Sexual and Relationship Therapy
ISSN: 1468-1994 (Print) 1468-1749 (Online) Journal homepage: http://www.tandfonline.com/loi/csmt20
Can we treat anorgasmia in women? The challenge
to experiencing pleasure
Ellen Laan & Alessandra H. Rellini
To cite this article: Ellen Laan & Alessandra H. Rellini (2011) Can we treat anorgasmia in
women? The challenge to experiencing pleasure, Sexual and Relationship Therapy, 26:4,
329-341, DOI: 10.1080/14681994.2011.649691
To link to this article: http://dx.doi.org/10.1080/14681994.2011.649691
Published online: 31 Jan 2012.
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Sexual and Relationship Therapy
Vol. 26, No. 4, November 2011, 329–341
Can we treat anorgasmia in women? The challenge to experiencing
pleasure
Ellen Laana* and Alessandra H. Rellinib
a
Department of Sexology and Psychosomatic Obstetrics and Gynaecology, Academic Medical
Center, University of Amsterdam, Amsterdam, The Netherlands; bHuman Sexuality Research
Clinic, Department of Psychology, University of Vermont, Burlington, USA
(Received 11 December 2011; final version received 12 December 2011)
A consistent finding in the literature has been that only about half of the women
experiencing orgasm difficulties also report associated distress. This may suggest
that orgasms are less important for women’s sexual satisfaction than they are for
men. Evidence is provided to suggest that orgasms are important for women’s
sexual satisfaction. The lack of distress seems related to women’s lesser
consistency of orgasm during partnered sexual activity and not to orgasms being
less important per se. In contrast to current suggestions that inability to orgasm
during vaginal intercourse points to psychological immaturity, data are presented
that imply that women’s orgasm consistency in all forms of partnered sexual
activity is associated with sexual autonomy (i.e., the extent to which one feels that
one’s sexual behaviours are self-determined). This paper ends with a brief
overview of organic and psychosexual factors associated with problems with
sexual excitation and sexual inhibition and reviews evidence-based treatment of
anorgasmia. For orgasm problems that are related to problems with sexual
excitation, effective treatments are available. We recommend that more effort is
given to studying factors associated with sexual inhibition.
Keywords: female orgasmic disorder; anorgasmia; importance of orgasm; orgasm
consistency; sexual autonomy; sexual pleasure; assessment; treatment; sexual
excitation; sexual inhibition
Introduction
In the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders,
Text Revision (DSM-IV-TR: American Psychiatric Association, 2000) female
orgasm disorder (FOD) is defined as a persistent or recurrent delay in, or absence
of, orgasm following a normal sexual excitement phase, causing marked distress or
interpersonal difficulty. The diagnosis is based on a clinical judgement that the
ability of a woman to experience orgasm is less than would be reasonable for her age,
sexual experience and the adequacy of the sexual stimulation she receives. The new
definition proposed for DSM-V contains physiological as well as experiential aspects
of orgasm (i.e., markedly reduced intensity of orgasmic sensation) (Graham, 2010).
An international classification committee sponsored by the American Urological
Association Foundation defined FOD as either lack of orgasm, markedly diminished
*Corresponding author. Email: [email protected]
ISSN 1468-1994 print/ISSN 1468-1749 online
Ó 2012 College of Sexual and Relationship Therapists
http://dx.doi.org/10.1080/14681994.2011.649691
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E. Laan and A.H. Rellini
intensity of orgasmic sensations or marked delay of orgasm from any kind of
stimulation, despite the self-report of high sexual arousal/excitement. This committee
introduced the concept of personal distress, to avoid labelling as dysfunctional
women whose partner is distressed by their inability to obtain orgasm but who were
not themselves distressed (Basson et al., 2003). However, in its current usage, it is by
no means clear what exactly personal distress represents. In large clinical trials
personal distress is defined as a total score 415 on the Female Sexual Distress ScaleRevised (FSDS-R: Derogatis, Clayton, Lewis-D’Agostino, Wunderlich, & Fu, 2008;
Jolly et al., 2009). Unfortunately, this FSDS-R total score is unable to discriminate
between personal distress about own sexual functioning and personal distress related
to negative interactions with the partner that may evolve from sexual difficulties of
one or both partners. Perhaps only two of the 13 items of the scale may relate to the
latter concept (Unhappy about your sexual relationship; Guilty about sexual
difficulties).
