Problems with Orgasm
The attainment of reasonably regular orgasms with a partner is a crucial personal developmental step for young women. This task of adult sexual development rests upon a subtle interplay of physiology, individual psychology and culture. Reliable orgasmic attainment is usually highly valued by the woman and is often reflected in enhanced self-esteem, confidence in her femininity, relationship satisfaction and the motive to continue to behave sexually.
Orgasm is the reflexive culmination of arousal. It is mani-fested by rhythmic vaginal wall contractions and the release of muscular tension and pelvic vasocongestion, accompanied by varying degrees of pleasurable body sensations. Its accomplish-ment requires: 1) the physiologic apparatus to augment and sus-tain arousal; 2) the psychological willingness to be swept away by excitement; and 3) tenacious focus on the required physical work of augmenting arousal. The diagnosis of female orgasmic disor-der (FOD) is made when the woman’s psychology persistently interferes with her body’s natural progression through arousal.
Estimates of prevalence of both lifelong and acquired psy-chological FOD range from 10 to 30% (Laumann et al., 1994b). Some of this variability is due to the different definitions of anor-gasmia. It remains a difficult scientific judgment, however, where to draw the line between dysfunction and normality, for example, is it normal to attain orgasms during one-third of partner sexual experiences? (Tiefer, 1998). Few women are always orgasmic.
During most of the 20th century, psychoanalysts thought that almost 90% of women were orgasmically dysfunctional. Prior to 1970, the accepted concept of normality required a woman to be brought to orgasm by penile thrusting. Orgasmic fulfillment through solitary masturbation or partner manual or oral stimula-tion was viewed as signifying the presence of a neurotic obstacle to mature femininity. This paternalistic idea has weakened con-siderably in the last generation.
The biologic potential for orgasmic attainment is an in-born endowment of nearly all physically healthy women. The cultural and psychological factors that influence orgasmic attain-ment are usually fundamental to the etiology of FOD. Centuries-old beliefs that sexual knowledge, behavior and sexual pleasure were not the prerogative of “good girls” powerfully affects some women’s sexual adjustment. These beliefs cause young women to be uninformed about the location and role of their clitoris and ashamed of their erotic desires and sexual sensations. For women with FOD, modern concepts of equality of sexual expression are insufficient to overcome these traditional beliefs. These emotion-ally powerful beliefs often lay behind their classic dysfunctional pattern: the women can become aroused to a personal plateau beyond which they cannot progress; thereafter, their excitement dissipates. After numerous repetitions, they begin to lose motiva-tion to participate in sex with their partner. They may eventually meet criteria for HSDD.
The doctor should know the answers to the following questions. Does the patient have orgasms under any of the following sex-ual circumstances: solitary masturbation, partner manual geni-tal stimulation, oral–genital stimulation, vibratory stimulation, any other means? Does she have orgasms with a partner differ-ent from her significant other? How are they stimulated? Does a particular fantasy make orgasmic attainment easier or possible? Under what conditions has she ever been orgasmic? Has she had an orgasm during her sleep?
The lifelong generalized variety of the disorder is recognized when a woman has never been able to attain orgasm alone or with a partner by any means, although she regularly is aroused. When a woman can only readily attain orgasm during masturbation, she is diagnosed as having a lifelong situational type. Women with any form of lifelong FOD more clearly have conflicts about personal sexual expression due to fear, guilt, ignorance, or obedi-ence to tradition than those with the acquired variety. Women who can masturbate to orgasm often feel fear and embarrassment about sharing their private arousal with any other person.
The acquired varieties of this disorder are more common and are characterized by both complete anorgasmia, too-infrequent orgasms and too-difficult orgasmic attainment. The most com-mon cause of this problem are serotonergic compounds. Pro-spective studies of various antidepressants have demonstrated up to 70% incidence of this disorder among those treated with serotonergic antidepressants. Bupropion and nefazadone do not cause this problem. When medications are not the cause of an acquired FOD, the doctor needs carefully to assess the meaning of the changes in her life prior to the onset of the disorder. Some of these women are in the midst of making a transition to a new partner after many years in another relationship. Some seem to suffer from memories of earlier shame-ridden behaviors such as incest.
