Orgasm Disorders


Female Orgasmic Disorder in the DSM

  • FOD was first included in DSM-III as “inhibited female orgasm”
  • Renamed FOD for DSM-IV and DSM-IV-TR
  • DSM-IV included distress criteria and interpersonal difficulty
  • In DSM-V they added duration and frequency criteria
    • "Marked delay in, marked infrequency of, or absence of orgasm"
    • "Markedly reduced intensity of orgasmic sensations
    • Recurrent and persistent
    • Mild, moderate, severe
    • Minimum duration of approx. 6 months
    • Experienced in at least 75% of specified sexual encounters
    • New criteria added for intensity of symptom
    • Reflects idea that orgasm is not “all or nothing”, it is a spectrum
    • Not better explained by: a nonsexual disorder, as a consequence of sever relationship distress, or result of substance/ meds
    • NOT: if a woman can only orgasm from external stimulation or cannot orgasm due to inadequate sexual stimulation


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DSM V: Other Important Considerations


●Prevalence
○10- 42% of women have identified as having FOD
○10% of women never experience an orgasm in their lifetimes
●Culture
○Prevalence ranges in different cultures, from 17.7% (N. Europe) to 42.2% (SE Asia)
●Risk Factors
○Psychological (anxiety, depression, sexual scripts)
○Environmental (gender roles, culture)
○Genetic and Physiological (medication, atrophy, genes)
●Cascading Effect/Comorbidity

Etiology


●Assess for: Partner factors, relationship factors, individual vulnerability factors, cultural/ religious factors, medical factors (DSM)
●Physiological
○Genital mutilation, vulvovaginal atrophy, medical side- effects, weight gain, post-surgery effects, alcohol or smoking
■“SSRIs are known to delay or inhibit orgasm in women, affecting between 30 and 60% of individuals taking them” (Binik & Hall, 99)
●Psychological
○Stress, anxiety, cultural norms, societal expectations, depression
●Relational
○Relationship conflict, reduced desire for partner, sudden relationship changes (new baby, job loss, death in the family, etc.)


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FOD Fast Facts

  • Affects 10- 42% of women
  • Lack of orgasm is the second most common complaint in women after low desire
  • 10% of women report never having an orgasm in their lifetimes

  • Culturally FOD has been reported very differently. Northern Europe reports 17.7%, while Southeast Asia reports 42.2%
  • Risk factors can be psychological, environmental, or physiological
    • Psychological: Stress, depression, ideas of what sex "should be", body image issues
    • Environmental: Pressure due to societal norms and expectations, cultural factors, gender roles
    • Physiological: Medication side effects, other health diagnoses, atrophy, weight issues
  • Differential diagnoses
    • Nonsexual mental disorders: depression, body dysmorphia
    • Substance use/ medications: SSRI side effects, loss of sensation due to alcohol use
    • Other medical conditions: Heart problems, vaginal atrophy
    • Interpersonal factors: relationship conflict, insufficient stimulation by partner
    • Other sexual dysfunctions: desire/ arousal disorder, anorgasmia (lifelong inability to ever reach orgasm)
  • Diagnosis is made based only on self-report!

  • Often seen with sexual interest/ arousal disorders


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In googling female orgasm and female orgasmic disorder, most of the results either give commercial suggestions like “10 new sex positions sure to get her off” like this number one result from MENS FITNESS.


In looking for information about this disorder in a simple Google search, results mostly showed information for female sexual dysfunction, which is not exactly the same as female orgasmic disorder.


Snippets from the FOD Literature


As discussed by Robinson et al. (2010), a sexual health model exists with ten factors being...“talking about sex, culture and sexual identity, sexual anatomy and functioning, sexual health care and safe sex, challenges to sexual health, body image, masturbation and fantasy, positive sexuality, intimacy and relationships, and spirituality.”