This paper addresses the question of how important orgasms are for women,
discusses the role of sexual autonomy, sexual pleasure and etiological factors
underlying orgasm problems and briefly reviews evidence-based treatment of
anorgasmia.
Are orgasms important?
Orgasm difficulties in women have not always been considered problematic, at least
after it became clear that female orgasm is not required for conception (Laqueur,
1990). Whereas in some eras women were seen as sexually insatiable, in others it was
considered inappropriate for women to have an orgasm (Drenth, 2004). The ‘‘sexual
liberation’’ that accompanied the second feminist ‘‘wave’’ in the Western world, a
period in which orgasms became a right to be claimed, was experienced by many as a
period in which having an orgasm became a duty to be fulfilled (Tiefer, 1995).
Recently, media messages about the importance of orgasm, as well as possible
expectations or pressure from sexual partners, may lead to distress, even when
women experience short-term and/or mild difficulties with orgasm (Graham, 2010).
The authors of a qualitative study in 33 women ranging in age from 19 to 60 years,
contended that the recent demand that a woman achieves orgasm has given her the
responsibility to ensure that her male partner experiences himself as a good lover.
The women in the study reported a strong desire to experience orgasm during
heterosexual intercourse for the sake of their male partners (Nicolson & Burr, 2003).
On the other hand, they believed that their male partner should always have an
orgasm in order to fulfill his sexual desire.
Many women who are unable to experience orgasm experience feelings of
inadequacy and failure (Wade, Kremer, & Brown, 2005) and difficulty in achieving
orgasm strongly correlates with negative emotions associated with intercourse.
Feelings of shame and guilt, anxiety, distress, detachment and withdrawal contribute
to the development and maintenance of orgasmic disorder (Birnbaum, 2003). Yet a
consistent finding in the literature has been that only about half of the women
experiencing orgasm difficulties also report associated distress (Graham, 2010). This
may suggest that orgasms are less important for women than they are for men. In
support of this suggestion, men have been consistently found to indicate a greater
interest in sex than do women (for a review see Baumeister, Catanese, & Vohs, 2001)
and studies have found that men are more sexually motivated by purely physical
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reasons, whereas women are more motivated by emotional reasons (Carroll, Volk, &
Hyde, 1985; Denney, Field, & Quadagno, 1984). A more recent study also found
support for pleasure motives, such as wanting to achieve an orgasm, as being more
strongly related to men’s motives for sex than to women’s motives for sex (Meston &
Buss, 2007). By contrast, though, there were no gender differences in the extent to
which emotional factors are related to motives for sex. Bancroft (2009) concluded
that women vary considerably in the extent to which they find orgasms important.
This variation may represent women’s ‘‘basic sexual pattern’’, which is considered to
represent a powerful sense of being desired (cf. Meana, 2010), whereas men’s basic
pattern is considered to be dominated by the pursuit of sexual pleasure (Bancroft &
Graham, 2011).
In support of the view that orgasms are important for women’s sexual well-being,
Fugl-Meyer, Oberg, Lundberg, Lewin and Fugl-Meyer (2006) showed that across
the life span, women’s perceived ability to reach orgasm is a prerequisite to feeling
overall sexually satisfied. Women who orgasmed more easily were also likely to find
sex important. In a similar vein, Waterman and Chiauzzi (1982) found orgasm
consistency to be significantly related to sexual satisfaction in women. It is unknown
how women who regard orgasm as very important differ from women who regard
orgasm as less important. One assumption could be that women who orgasm less
easily are also more likely to regard orgasms as less important. Such a hypothesis
would be consistent with a phenomenon named cognitive dissonance, which
indicates discomfort caused by holding conflicting values or characteristics
simultaneously (Festinger, 1957). Cognitive dissonance is best reduced by adjusting
the characteristic that is most open to change to the one that is least amenable to
change. It can thus be considered a sensible coping strategy to place less value on
orgasms if they are very difficult or impossible to have. The fact that heterosexual
men are much more likely to orgasm from partnered sex on a regular basis than are
heterosexual women (Kinsey, Pomeroy, Martin, & Gebhard, 1953; Laumann, Paik,
& Rosen, 1999) might explain the greater importance assigned to orgasm by
heterosexual men than by heterosexual women. Of note, women who have sex with
women are found to orgasm during partner sex more regularly than heterosexual
women (Douglas & Douglas, 1997; Kinsey et al., 1953). It is unknown whether
lesbian women place greater value on orgasms than heterosexual women.
