4] These exercises are used by many healthcare providers today, although Meston and colleagues note that there has been no reported substantial improvement in orgasmic ability with these exercises [6] There are no pharmacologic agents that have been demonstrated to be effective for treating women with orgasmic disorders However, a good history will determine if other medical conditions or medications taken may inhibit orgasmic response A change of medication or taking bupropion with an SSRI, or in place of the SSRI, may help More doubleblind, placebo-controlled studies are needed here There is an excellent review of psychosocial and pharmacologic treatments for orgasmic disorders in West et al [13] It may be that permission and education are the most important treatment modalities And since orgasm is not always essential for sexual satisfaction,
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the recommendations on sexual dysfunctions in women J Sex Med 2004;1:24 39 Jones KP, Kingsberg S, Whipple B Women s Sexual Health in Midlife and Beyond: Clinical Proceedings Washington, DC: Association of Reproductive Health Professionals, 2005 Rosen RC Prevalence and risk factors of sexual dysfunction in men and women Curr Psychiatry Rep 2000;2:189 195 West SL, Vinikoor LC, Zolnoun D A systematic review of the literature on female sexual dysfunction prevalence and predictors Ann Rev Sex Res 2004;15:40 172 Laumann EO, Gagnon JH, Michael RT, Michaels S The social organization of sexuality: sexual practices in the United States Chicago, IL: University of Chicago Press, 1994 Bachmann GA, Leiblum SR The impact of hormones on menopausal sexuality: a literature review Menopause 2004;11:120 130 Avis NE, Stellato R, Crawford S, et al Is there an association between menopause status and sexual functioning Menopause 2000;7:297 309 Crouch NS, Minto CL, Laio L-M, Woodhouse CRJ, Creighton SM Genital sensation after feminizing genitoplasty for congenital adrenal hyperplasia: a pilot study BJU Int 2004;93:135 138 Oberg K, Fugl-Meyer KS On Swedish women s distressing sexual dysfunctions: some concomitant conditions and life satisfaction J Sex Med 2005;2: 169 Masters WH, Johnson VE, Kolodny RC Human Sexuality Boston, MA: Little Brown & Co, 1982 Sipski ML, Alexander CJ, Rosen RC Sexual arousal and orgasm in women: effects of spinal cord injury Ann Neurol 2001;49:35 44 Komisaruk BR, Whipple B, Crawford A, Grimes S, Liu W-C, Kalin A, Mosier K Brain activation during vaginocervical self-stimulation and orgasm in women with complete spinal cord injury: fMRI evidence of mediation by the vagus nerves Brain Res 2004;1024: 77 88 Komisaruk BR, Whipple B Brain activity imaging during sexual response in women with spinal cord injury In Hyde J ed Biological Substrates of Human Sexuality Washington, DC: American Psychological Association, 2005, pp 109 146 Whipple B, Komisaruk BR Brain (PET) responses to vaginal-cervical self-stimulation in women with complete spinal cord injury: preliminary ndings J Sex Marital Ther 2002;28:79 86
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and the inability to orgasm during intercourse is not abnormal, when would an orgasm dif culty warrant therapy If it is a problem for the woman and causes her personal distress It is important for women to know that they are in charge of their own orgasms, that no one can give them an orgasm, and they are responsible for their pleasure and satisfaction It is also important to remember that each woman is unique, that each woman responds differently, and that we cannot put women into one linear way of responding sensually and sexually Women need to be encouraged to feel good about what brings them pleasure, to be aware of this, to acknowledge it, and then to communicate it to a partner if they choose
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