'Standard Operating Procedures' Study
Laan, Rellini, and Barnes (2013) selected by the International Society for the Study of Sexual Medicine, outline standard operating procedures for treating FOD being…

1. Do not diagnose FOD only on failure to have an orgasm during intercourse alone as normal sexual
responses vary.
2. Preferred stimulation should be carefully assessed before diagnosing FOD.
3. Distress needs to be clearly reported.
4. There is evidence to suggest that the clitoral complex may be stimulated via vaginal intercourse.
5. Many risk factors should be assessed during treatment and diagnosis of FOD (psychosocial factors,
cognitive/affect factors, relationship factors, childhood history, medical history, medications)
6. When orgasm problems exist only during sex with a partner, the partner should be involved in treatment.
7. PLISST treatment is suggested (Providing Permission, Limited information, followed by Specific

suggestions if the problem is not resolved, followed by Intensive Therapy.)
8. Cognitive and behavioral therapies should be used, as well as directed masturbation, sensate focus, and
mindfulness.
9. Possibly look at hormone therapies, specifically for post-menopausal women with suggestion that
researchers continue to look at the effects on women.
10. Researchers also suggest that more research be done on PDE5 (phosphodiesterase type 5 inhibitors).
11. Recommend further research be done on nutritional supplements
12. When FOD is medication-induced, researchers suggest to first wait for tolerance to build, then for medication switches.

Mixed messages within the literature about not only best practices, but prevalence of orgasms. Brody et al. (2013) report that Laan’s research of best practice is misinformed at “risks harming women’s health” (Brody et al. 2013 pp 2606). Their work reports that evidence suggests that nearly a majority of women can reach orgasm vaginally without need for clitoral stimulation.

“Communication problems are believed to play a central role in
many sexual dysfunctions. The present study behaviorally assessed
communication patterns within heterosexual couples in which the
woman was

experiencing female orgasmic disorder and within two

groups of control couples. The sexually dysfunctional couples evidenced
significantly poorer communication than controls, primarily
but not exclusively when discussing sexual topics. Specifically,
women with orgasmic disorder or their male partners demonstrated
more blame a

nd less receptivity.”

Kelly, Strassberg, & Turner (2006)
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----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Zietsch et al. (2011) that medical models and evolutionary/biology perspectives suggest that if low to no rates of orgasm is dysfunctional, then high rates of orgasm is functional.


Researchers conducted a study on twins to test whether phenotypic or genotypic information as well as several other factors (perceived “sexually relevant traits” pp. 2307) had any relation with orgasm rates.
This data hoped to distinguish if there was a biological/ evolutionary link in orgasms.
Researchers found that rates of types of orgasm varied greatly, independent of the evolutionary factors and sexually relevant traits (SES, personality, health, number of partners, sexual preference).Women in this study were most likely to orgasm during masturbation than any other sex act.

Lavie-Ajayi (2005) interviewed women on their perceptions of orgasm and their wants regarding treatment.

The articles author points out that both the pro-medical and pro-psychosocial sides argue they are looking out for what is best for women and attempting to legitimize and improve women's sexual functioning.

What authors suggest looking at is women’s view on their sexual functioning and what influences their sexual satisfaction. Women frequently point out that their partners perspective is important and that social pressures about what is “normal” influence their perspective on satisfaction.

Authors stress the emotional/ relational meaning of inability to orgasm as something that needs to be the focus of future research.

Researchers conducted semi-structured interviews with women of different ages and status (with and without children, married, unmarried) as well as half defining themselves as having orgasm difficulties.

Qualitatively, women in this reported relational difficulties in that their partners would experience distress causing them to either be pressured or appreciative of their partners efforts/focus on their orgasm.

Communication with partners was reportedly difficult due to perceived social norms of talking about self satisfaction

Other women reported lack of orgasm through non-clitoral stimulation as not a problem or not a large part of their life as a whole (however a few of these women also noted social pressures such as media suggesting they should want to orgasm as influencing their views).

