Female orgasmic disorder (FOD) is the persistent or recurrent inability of a woman to have an orgasm (climax or sexual release) after adequate sexual arousal and sexual stimulation. According to the handbook used by mental health professionals to diagnose mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (also known as the DSM-IV-TR), this lack of response can be primary (a woman has never had an orgasm) or secondary (acquired after trauma), and can be either general or situation-specific. There are both physiological and psychological causes for a woman's inability to have an orgasm. To receive the diagnosis of FOD, the inability to have an orgasm must not be caused only by physiological problems or be a symptom of another major mental health problem. FOD may be diagnosed when the disorder is caused by a combination of physiological and psychological difficulties. To be considered FOD, the condition must cause personal distress or problems in a relationship. In earlier versions of the Diagnostic and Statistical Manual of Mental Disorders,FOD was called "inhibited sexual orgasm."
Description
FOD is the persistent or recurrent inability of a woman to achieve orgasm. This lack of response affects the quality of the woman's sexual experiences. To understand FOD, it is first necessary to understand the physiological changes that normally take place in a woman's body during sexual arousal and orgasm.
Normally, when a woman is sexually excited, the blood vessels in the pelvic area expand, allowing more blood to flow to the genitals. This is followed by the seepage of fluid out of blood vessels and into the vagina to provide lubrication before and during intercourse. These events are called the "lubrication-swelling response."
Body tension and blood flow to the pelvic area continue to build as a woman receives more sexual stimulation; this occurs either by direct pressure on the clitoris or as pressure on the walls of the vagina and cervix. This tension builds as blood flow increases. When tension is released, pleasurable rhythmic contractions of the uterus and vagina occur; this release is called an "orgasm." The contractions carry blood away from the genital area and back into general circulation.
It is normal for orgasms to vary in intensity, length, and number of contractions from woman to woman, as well as in a single individual from experience to experience. Unlike men, woman can have multiple orgasms in a short period of time. Mature women, who may be more sexually experienced than younger women, may find it easier to have orgasms than adolescents or the sexually inexperienced.
In FOD, sexual arousal and lubrication occur. Body tension builds, but the woman is unable or has extreme difficulty reaching climax and releasing the tension. This inability can lead to frustration and unfulfilling sexual experiences for both partners. FOD often occurs in conjunction with other sexual dysfunctions. Also, lack of orgasm can cause anger, frustration, and other problems in the relationship.
Causes and symptoms
With FOD, a woman either does not have an orgasm or has extreme difficulty regularly reaching climax. It is normal for women to lack this response occasionally, or to have an orgasm only with specific types of stimulation. The occasional failure to be reach orgasm or dependence on a particular type of stimulation is not the same as FOD.
The causes of FOD can be both physical and psychological. FOD is most often a primary or lifelong disorder, meaning that a woman has never achieved orgasm under any type of stimulation, including self-stimulation (masturbation), direct stimulation of the clitoris by a partner, or vaginal intercourse. Some women experience secondary, or acquired FOD. These women have had orgasms, but lose the ability after illness, emotional trauma, or as a side effect of surgery or medication. Acquired FOD is often temporary.
FOD can be generalized or situation-specific. In generalized FOD, the failure to have an orgasm occurs with different partners and in many different settings. In situational FOD, inability to reach climax occurs only with specific partners or under particular circumstances. FOD may be due either to psychological factors or a combination of physiological and psychological factors, but not due to physiological factors alone.
Physiological causes of FOD include:
damage to the blood vessels of the pelvic region
spinal cord lesions or damage to the nerves in the pelvic area
FOD is more likely to have a psychological, rather than a physical cause. Inadequate time spent in foreplay, inadequate arousal, lack of appropriate sexual stimulation, poor sexual communication with a partner, and failure to continue with stimulation for an adequate length of time may cause failure to climax, but are not considered causes of FOD.