When a doctor applies a label of disorder to a relatively anorgas-mic woman, the woman often privately interprets the diagnosis as meaning that she has a serious and difficult problem to overcome. Physicians need to be careful about this because some of these women are relatively easy to help. It must be realized that many women gradually undo the effects of their culture on their own and grow to be increasingly responsive sexually with time and growing trust of their partners. Clinicians can do many women a great service by offering education and reassurance. Giving an inhibited woman new-to-her information in an encouraging man-ner can subdue her anxiety and foster her optimism. On the other hand, some women with this disorder are profoundly entrenched in not being too excited and treatments fail. The ideal era to begin treatment is young adulthood.
Four formats are known to be of help. Individual therapy is the most commonly employed. In lifelong varieties of the dis-order, therapy focuses on the cultural sources of sexual inhibition and how and when they impacted upon the patient. In the situ-ational varieties, the therapist focuses on the meaning of the life changes that preceded the onset of the disorder. Group therapy is highly effective in helping women reliably to masturbate to orgasm and moderately effective in overcoming partner inhibi-tion. It is typically done with college and graduate students in campus settings, not older women. Couple therapy may be useful to assist the couple with the subtleties of their sexual equilibrium. The personal and interpersonal dimensions of orgasmic attain-ment can be stressed. Often other issues then come to the fore that initially seemed to have little to do with orgasmic attain-ment. The most cost-effective treatment is bibliotherapy. Female orgasmic attainment has been widely written about in the popu-lar press since the early 1970s. It is widely believed that these articles and books, which strongly encourage knowledge of her genital anatomy, masturbation and active pursuit of orgasm, have enabled many women to grow more comfortable and competent in sexual expression.
When a man can readily attain a lasting erection with a partner, yet is consistently unable to attain orgasm in the body of the partner, he is diagnosed with male orgasmic disorder (MOD). The disorder has three levels of severity: 1) the most common form is characterized by the ability to attain orgasm with a partner outside of her or his body, either through oral, manual, or personal masturbation; 2) the more severe form is character-ized by the man’s inability to ejaculate in his partner’s pres-ence; and 3) the rarest form is characterized by the inability to ejaculate when awake. The disorder is usually lifelong and not partner specific. These men cannot allow themselves to be swept away in arousal by another person. They are sexu-ally vigilant not to allow themselves to be controlled by the partner’s power to convey them to orgasm. This power would provide the partner with personal pleasure and the man with this disorder, while initially appearing to be a sexual super-man, ultimately disappoints the partner. Their psychological dysfunction represents a capacity to use a mental mechanism which other men would love to possess in smaller degrees. Both the partners and the therapists of these men tend to describe them as controlling, unemotional, untrusting, hostile, obses-sive–compulsive, or paranoid. Some of these men improve with psychotherapy, others improve spontaneously with time and, for others, the dysfunction leads to the cessation of the as-piration for sex with a partner. One controlled study of patients with numerous sexual dysfunctions suggested that bupropion 300 to 450 mg/day may improve the capacity to ejaculate in a minority of patients.
Premature ejaculation is a high prevalence (25–40% disorder seen primarily in heterosexuals characterized by an untameably low threshold for the reflex sequence of orgasm. The problem, a physiological efficiency of sperm delivery, causes social and psychological distress. In failing to develop a sense of control over the timing of his orgasm in the vagina, the man fails to meet his standards of being a satisfying sexual partner. However, if his partner does not explicitly or implicitly object, his rapidity is not likely to cause him to seek medical attention. The range of intrav-aginal containment times among self-diagnosed patients extends from immediately before or upon vaginal entry (rare), to less than a minute (usual), to less than the man and his partner desire (not infrequent). Time alone is a misleading indicator, however. The essence of the self-diagnosis is an emotionally unsatisfying sex-ual equilibrium apparently due to the man’s inability to temper his arousal. Most men sometimes ejaculate before they wish to, but not persistently.
The history should clarify the answers to following questions: Why is he seeking therapy now? Is the patient a sexual beginner or a beginner with a particular partner? Does he have inordi-nately high expectations for intravaginal containment time for a man his age and experience? Is he desperate about losing the partner because of the rapid ejaculation? Is the relationship in jeopardy for another reason? Does his partner have a sexual dys-function? Does she have orgasms with him other than through intercourse? Is he requesting help in order to cover his infidel-ity? Is his partner now blaming the man’s sexual inadequacy for her infidelity? Is his new symptom a reflection of his fear about having a serious physical problem during sex such as angina, a stroke, or another myocardial infarction? The answers will en-able the doctor to classify the rapid ejaculation into an acquired or lifelong and specific or general pattern, to sense the larger context in which his sexual behavior is conducted and to plan treatment.