To our knowledge, only one very recent study investigated whether women who
orgasm more easily are also more likely to regard orgasms as more important
(Anthony, Levin, & Laan, in preparation). In this convenience sample of 300 women in
a heterosexual relationship, women who reported a higher frequency of orgasms were
significantly more likely to find it important to have an orgasm during partnered sex
than women who reported a lower frequency of orgasms. This finding suggests that
orgasms are important for women’s sexual satisfaction, and that placing less importance
on orgasms is related to women’s lesser consistency of orgasm during partnered sexual
activity and not to orgasms being less important per se. Perhaps women’s overall greater
value attached to partner-related emotional rewards during partnered sexual activity
reflect their difficulties to experience orgasms with that activity.
Sexual autonomy and sexual pleasure
There is a large variability in the type and intensity of stimulation that is required to
experience an orgasm. Hite (1976) showed that 30% of women orgasm reliably
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E. Laan and A.H. Rellini
during intercourse. Almost all women in her study who reached orgasm through
stimulation from coitus alone had experienced orgasm through masturbation. Many
women needed additional manual stimulation to orgasm during coitus and an even
larger number was unable to orgasm during vaginal intercourse altogether.
Apparently, intercourse alone is not a very effective stimulus for orgasm in women.
Similarly, Lloyd (2005) concluded, after an extensive review of the literature, that
only a quarter of women always or nearly always orgasm during intercourse.
The inability to experience orgasm during intercourse in the absence of additional
glans clitoris stimulation is now considered a ‘‘normal variation of sexual response’’
rather than a ‘‘pathological inhibition’’ (American Psychiatric Association, 1980). At
the beginning of the twentieth century Freud wrote that women who required clitoral
stimulation for orgasm are psychologically ‘‘immature’’ (Freud, 1953/1905). Kinsey
and Masters and Johnson argued against this assertion by assuming that all orgasms
are physiologically identical, regardless of the site of stimulation (Kinsey et al., 1953;
Masters & Johnson, 1966; but see King, Belsky, Mah, & Binik, 2011). Today,
however, there are again authors who claim that ‘‘clitoral’’ orgasms are inferior to
‘‘vaginal’’ orgasms (Brody, 2010). Unfortunately, there are at least two fundamental
problems, and several other serious problems, with this line of research.
The first fundamental problem is that it is based on inaccurate assumptions
about female genital anatomy. The organ that is labelled the clitoris in the ‘‘vaginal’’
versus ‘‘clitoral’’ orgasm discussion is in fact only the glans clitoris. The internal
clitoral body and bulbs, also referred to as the ‘‘clitoral complex’’, are, particularly in
a sexually aroused state, many times larger than the glans itself. Therefore, as Levin
(2003) pointed out, it is hard to imagine any type of sexual activity, including vaginal
intercourse, that does not involve the clitoris.
Even if we were to ignore this first fundamental problem, the second problem
also seriously questions one of the basic premises of this work. In an effort to explain
how use of sources of sexual stimulation other than ‘‘pure’’ penile-vaginal
intercourse may be related to immature defense mechanisms, Costa and Brody
(2008) claim that these other sources of stimulation force women to shift their
attention from a focus on vaginal sensations to a focus on clitoral sensations,
possibly reflecting a desire to stay ‘‘distant’’ from their male partner. This distinction
between vaginal and clitoral sensations suggests that women should be able to
localize differences in source (if at all present) of their sexual feelings, which is highly
questionable. This would be similar to expecting men to be able to differentiate
between penile ‘‘tip’’ and ‘‘shaft’’ sexual feelings during intercourse.