Demographics
Inability to have an orgasm, discontent with the quality of orgasms, and the ability to have orgasms only with one type of stimulation are common sexual complaints among women. Some studies have found that about half of all women experience some orgasmic difficulties, but not of all these difficulties are considered FOD. About 50% of women experience orgasm through direct clitoral stimulation but not during intercourse, thus not meeting the criteria for a diagnosis of FOD. About 10% of women never experience an orgasm, regardless of the situation or stimulation. These women are more likely to be unmarried, young, and sexually inexperienced.
Diagnosis
FOD is diagnosed through a medical and psychological history and history of the conditions under which orgasm fails to occur. It is especially helpful for the clinician or sex therapist to understand how long the problem has persisted, and whether it is general or situational. FOD is sometimes found in conjunction with sexual aversion disorderand female sexual arousal disorder, making the diagnosis complex. To be diagnosed with FOD, the lack of orgasmic response must occur regularly over an extended period of time; based on the clinician's judgment, it must be less than would be reasonable based on age, sexual experience, and the adequacy of sexual stimulation. The lack of orgasm must cause emotional distress or relationship difficulties for the woman and be caused either only by psychological factors alone or by a combination of psychological and physical factors. According to the American Psychiatric Association (APA), a diagnosis of FOD is not appropriate if failure to climax is due only to physiological factors. FOD is also not diagnosed if it is a symptom of another major psychological disorder, such as depression.
Treatments
When failure to reach orgasm is caused by a physical problem, the root problem is treated. In other cases, a combination of education, counseling, psychotherapy, and sex therapy are used—often along with directed exercises to increase stimulation and decrease inhibitions—either for the individual or for the couple. As of 2002, clinical trials are under way to investigate the effect of sildenafil (Viagra) on women's sexual response. Sildenafil has already been proved effective in helping men to attain and maintain an erection.
Sex therapists have special training to help individuals and couples focus on overcoming specific sexual dysfunctions. In couples therapy, they often assign "homework" that focuses on relaxation techniques, sexual exploration, improving sexual communication, decreasing inhibitions, and increasing direct clitoral stimulation. Individually, a woman might be encouraged to masturbate either through self-stimulation or with a vibrator. In addition, Kegel exercises, which improve the strength and tone of the muscles in the genital area, may be recommended.
Traditional psychotherapy, or talk therapyalone or in conjunction with sex therapy, can be effective in resolving psychological causes of FOD, especially when those causes are rooted in past sexual or emotional exploitation or cultural taboos. Psychotherapy is also helpful in resolving relationship tensions that develop as a result of frustration from FOD.
Prognosis
Many women with FOD can be helped to achieve orgasm through a combination of psychotherapy and guided sexual exercises. However, this does not mean that they will be able to achieve orgasm all the time or in every situation, or that they will always be satisfied with the strength and quality of their climax. Couples often need to work through relationship issues that have either caused or resulted from FOD before they see improvement. This process takes time and requires a joint commitment to problem solving.
Prevention
There are no sure ways to prevent FOD. However, reducing life factors that cause stresscan be effective. Seeking counseling or psychotherapy for past trauma, or when problems begin to appear in a relationship, can help minimize sexual dysfunction problems.
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.4th edition, text revised. Washington DC: American Psychiatric Association, 2000.
Berman, Jennifer, M.D., and Laura Berman, Ph.D. For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life.New York: Henry Holt, 2001.
Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry.7th ed. Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.
PERIODICALS
Everaerd, Walter and Ellen Laan. "Drug Treatments for Women's Sexual Disorders." Journal of Sex Research37 (August 2000):195-213.
Phillips, Nancy. "Female Sexual Dysfunction: Evaluation and treatment." American Family Physician(1 July 2000).
ORGANIZATIONS
American Association of Sex Educators, Counselors, and Therapists (AASECT). P. O. Box 238, Mount Vernon, IA 53214-0238. (319) 895-8407. <www.aasect.org>.
Sexual Information and Education Council of the United States (SIECUS). West 42nd Street, Suite 350, New York, NY 10036-7802. <www.siecus.org>.
