Cindy M. Meston & Amelia M. Stanton
Definition, Diagnosis, and Prevalence
The DSM-5 defines female orgasmic disorder (FOD) as reduced intensity, delay, infrequency, and/or absence of orgasm. These symptoms must persist for at least six months, and they may not be related to other physical or relational problems. The presence of distress related to these symptoms is necessary for a diagnosis of FOD. The DSM-5 classification of FOD distinguishes between lifelong and acquired subtypes as well as between generalized and situational subtypes. Although not stated in the DSM-5, the clinical consensus is that a woman who can obtain orgasm during intercourse with manual stimulation but not intercourse alone would not meet criteria for clinical diagnosis unless she is distressed by the low frequency of her sexual response
Operationalizing FOD is complicated by the fact that the field still lacks a clear consensus on the definition of the female orgasm. Indeed, a one study cited more than 25 distinct definitions proposed by different authors (Mah & Binik, 2001). The following definition of female orgasm was derived by the committee on female orgasm, presented at the International Consultation on Urological Diseases in Official Relationship with the World Health Organization (WHO), Paris, 2003:
An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually accompanied by involuntary, rhythmic contractions of the pelvic, striated circumvaginal musculature often with concomitant uterine and anal contractions and myotonia that resolves the sexually-induced vasocongestion (sometimes only partially), usually with an induction of well-being and contentment (C. M. Meston, Hull, Levin, & Sipski, 2004).
Orgasms are caused by erotic stimulation of both genital and nongenital zones of women’s bodies. These areas include the clitoris, vagina, other areas of the vulva, and the breasts and nipples. Orgasm may also be caused by fantasy, mental imagery, and hypnosis. Orgasms can occur during sleep, precluding the necessity of consciousness for an orgasm to occur. Orgasms are not generally reported to occur spontaneously without at least some amount of physical or psychological sexual stimulation; however, some psychotropic drugs have been reported to induce spontaneous orgasms in women.
Women who are having difficulties with orgasm do not typically present with the same degree of distress that has been reported in men with ED. This may be because women, unlike men, are able to “fake” orgasm, thus rendering the performance anxiety seen in men unlikely.
Orgasm difficulties are the second most frequently reported sexual problems for women in the United States, with between 22% and 28% of women ages 18 to 59 years reporting they are unable to attain orgasm (Laumann, Michael, Gagnon, & Kolata, 1994). Young women (18 to 24 years) show lower rates of orgasm than older women for both orgasm with a partner and orgasm during masturbation (Laumann et al., 1994). This is likely due to age differences in sexual experience. It is important to note that differences in research methodology and diagnostic criteria make it difficult to accurately determine prevalence rates for FOD. In a review of 11 epidemiological studies, Graham (2010) found that the lowest prevalence rate of FOD was 3.5% when DSM-III criteria were used, and the highest rate of 34% was found when women were simply asked whether or not they had difficulties experiencing orgasm.
Factors Associated With Women’s Orgasm and FOD
The female orgasm results from a complex interaction of biological, psychological, and cultural processes. Disruptions in any of these systems can affect a woman’s ability to orgasm. The most common causes of the disorder include disturbances in the sympathetic nervous system, different types of chronic illness, particularly spinal cord injury, sexual guilt, anxiety, and relationship concerns.
Biological Factors
Impairments in nervous system, endocrine, or brain mechanisms involved in female orgasm may cause orgasmic dysfunction in some women. Disease, injury, and disruptions of the sympathetic or parasympathetic nervous systems in women have been identified as potential causes of orgasmic difficulties in women (Heiman, 2002). Medical conditions that affect women’s orgasmic ability include damage to the sacral/pelvic nerves, multiple sclerosis, Parkinson’s disease, epilepsy, hysterectomy complications, vulvodynia, hypothalamus-pituitary disorders, kidney disease, fibromyalgia, and sickle-cell anemia. Women with spinal cord injuries in the sacral region (interfering with the sacral reflex arc of the spinal cord) have shown difficulty attaining orgasm (Sipski et al., 2001). This is believed to be caused by interference with the vagus nerve, which has been shown to connect the cervix to the brain (Whipple, Gerdes, & Komisaruk, 1996).
Both vascular and nervous system problems have also been association with orgasm difficulties. Vascular disease, such as diabetes mellitus and atherosclerosis, have been linked to orgasmic dysfunction (e.g. Basson & Schultz, 2007). With respect to the nervous system, studies examining blood plasma levels of neuromodulators before, during, and after orgasm suggest that epinephrine and norepinephrine levels peak during orgasm in normally functioning women (e.g., Exton et al., 2000). With respect to the endocrine system, oxytocin levels are positively correlated with subjective intensity of orgasm among orgasmic women, and prolactin levels are elevated for up to 60 minutes following orgasm (for review, see Meston & Frohlich, 2000). Studies in humans suggest that the paraventricular nucleus of the hypothalamus, an area of the brain that produces oxytocin, is involved in the orgasmic response (McKenna, 1999). Impairments in any of these systems could feasibly lead to FOD.