Findings from Kingsberg et al. (2013): The term “frustrated” was the most relevant and common emotion women feel when they have difficulties in achieving orgasm. Additionally, the women consistently supported the content validity of question 15 of the FSDS-DAO. Despite the use of the term “distress” in the DSM-IV-TR criteria for FOD, the term reflects the medical construct required to become a sexual dysfunction and does not appear to be an accurate representation of most women’s feelings of orgasm difficulties.

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IsHak, W. W., Bokarius, A., Jeffrey, J. K., Davis, M. C., & Bakhta, Y. (2010). Disorders of orgasm in women: A literature review of etiology and current treatments. Journal Of Sexual Medicine, 7(10), 3254-3268:
This study was done to review the current and past literature on women’s orgasmic disorders and to gain more knowledge on what contributes to the condition. They are also hoping to review treatment options and success rates. Using PSYCinfo to search terms such as “orgasm”, “female”, and “female orgasmic disorder” from 1980 to 2009, researchers found peer reviewed journal publications written in English on these topics to research. They included 100 studies, which indicated that common factors associated with orgasmic dysfunction in women were related to a wide variety of causes that were biological, psychological, and interpersonal. While most of the studies that were looked at lacked generalizability due to certain factors such as small sample sizes or studies done on specific populations, results did indicate that there are somewhat effective treatments available, and that better and more effective treatments will emerge once more research is done on female orgasmic disorders.

Burri, A. V., Cherkas, L. M., & Spector, T. D. (2009). Emotional intelligence and its association with orgasmic frequency in women. Journal Of Sexual Medicine, 6(7), 1930-1937:
This study was done to find out if normal levels of emotional intelligence were associated with orgasmic frequency during intercourse and masturbation. This could help determine behavioral risk factors for FOD. For this study, 2,035 individual females from the TwinsUK London registry filled out a self-report questionnaire assessing various aspects of their lives with emphasis on sexual functioning. The findings showed an association between female orgasmic frequency and normal variations in emotional intelligence. Researchers concluded based on the findings that women who have a high emotional intelligence level have a higher ability to achieve orgasm more frequently. Note: because the study did not use the standardized definition of female orgasmic disorder and did not measure distress, these results may not be generalized to FOD. The correlations between emotional intelligence and masturbation were stronger than the correlations between emotional intelligence and intercourse, which may be explained by another finding, which is that the women experienced more orgasms during masturbation. Also of note is “alexythymia”, which is the “difficulty in recognizing, identifying, and communicating emotions, reduced fantasy capacity and an externally oriented cognitive style--- which has been reported to be strongly and inversely related with emotional intelligence” (Burri, 2009), indicating that it may lead to lower ability to have orgasms.














Interesting Websites:



Four Types of Orgasms Every Woman Should Have...by a women's health magazine?!

Men's Health Magazine: How to Get Women to the O'Zone

Orgasmic Birth



Treatment of FOD:
“Currently cognitive behavior therapy (CBT) is the most effective treatment for FOD but there is little published data on success rates. These CBT methods include directed masturbation, sensate focus exercises, and systematic desensitization. The goal of most of these strategies is to help women become more comfortable with their o
wn genitals and sexuality by altering negative attitudes, decreasing anxiety, and learning self-stimulation. There are currently no pharmacologic treatment options for women with FOD.”
Kingsberg et al. (2013)












The above video discusses a nasal spray that is being discussed as a treatment to increase orgasms!

DSM V: Delayed Ejaculation

Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%–100%) of partnered sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay:

1.Marked delay in ejaculation.
2.Marked infrequency or absence of ejaculation.
2.Symptoms have persisted for a minimum duration of approximately 6 months.
3.The symptoms in Criterion A cause clinically significant distress in the individual.
4.The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.
Specify whether:
Lifelong or Acquired, Generalized or Situational
Mild, Moderate, Severe
According to the DSM V, prevalence for this disorder is unknown due to an unclear definition and it being a rare complaint for men (> 1%). Coital anorgasmia is the most common complaint among men.