Another serious problem of this work is that bold causal inferences are made
(vaginal orgasms, defined as an orgasm through vaginal intercourse without
additional stimulation of the glans clitoris, are beneficial to mental and physical
health) based on correlational studies only. Causal inferences in the opposite
direction (e.g. mental and physical health facilitate, directly or by an as yet unknown
mediating factor, orgasms during vaginal intercourse), are equally possible. By
stipulating that immaturity impairs a vaginal orgasm, they ignore the possibility that
maturity may support it. It can be argued that rather than linking the lack of orgasm
through vaginal intercourse without additional glans clitoris stimulation to
immature defenses, the presence of orgasm through vaginal intercourse without
additional glans clitoris stimulation may be connected to sexual autonomy. Sexual
autonomy is defined as the extent to which one feels that one’s sexual behaviours are
self-determined (Sanchez, Crocker, & Boike, 2005). For instance, if timed well, that
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is, after a sufficient amount of sexual play that enables the woman’s ‘‘clitoral
complex’’ to become swollen and engorged with blood and the vaginal wall to
become fully engorged and lubricated, chances of experiencing orgasm with vaginal
intercourse may increase. This suggests that sexual autonomy, which might be
considered an indicator of (mental) health, should be positively related to
experiencing orgasm during partnered sex. Indeed, Sanchez and colleagues found
that sexual autonomy was positively associated with sexual pleasure (Sanchez et al.,
2005; Sanchez, Kiefer, & Ybarra, 2006). More direct support for this line of
reasoning comes from a very recent study in which it was found that compared to
less sexually autonomous women, more sexually autonomous women were more
inclined to engage in more and more varied forms of sexual behavior prior to vaginal
intercourse and were more likely to experience orgasms from all types of partnered
sexual activity, including vaginal intercourse with and without additional glans
clitoris stimulation (Anthony et al., in preparation). Also, relative to women low in
sexual autonomy, women high in sexual autonomy were more likely to continue
sexually stimulating activities (solo or partnered) if their partner had already had an
orgasm, allowing them to also experience orgasm. Thus, to the extent to which
frequencies in which people engage in certain behaviours reflect people’s preferences,
we tentatively conclude that women, like men, have a preference for those sexual
activities that are more likely to lead to sexual pleasure and orgasm.
The last serious problem that will be discussed here is that all the conclusions are
based on studies of one group and have, up till now, never been replicated by
independent researchers. In a direct attempt to replicate the finding that vaginal
intercourse with, but not without additional glans clitoris stimulation is related to
immature psychological defenses, 300 women filled out the scale assessing orgasm
consistency during various types of partnered- and solo sexual activities, designed by
Brody and Costa (2008), as well as the scale they used to measure psychological
defense mechanisms. In our sample, orgasm consistency during vaginal intercourse
without, but not with, additional glans clitoris stimulation was weakly but
significantly positively correlated with immature defense mechanisms (Anthony
et al., in preparation). Orgasm consistency of both types of vaginal intercourse was
equally weakly positively related with mature defense mechanisms. Thus, orgasm
consistency with both types of vaginal intercourse increased with increased use of
mature defenses. Sexual autonomy, however, was more strongly related to orgasm
consistency with both types of vaginal intercourse than were psychological defense
mechanisms. To conclude, the first independent test of some of the hypotheses of
Brody and colleagues did not result in a replication of their findings.
Problems with making the diagnosis
In clinical practice, the main criterion for the disorder, following a normal sexual
excitement phase, is very difficult to establish. It is equally difficult to ascertain
whether the self-report of high sexual arousal/excitement is a sufficient requirement
for orgasm to occur, which is particularly true for primary anorgasmic women. It is
hard to imagine how they themselves can differentiate between orgasm and high
levels of sexual arousal, because they have never experienced the former. Research
on the basis of which clear criteria for adequate sexual stimulation can be formulated
is lacking (Brotto, Bitzer, Laan, Leiblum, & Luria, 2010). It is possible that the
woman does not know which types of sexual stimulation may be adequate or more
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E. Laan and A.H. Rellini
effective than what is offered or available. Particularly women with arousal or
orgasm complaints may avoid effective sexual stimulation (Laan, van Driel, & van
Lunsen, 2008). In general, women seem relatively unaware of their own genital
changes, with which they lack adequate proprioceptive feedback that may further
increase their arousal (Laan & Everaerd, 1995; Laan & Janssen, 2007). It is therefore
possible that women who are diagnosed with FOD are in fact suffering from a sexual
arousal disorder (Laan & Both, 2011).
Therefore, one of the most important but difficult tasks for the clinician is to
verify that inadequate sexual stimulation is not underlying the orgasm problems.
This requires detailed probing of (variety in) sexual activities (masturbation methods
and experiences, sexual stimulation provided by the partner, use of additional
imaginary [fantasy], tactile [e.g. vibratory] and visual stimulation) and the conditions
in which sexual activity takes place.