A number of psychotherapeutic drugs have been noted to affect the ability of women to attain orgasm. Drugs that increase serotonergic activity (e.g., antidepressants, such as paroxetine, fluoxetine, and sertraline) or decrease dopaminergic activity (e.g., antipsychotics) have been shown to affect orgasmic capacity (Meston et al., 2004; Graham et al., 2010). Indeed about one third of women who take SSRIs report problems with orgasm (Stimmel & Gutierrez, 2006). These drugs can lead to delayed orgasm or a complete inability to reach orgasm. There is variability, however, in that some antidepressants have been associated with impaired orgasm more often than others. This seems to be related to which specific serotonin receptor subtype is being activated. As noted earlier, drugs that inhibit serotonin activity at the serotonin2 receptor (e.g., nefazodone, cyproheptadine) cause fewer sexual side effects in women (for review, see Meston et al., 2004).
Recently, clinicians have reported that an increasing number of women believe that the structure of their genitalia may be contributing to difficulties achieving or maintaining orgasm. This belief has contributed to an increase in genital plastic surgery, specifically labiaplasty (reduction of the size of the inner labia and the outer labia), vaginoplasty (rebuilding the vaginal canal and its mucous membrane), hymenoplasty (reconstruction of the hymen), perineoplasty (tightening or loosening of the perineal muscles and the vagina and/or correcting clinical defects or damages of the vagina and the anus), and G-spot augmentation. A few studies have indicated that these surgeries resulted in increased sexual satisfaction (e.g. Goodman et al., 2010), but the little current evidence that supports these procedures failed to use standardized measures that formally assess for sexual dysfunction and did not include control groups. For these reasons, the American College of Obstetricians and Gynecologists (Committee on Gynecologic Practice, 2007) and the Society of Obstetricians and Gynaecologists of Canada (Clinical Practice Gynaecology Committee of Canada, 2013) discourage physicians from performing genital plastic surgery.
Psychological Factors
The psychological factors associated with FOD include sexual guilt, anxiety related to sex, childhood loss or separation from the father, and relationship issues (for review, see Meston et al., 2004). Sexual guilt can affect orgasmic abilities by increasing anxiety and discomfort during sex and also by distracting a woman from what gives her pleasure. Women who strictly abide byto the values of Western religions sometimes view sexual pleasure as a sin. Sins are later connected with a sense of shame and guilt, which could produce negative affect and cause distracting thoughts during sexual activities. Women who initiate and are more active participants during sexual activities report more frequent orgasms, most likely because being active allows women to assume positions that can provide a greater sense of sexual pleasure. More frequent masturbation and sexual activities are associated with more frequent orgasms. It is likely that women who engage in more sexual activities have a greater understanding of what gives them sexual pleasure and this can help them more easily reach orgasm. A romantic relationship in which the woman feels comfortable communicating her sexual needs may facilitate orgasmic capacity. Therefore, women experiencing relationship discord might be more at risk of orgasm problems than women who are satisfied with their relationships. It is important to note that only a small percentage of women are distressed by their anorgasmia (Graham, 2010).
Certain demographic factors such as age, education, and religion also provide clues as to psychological factors involved in FOD. Younger women, aged 18 to 24 years, compared to older women are more likely to report orgasm problems, during both masturbation and partnered sexual activity (Laumann et al., 1994). It is possible that as women age they gain more sexual experience as well as become more aware of what their bodies need to attain orgasm. Women with lower levels of education reported more orgasm difficulties during masturbation than women with higher levels of education. Approximately 42% of women with a high school education report “always or usually” achieving orgasm during masturbation, compared to 87% of women with an advanced degree (Laumann et al., 1994). More educated women might hold more liberal views on sexuality and might be more likely to see their own pleasure as a goal of sexual activity.
A negative relation between high religiosity and orgasmic ability in women is frequently reported in the clinical literature. Possibly, the more religious a person, the more likely they are to experience guilt during sexual activity. Feasibly, guilt could impair orgasm via a number of cognitive mechanisms, in particular distraction processes. A relationship between improved orgasmic ability and decreased sexual guilt has also been reported (Davidson & Moore, 1994). Laumann and colleagues (1994) reported a substantially higher proportion (79%) of women with no religious affiliation reported being orgasmic during masturbation compared with groups of religious women (53% to 67%).
In addition to specific demographics, it is also possible that overarching cultural notions of women’s sexuality in general, and the value of women’s sexual pleasure, in particular, may also play a role in women’s orgasmic capacity. Women who live in societies that value female orgasm tend to have more orgasms than women living in societies that discourage the concept of sexual pleasure for women (for review, see Meston, Levin, Sipski, Hull, & Heiman, 2004). Examples of societies that foster sexual pleasure for women and expect them to enjoy intercourse include the Mundugumor of Papua New Guinea and the Mangaia of the Cook Islands. Mangaian women are taught to have orgasms, hopefully two or three to each one of her male partner’s, and to try to attain mutual orgasm. Mangaian males who are not able to give their partners multiple orgasms are looked down on. At the opposite end of the spectrum are societies that assume women will have no pleasure from coitus and that the female orgasm does not exist. The Arapesh of Papua New Guinea are such a society. In fact, they do not even have a word in their language for the female orgasm. It is feasible that women in societies that promote women’s sexual pleasure are more likely to experiment and therefore learn about what facilitates their ability to have an orgasm. It may also be that in societies where sexual pleasure is discouraged it may be shameful to admit to having an orgasm.