DE Treatment
Perelman (2013) suggests behavioral treatments as there are no FDA approved medications for this disorder, including...
-Suspended masturbation
-Altering masturbation style (using condoms, switching hands)
-Exploration and focus on fantasies or alteration in fantasy

DSM V: Premature Ejaculation



1.A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it.

Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities.

2.The symptom in Criterion A must have been present for at least 6 months and must be experienced on almost all or all (approximately 75%–100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts).

3.The symptom in Criterion A causes clinically significant distress in the individual.

4.The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

Lifelong or Acquired; Generalized or Situational; Mild, Moderate or Severe.



This Youtuber has some funny, friendly, nonclinical tips and some good information on sex! Check her out!

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References & Recommended Literature

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.
Binik, Y. M., & Hall, K. S. K. (Eds.). (2014). Principles and practice of sex therapy (5th ed.). New York, NY: The Guilford Press.
Brody, S., Costa, R. M., & Hess, U. (2013). “Standard operating procedures for female orgasmic
disorder” is not based on best evidence. Journal Of Sexual Medicine, 10(10), 2606-2609.
Burri, A. V., Cherkas, L. M., & Spector, T. D. (2009). Emotional intelligence and its association with orgasmic frequency in women. Journal Of Sexual Medicine, 6(7), 1930-1937. doi:10.1111/j.1743-6109.2009.01297.x
IsHak, W. W., Bokarius, A., Jeffrey, J. K., Davis, M. C., & Bakhta, Y. (2010). Disorders of orgasm in women: A literature review of etiology and current treatments. Journal Of Sexual Medicine, 7(10), 3254-3268. doi:10.1111/j.1743-6109.2010.01928.x
Kingsberg, S.A., Tkachenko, Lucas, J., Burbrink, A., Kreppner, W., & Dickstein, J.B. (2013). Characterization of orgasmic difficulties by women: Foxus group evaluation. Journal of Sexual Medicine, 10(9), 2242-2250.
Laan, E., Rellini, A. H., & Barnes, T. (2013). Standard operating procedures for Female Orgasmic
Disorder: Consensus of the International Society for Sexual Medicine. Journal Of Sexual Medicine, 10(1), 74-82.
Kelly, M.P., Strassberg, D.S., & Turner, C.M. (2006). Behavioral Assessment of Couples’ Communication in Female Orgasmic Disorder. Journal Of Sex & Marital Therapy, 32(2), 81-95.
Lavie-Ajayi, M. (2005). 'Because all real women do': The construction and deconstruction of
'female orgasmic disorder'. Sexualities, Evolution & Gender, 7(1), 57-72.
McMahon, C. G., Jannini, E., Waldinger, M., & Rowland, D. (2013). Standard operating procedures in the
disorders of orgasm and ejaculation. Journal Of Sexual Medicine, 10(1), 204-229.
Perelman, M. A. (2013). Delayed ejaculation. Journal Of Sexual Medicine, 10(4), 1189-1190.
Robinson, B. E., Munns, R. A., Weber-Main, A. M., Lowe, M. A., & Raymond, N. C. (2011).
Application of the sexual health model in the long-term treatment of hypoactive sexual desire and female orgasmic disorder. Archives Of Sexual Behavior, 40(2), 469-478.
Rowland, D., & Cooper, S. (2011). Practical tips for sexual counseling and psychotherapy in premature
ejaculation. Journal Of Sexual Medicine, 8(Suppl 4), 342-352.
Vandenberghe, L., de Oliveira Nasser, K. F., & e Silva, D. P. (2010). Couples therapy, female
orgasmic disorder and the therapist-client relationship: Two case studies in functional analytic psychotherapy. Counselling Psychology Quarterly, 23(1), 45-53.