Premature ejaculation reflects to the man’s sense that his contribution to the sexual equilibrium is deficient. It implies that he considers that he is far behind most men in his vaginal con-tainment time and that he wants to provide his partner with a better opportunity to be nurtured during lovemaking through prolonged intercourse. Typically, he aspires to “bring” his part-ner to orgasm during intercourse. If anxiety lowers the ejacula-tory threshold and keeps it from its natural evolution to a higher level over time, then premature ejaculation is a self-perpetuating pattern. Premature ejaculation may last a lifetime.
There are three efficient approaches to this dysfunction. The
first is simply to refuse to confirm the patient’s self- diagno-sis. Some anxious beginners, men with reasonable intravagi-nal containment times of two or more minutes, and those with exaggerated notions of sexual performance can be calmed down by a few visits. When they no longer think of them-selves as dysfunctional their intravaginal containment times improve. The second is the use of serotonergic medications. In a study of 15 carefully selected stable couples, daily adminis-tration of clomipramine 25 and 50 mg increased intravaginal containment times on average of 249% and 517% over base-line observations (Althof et al., 1995). At these dosage levels, there were few side effects. Numerous similar reports testify to the fact that various serotonergic reuptake inhibitors can significantly lengthen the duration of intercourse. Clinicians need to determine with each patient whether the medication can be taken within hours or days of anticipated intercourse. Improvement is not sustained after medication is stopped. Serotonergic medications are the most common treatment of rapid ejaculation because they are so quickly effective in over 90% of men. The third approach is behaviorally-oriented sex therapy that trains the man to focus his attention on his penile sensations during vaginal containment and to signal his part-ner to cease movement or to apply a firm squeeze of the glans/ shaft area to interrupt the escalation of arousal. This requires an increase in communication and full cooperation of the part-ner which in themselves can go a long way in improving their sexual equilibrium.
Rapid ejaculation in some men reflects mere inexperience; for others it is stubborn physiological efficiency; for others it re-flects fear of personal harm, which is either related to physical illness or to unresolved fears of closeness to a woman; and yet for others it reflects a partnership with a profoundly inhibited blam-ing partner. If the psychodynamic question is asked of men with persistent rapid ejaculation, “Why does this man want to finish intercourse so quickly?” the answers vary from, “It is not a rel-evant question!” to “I’m afraid of her!” to “I’m afraid of what will happen to me”. For instance, a large percentage of men ejaculate quickly for the first months after a myocardial infarction.
The advantages of costlier couple psychotherapy are to allow the man and his partner to understand their lives better, to address both of their sexual anxieties, and to deal with other important nonsexual issues in their relationship. Effective psy-chotherapy allows the man to become positioned to continue the usual biological evolution that occurs during the life-cycle from rapid ejaculation, which is true for many young men, to occa-sional difficulty in ejaculating, which is true for many men in their sixties.
The clinician needs to consider a series of questions when deal-ing with a woman who reports painful intercourse. Does she have a known gynecologic abnormality which is generally as-sociated with pain? Is there anything about her complaint of pain that indicates a remarkably low pain threshold? Does she now have an aversion to sexual intercourse? At what level of physical discomfort did she develop the aversion? Does her private view of her current relationship affect her willingness to be sexual and her experience of pain? Does her partner’s sexual style cause her physical or mental discomfort, for example, is he overly aggres-sive or does he stimulate memories of former abuse? What has been the partner’s response to her pain? What role does her an-ticipation of pain play in her experience of pain?
These clinical questions are typical biopsychosocial ones. Sex-limiting pain often is the result of the subtle interplay of personal and relational, cognitive and affective, and fundamen-tal biological processes that are inherent in other human sexual struggles that operate to produce these confusing disorders.
The DSM-IV presents dyspareunia and vaginismus as dis-tinct entities. However, they have been viewed as inextricably connected in much of the modern sexuality literature: vaginis-mus is known to create dyspareunia and dyspareunia has been known to create vaginismus.