Assessment and Treatment of FOD
A doctor or psychologist familiar with the structure and function of orgasms should conduct the assessment of FOD. Depending on the etiology of the orgasm problem, a variety of both cognitive behavioral and physical therapy techniques can be effective for increasing orgasmic capacity.
Assessment
Assessment of FOD involves a comprehensive sexual, medical, and psychosocial history similar to that used for assessing FSIAD. It is important for the clinician to determine whether the woman is unable to attain orgasm in all situations or just with a certain partner or during certain intercourse positions or sexual activities because this information may help determine the most appropriate type of therapy.
Treatment
In general, sex therapy for FOD focuses on promoting healthy changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. Sensate focus and systematic desensitization are used to treat FOD when anxiety seems to play a role. Sex education and communication skills training are often included as adjuncts to treatment. Kegel exercises (Kegel, 1952), which involve tightening and relaxing the pubococcygeous muscle, are also sometimes included as part of a treatment regime. Feasibly, they could help facilitate orgasm by increasing blood flow to the genitals, or by helping the woman become more aware and comfortable with her genitals.
To date, the most efficacious treatment for FOD is directed masturbation (DM). This treatment utilizes cognitive behavioral therapy techniques to educate a woman about her body and the sensations of manual self-stimulation. DM includes several stages that gradually build on one another. The first step of DM involves having the woman visually examine her nude body with the help of a mirror and diagrams of female genital anatomy. She is then instructed to explore her genitals using touch with an emphasis on locating sensitive areas that produce feelings of pleasure. Once pleasure-producing areas are located, the woman is instructed to concentrate on manual stimulation of these areas and to increase the intensity and duration until “something happens.” The use of topical lubricants, vibrators, and erotic videotapes are often incorporated into the exercises. Next, once the woman is able to attain orgasm alone, her partner is usually included in the sessions in order to desensitize her to displaying arousal and orgasm in his or her presence, and to educate the partner on how to provide her with effective stimulation.
Directed masturbation has been shown to effectively treat primary FOD when provided in a variety of formats, including individual, group, couples therapy, and bibliotherapy (for review, see Meston, 2006). A study of therapist-directed group therapy using DM reported a 100% success rate in treating primary FOD at 2-month follow-up (Heinrich, 1976). It has been proposed that DM is so effective because, in the early stages, it eliminates several factors that can impair orgasmic capacity, such as anxiety that may be associated with the presence of a partner. Since the exploration is focused on the woman’s manual sexual stimulation, she is not dependent on her partner’s sexual ability, or her ability to communicate her sexual needs to her partner until later in the treatment. Recent research has indicated that DM is particularly effective for women with primary FOD (Graham, 2014). It appears the DM can also be effective for women with secondary FOD who are uncomfortable touching their genitals, but studies have found DM to be less effective for secondary FOD, than primary FOD (Fichen, Libman, & Brender, 1983). This may be because many women with secondary FOD only have trouble attaining orgasm with their partner. Therefore, treatments for secondary FOD typically??often focus on couple’s issues of communication, sexual skills, comfort, and trust.
If the etiology of the FOD appears to be related to anxiety about sex, then anxiety reduction techniques such as systematic desensitization and sensate focus may be useful. These strategies are often combined with sexual techniques training, DM, sex education, communication training, bibliotherapy, and Kegel exercises. As described earlier, Kegel exercises strengthen the pubococcygeous muscle, and are believed to facilitate orgasm by increasing vascularity of the genitals (Kegel, 1952). Supporting this technique, one study found a difference in the size of the pubococcygeous muscle between orgasmic and nonorgasmic women (Graber & Kline-Graber, 1979). Yet if anxiety is not the presenting cause of the orgasm problem, these techniques, while effective for desire and arousal problems, do not appear to be effective for treating orgasm problems (Meston, Levin, Sipski, Hull, & Heiman, 2004).
For women who have orgasm difficulties resulting from hysterectomy and oophorectomy, combined estrogen and testosterone therapy has been shown to enhance orgasmic ability (Shifren et al., 2000). A number of psychotherapeutic drugs have been used to try to eliminate orgasm problems that are secondary to antidepressant drug treatments. Results from placebo-controlled studies, to date, have failed to identify any drugs that enhance orgasmic ability better than placebo. However, one study indicated that exercise increases genital arousal in women taking both SSRIs and SNRIs (Lorenz & Meston, 2012). As SSRIs are known to have greater SNS suppression compared to SNRIs, women talking SSRIs experienced significantly greater genital response post-exercise than women taking SNRIs (Lorenz & Meston, 2012).
