Psychosocial and context-dependent factors in VS .NET

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A number of psychosocial factors have been discussed in relation to a woman s ability to experience orgasm These include interpersonal and marital distress, psychologic distress, psychiatric disorders, the use of antidepressants, especially selective serotonin
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Orgasmic Disorders in Women
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Fig 243 Functional magnetic resonance imaging (fMRI) of the same brain sections as in Fig 242, during orgasm induced by cervical selfstimulation
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reuptake inhibitors (SSRIs), age, education, social class, and religion [6,11] However, there are no consistent empirical ndings that psychosocial factors alone differentiate orgasmic from anorgasmic women [6] What we do know about some psychosocial factors is that Laumann et al found that 87% of women with an advanced degree reported always or usually experiencing orgasm during masturbation, compared with 42% of women with a high-school education [14] There is no signi cant relation between education level and orgasmic ability with a partner [26] Laumann and colleagues also found a negative relation between experiencing orgasm and high religiosity That is, 79% of women with no religious af liation reporting experiencing orgasm during masturbation, compared with 53 67% of those having an af liation with religious groups [14] In a review article, Mah and Binik reported that orgasm consistency, quality, and satisfaction in women have been related to relationship factors, such as marital satisfaction, marital adjustment, happiness, and stability [27] Orgasm and orgasm through vaginal intercourse may be learned rather than a natural biologic act, and may have cross-cultural in uences There are cultures in which sexual pleasure has a high value
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and women are taught to be orgasmic and often multi-orgasmic [28,29] In some cultures, women are taught to experience female ejaculation, such as the Batoro of Uganda [30] Other cultures assume that women have no pleasure from vaginal intercourse and that orgasm for women does not exist, such as the Arapesh In this culture orgasm in women does not occur [31] Therefore, many factors have to be considered when a woman reports orgasmic dif culties that cause personal distress Usually orgasmic problems involve many factors and a multidisciplinary approach is usually most effective in treatment It is important for the clinician to remember that each woman is unique and that women cannot be compartmentalized into one linear way of responding or be labeled with one sexual response pattern Women need to be aware of what brings them pleasure and what helps them to experience orgasm and to feel good about the various ways that they can experience sensual and sexual pleasure and orgasm
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Clinical Approaches
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In taking a sexual history in a woman who is experiencing personal distress due to either a lack of orgasm, markedly diminished intensity of orgasmic
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24 What, in your opinion, is causing your orgasmic dif culty Check the potential role of worsening incontinence, depression, pain, too rapid or absence of sex-play, loss of sexual drive and arousal, alcohol abuse, and relationship problems Do you feel a selective loss in your clitoral sensitivity and pleasure ability and/or a reduction in your coital pleasure If the complaint is focused on the clitoris, and vulvar involution or dystrophia is present, then topical androgen treatment may be useful If it is coital, two further questions should be asked Do you have a decreased coital sensation This latter may suggest a hypotonia of the perivaginal muscles, which may be related to loss of estrogen due to menopause and/or loss of androgens associated with aging Vaginal pleasure and sensitivity are physically dependent also on the tonus of perivaginal muscles Biofeedback retraining of the pelvic oor muscles or teaching Kegel exercises may help Many women experience female ejaculation, an expulsion of about 3 5 ml of uid from the urethra, which is chemically different from urine and is perfectly normal It comes from the female prostate gland (G spot), formerly called the paraurethral glands [32] A differential diagnosis between urinary incontinence and female ejaculation must be made (see Table 241) Do you feel pain during intercourse Coital pain of whatever origin must be investigated Have you changed positions of intercourse to a position that does not stimulate the anterior vaginal wall (Grafenberg or G spot)
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sensations, or marked delay of orgasm from any kind of stimulation, asking the following questions may be helpful Do you feel pleasure and satisfaction without orgasm Is not experiencing orgasm a concern for you If it is a concern, the following questions are recommended Is your orgasmic dif culty generalized (in every situation and independent of the partner) or is it situational If generalized, it may suggest a biologic component, particularly if sex drive and arousal is maintained There may also be nerve damage from surgery or an injury that must be assessed If situational, there may be relationship issues to be addressed Was the onset gradual or rapid Gradual orgasmic dif culties are usually age-dependent and may be exacerbated by menopause They are characterized by an increased length of time between sex-play and orgasm, more intense stimulation required, decreased quality and intensity of the orgasmic pleasure, and possibly diminished number of orgasmic contractions Also co-morbidity must be considered in both gradual and rapid onset If rapid, the use of medications such as amphetamines and related anorexic drugs, antipsychotics, benzodiazepines, methyldopa, narcotics, tricyclic antidepressants, and SSRIs should be investigated Other medications should also be investigated because of their effect on sexual response in women
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Table 241 Differential diagnosis Incontinence at orgasm Weak pelvic oor muscles Contains: urea, creatinine Volume: >15 ml Urine characteristics Associated with daily or night symptoms of incontinence Intensity of orgasm may be inhibited for fear of leaking Urodynamic examinations indicate detrusor instability Female ejaculation Strong pelvic oor muscles Contains: glucose, fructose, prostatic speci c androgen, prostatic acid phosphatase Volume: 3 5 ml Clear, pale white liquid with no urine No symptoms of urgency and/or stress incontinence Is associated with intense pleasure at orgasm Urodynamic examination shows a continent bladder
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Modi ed from Graziottin (1996) [40], Belzer et al (1984) [41], Addiego et al (1981) [42], Ladas et al (2005) [30], and Zaviacic (1999) [32]
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Orgasmic Disorders in Women Based on the information emerging from the clinical history, the healthcare provider should look for: Hormonal balance Signs and symptoms of vulvar dystrophia and, speci cally, of clitoral and vaginal involution and traumatic consequences of ritual genital mutilation Signs and symptoms of incontinence, or of either hypotonic or hypertonic pelvic oor, or female ejaculation (education and permission-giving is needed here) Iatrogenic in uences, when potentially orgasmicinhibiting drugs are prescribed
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