Organic correlates of orgasm difficulties
Not much is known about organic causes for orgasm difficulties resulting from a
paucity of knowledge concerning the neurophysiological basis of orgasm. Clearly,
well-innervated clitoral tissue is important for orgasms, but orgasms are also
possible with the glans clitoris missing or damaged (Heiman, 2007). Damage to the
central nervous system, the spinal chord or the peripheral nerves as a result of
trauma or multiple sclerosis may lead to orgasm difficulties. Approximately half of
the women with a spinal chord injury (SCI) are able to experience orgasm, even
though orgasmic response is more compromised with higher spinal chord lesions.
There is strong evidence for the occurrence of sexual arousal and orgasm in women
with SCI who have an intact S2-S5 reflex arc (Sipski, Alexander, & Rosen, 2001).
Whipple and Komisaruk (1998) suggested that, based on their studies in SCI women
in which cervical stimulation was applied, the vagus nerve conveys a sensory
pathway from the cervix to the brain, bypassing the spinal cord, that is responsible
for the preservation of sexual arousal and orgasm in these women.
That central processes are an important source of sexual arousal and orgasm in
women is also demonstrated in studies that show that women can be orgasmic
without direct genital stimulation. Whipple and colleagues studied 10 women who
were orgasmic with sexual fantasy only (Whipple, Ogden, & Komisaruk, 1992).
Changes related to orgasm can be found in the neo-cortex, the limbic system and the
cerebellum (Komisaruk & Whipple, 2005). Georgiadis et al. (2006) saw a prominent
orgasm-related deactivation in the orbitofrontal cortex and the anterior temporal
lobes, suggesting that some behavioural disinhibition (letting go of control) is
mandatory for orgasm to occur. Activation of the mesolimbic dopamine system is
related to anticipating intense pleasure and the motivation to obtain a sexual reward,
but it is unclear what role dopamine or other neurotransmitters have in the orgasmic
experience itself (Bancroft, 2009). Pleasurable feelings after orgasm are probably
related to oxytocin, a hormone released after orgasm, which is assumed to promote
bonding by inducing feelings of satiation and intimacy (Meston, Levin, Sipski, Hull,
& Heiman, 2004).
Orgasm difficulties can be comorbid with hormonal changes occurring during
menopause. Free testosterone levels were correlated with the subjective experience
of orgasm (i.e., relaxing, soothing and peaceful sensations) and estrogen was linked
with the physical experience of orgasm (van Anders & Dunn, 2009). The
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connection with testosterone was found during partnered sex and that with
estrogen during masturbation. In a recent study, dehydroepiandrosterone sulphate
was found to be related to better orgasmic function (Gracia, Freeman, Sammel,
Lin, & Mogul, 2007).
Selective Serotonin Reuptake Inhibitors (SSRI) antidepressants comprise a
group of medications that have a well-established negative effect on orgasmic
functioning, with approximately 31–57% of women taking SSRIs reporting delay or
inhibition of orgasm (Montejo-Gonzalez et al., 1997). However, some forms of
SSRIs, and especially those that have a more positive effect on norepineprhine and
dopaminergic levels, have fewer sexual side-effects. Medications such as antipsychotics, mood stabilizers, cardiovascular medications, chemotherapeutic agents and
hypertension drugs have also been flagged for their potential negative effects on
orgasm functioning, although other factors associated with the reasons for taking
the medications (e.g. nerve damage, anxiety, depression etc) are hard to distinguish
from the actual effects of the medication (Clayton & Balon, 2009).
Large epidemiological studies in the USA have shown an association between
orgasm functioning and arthritis, hypertension, chronic medical conditions, chronic
pain, thyroid problems, asthma, diabetes and coronary heart disease or other heart
conditions (Basson, Rees, Wang, Montejo, & Incrocci, 2010; Shifren, Monz, Russo,
Segreti, & Johannes, 2008). It is often unclear whether it is the medical condition per
se, the treatment or the psychological side-effects of such conditions that affect the
orgasmic functioning.
In recent years a number of studies have looked at genetic influences on variation
in female sexual function. It was found that the capacity to experience orgasm during
intercourse and (to a lesser extent) masturbation was partly genetically determined
(Dawood, Kirk, Bailey, Andrews, & Martin, 2005). In contrast, another study found
that sexual problems, among which are problems with orgasm, were mainly related
to individual-specific environmental factors with only a very modest role for
heritability (Witting et al., 2009).
Psychosexual correlates of orgasm difficulties
A number of psychosocial factors seems to interfere with women’s capacity for
orgasm, such as low educational level, religiosity and feeling guilty about sex
(Meston et al., 2004). Inadequate sexual stimulation based on being sexually
inexperienced or a negative attitude towards sex may therefore be an important
determinant of orgasm difficulties. As we have seen, a lack of sexual autonomy,
which may interfere with one’s ability to obtain adequate sexual stimulation, is
related to reduced sexual pleasure and orgasm problems (Anthony et al., in
preparation; Sanchez et al., 2005, 2006).
Knowledge about one’s own sexual anatomy is related to the ability to experience
orgasm during masturbation, but knowledge alone was found not to translate into
increased orgasm-likelihood for women during partnered sex (Wade et al., 2005).
This suggests that in partnered sex, factors other than knowledge play a role in
women’s chances of experiencing an orgasm. Authors have suggested that asserting
sexual desires is incompatible with feminine attractiveness (e.g., Tolman, 1994).
There is evidence to suggest that women with orgasm disorder tend to behave
according to the traditional female script in which the woman remains passive, does
not let go and waits until her male partner evokes in her feelings of arousal and
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pleasure (Barbach & Flaherty, 1980; Sanchez et al., 2006). With such a rigid sexual
pattern it will likely be difficult to assertively aim for one’s own sexual arousal and
pleasure. This would again suggest an important role for sexual autonomy as a
factor positively affecting women’s sexual pleasure and orgasm.
Cognitive theories on sexual functioning emphasize the importance of anxiety
and attention to sexual stimuli. Anxiety associated with sexual experiences can
interfere with the ability to relax and can lead to attention to a number of (nonsexual) concerns resulting in inhibition of sexual arousal and orgasm (Barlow, 1986;
van den Hout & Barlow, 2000). Women who feel that they must remain in control,
and who may have learned to fear the loss of control at high levels of arousal, are
more likely to have difficulties in focusing their attention to sexual stimuli and their
own subsequent bodily sensations (‘‘solo’’-phase) (Heiman, 2007). Couples where the
female partner is anorgasmic report more problems with sexual communication than
couples without sexual difficulties or couples experiencing chronic illness (Kelly,
Strassberg, & Turner, 2004). Since communication is an interactive experience,
understanding the communication dynamics of the couple is important. Male
partners of women with FOD experience greater discomfort discussing sexual
problems as compared to controls, thus suggesting that inability to effectively and
openly communicating about sex should be addressed at the couple level (Kelly,
Strassberg, & Turner, 2006). In recent study of middle-aged women, orgasm was
negatively influenced by low scores in overall satisfaction with partner and lack of
emotional closeness with partner (Gonzalez, Viafara, Caba, Molina, & Ortiz, 2006).
A large body of literature correlates orgasm to childhood sexual abuse. Studies
on clinical cases of women who experienced rape (sexual abuse with the use of
physical violence) tend to report greater effects on sexual functioning, including
orgasmic disorder, than studies utilizing the college population (Leonard & Follette,
2002; Rellini & Meston, 2007). It is important to note that not all women with a
history of sexual abuse develop orgasmic disorders and that the etiology of the
orgasmic disorder should not be automatically assumed to be the experience of
abuse. A recent study showed that the tendency to avoid interpersonal connections
and experiences mediated the relationship between a history of childhood sexual
abuse and low orgasmic functioning (Staples, Rellini, & Roberts, in press),
suggesting that increasing a woman’s openness to positive sexual experiences could
be useful to reduce the orgasmic difficulties experienced after sexual abuse that
occurred prior to age 16 years.
Finally, in women who report being capable of reaching high levels of sexual
excitement, and who feel that they are almost reaching orgasm, fear of loss of control
may be an issue. In that case the woman can be asked to what extent she is able to
surrender to strong emotions in general. In primary anorgasmic women irrational
cognitions about the nature of loss of control is often seen, such as the fear of
looking ‘‘strange’’ while having an orgasm or of uttering uncontrolled sounds. Often
these fears of losing control manifest themselves only later in the treatment process.
Sexual excitation: how to enhance sexual pleasure
For orgasm problems related to a lack of sexual excitation, effective cognitivebehavioural treatment is available (directed masturbation), consisting of (a
combination of) behavioural and cognitive interventions that can be applied
individually as well as in a treatment in which the partner participates (Both & Laan,
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2009). It involves graded exposure to genital stimulation, may include role playing
orgasm response, and use of sexual fantasy and/or vibrators to facilitate heightened
arousal and orgasm. It has shown well-established efficacy when administered in a
variety of modalities: group, individual, couples therapy and bibliotherapy. Of the
eight controlled randomized trials that compared directed masturbation with no
treatment, only one study failed to show efficacy for the active treatment (Ter Kuile,
Both, & van Lankveld, in press). The success rates for directed masturbation training
(administered individually or in groups, with or without involvement of the partner) in
women with primary anorgasmia are generally high: 60–90% of the women become
orgasmic with masturbation and 33–85% will become orgasmic with partnered sexual
activity. Some studies have shown significant results after four sessions of 30 minutes,
while other studies were able to demonstrate that beneficial effects remained up to two
months after the end of therapy (Heinrich, 1976; Hurlbert & Apt, 1995). Heiman
(2002) concluded that behavioural and cognitive behavioural treatments for primary
orgasmic disorder fulfill well-established criteria for ‘‘efficacy’’, while for secondary
orgasmic disorder they are only ‘‘probably efficacious’’.
For orgasm problems not due to medical conditions, sildenafil is often used, but
efficacy studies have reported mixed results (Rellini & Clifton, 2011). Few studies are
available that demonstrate an enhancing effect of hormones on sexual pleasure and
orgasm. Among 300 women who received bilateral salpingo-oophorectomy and
hysterectomy, 300 mg of testosterone patch showed improvements in FOD
symptoms (Braunstein et al., 2005). Similarly, 10 mg of testosterone gel had positive
effects on orgasm (Davis et al., 2008). Additionally, tibolone, a synthetic steroid
available in Europe, has shown improvements in orgasmic functioning (Kamenov,
Todorova, & Christov, 2007).
Sexual inhibition: how to decrease control
Not much is known about orgasm problems that may be due to not being able to
lose control. It is generally assumed that in order for sexual arousal to occur and to
allow it to continue to orgasm, the woman needs to ‘‘let go’’ and, to some extent, lose
control (Bancroft, 2009). These theoretical and clinical assumptions agree with a
recent brain imaging study that showed that orgasm requires deactivation of parts of
the frontal cortex (Georgiadis et al., 2006).
Some women have the erroneous idea that the orgasm-experience represents
ultimate loss of control and a vulnerability that should be avoided. For these women
and for women who fear of losing even moderate control, the use of ‘‘role play’’
orgasm may be used (Heiman & LoPicollo, 1986). In such ‘‘role play’’ a woman
pretends she is losing control and is experiencing high sexual arousal and orgasm.
This may help to overcome the fear of showing the uncontrolled behavior that may
accompany orgasm. ‘‘Role playing’’ may be effective on its own (Lobitz &
LoPiccolo, 1972). Currently, however, there is a lack of empirical evidence that
supports the importance of this technique (Laan, Rellini, & Barnes, in press).
Mindfulness and yoga practices can be considered to be related to sensate-focus
exercises, but may specifically be helpful with fear of losing control because they
facilitate attentional focus directed towards ‘‘being in the moment without
judgement’’. A small, open study reported improvement in sexual function in 40
women receiving 12 weeks of yoga (Dhikav et al., 2010). Assessments using the
Female Sexual Function Index showed that women over 45 years of age improved
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maximally on their arousal scores, while younger women were most likely to
experience improvement in the quality of orgasm and satisfaction. A non-controlled
study of 22 women with cervical or endometrial cancer found a structured threesession mindfulness-based psychoeducation to significantly improve self-reported
sexual desire, arousal, orgasm and satisfaction (Brotto et al., 2008). The same
treatment protocol administered in a group format was also efficacious (Brotto,
Basson, & Luria, 2008). The first study using wait-list controls also found significant
improvements in all domains of sexual response (Brotto et al., under review). We
recommend that more research effort is given to studying factors associated with
sexual inhibition.
Notes on contributors
Ellen Laan, PhD, is a registered sexologist, health-care psychologist and associate professor at
the Department of Sexology and Psychosomatic Obstetrics and Gynaecology, Academic
Medical Center, University of Amsterdam, The Netherlands.
Alessandra H. Rellini, PhD, is a licensed clinical psychologist and assistant professor at the
Human Sexuality Research Clinic, Department of Psychology, University of Vermont, USA.
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