Female orgasmic disorder involves orgasm that is absent, infrequent, markedly diminished in intensity, or markedly delayed in response to stimulation despite normal levels of subjective arousal.
Female orgasmic disorder can be primary or secondary:
- Primary: Women have never been able to have an orgasm.
- Secondary: Women were previously able to have an orgasm but are now no longer able to do so.
Factors that contribute to female orgasmic disorder include
- Contextual factors (eg, consistently insufficient foreplay, early ejaculation by the partner, poor communication about sexual preferences)
- Psychologic factors (eg, anxiety, stress, lack of trust in a partner)
- Cultural factors (eg, lack of recognition of or attention paid to female sexual pleasure)
- Drug therapy (eg. some antipsychotics or, commonly, selective serotonin reuptake inhibitors [SSRIs])
- Lack of knowledge about sexual function
- Damage to genital sensory or autonomic nerves or pathways (eg, due to diabetes or multiple sclerosis)
- Vulval dystrophy (eg, lichen sclerosus)
Symptoms and Signs
Women with orgasmic disorder often have other types of sexual dysfunction (eg, dyspareunia, pelvic floor dysfunction). Anxiety disorders and depression are also more common among women with this disorder.
- Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5])
Clinicians interview both partners separately and together if possible; the woman is asked to describe the problem in her own words and should include specific elements (see table Components of the Sexual History for Assessment of Female Sexual Dysfunction).
Diagnosis of orgasmic disorder is clinical, based on criteria in the DSM-5:
- Delayed, infrequent, or absent orgasm or markedly decreased intensity of orgasm after a normal sexual arousal phase on all or almost all occasions of sexual activity
- Distress or interpersonal problems due to orgasmic dysfunction
- No other disorder or substance that exclusively accounts for the orgasmic dysfunction
Symptoms must have been present for ≥ 6 months.
Because the type of stimulation that triggers orgasm varies widely, clinicians must use clinical judgment to determine whether the woman's response is deficient, based on her age, sexual experience, and adequacy of the sexual stimulation she receives.
Treatment of Orgasmic Disorder
- Psychologic therapies
Data support encouraging self-stimulation (masturbation). First-line treatment of female orgasmic disorders is directed masturbation, which involves a series of prescribed exercises.
A vibrator placed on the mons pubis close to the clitoris may help, as may increasing the number and intensity of stimuli), simultaneously if necessary. Education about sexual function (eg, need to stimulate other areas of the body before the clitoris) may help.
Sex therapy for women, with or without their partners, can often help them with concerns about sexual performance and feelings.
Other psychologic therapies, including cognitive-behavioral therapy and psychotherapy, may help women identify and manage fear of vulnerability and issues of trust with a partner. Recommending the practice of mindfulness and using mindfulness-based cognitive therapy (MBCT) can help women pay attention to sexual sensations (by staying in the moment) and not judge or monitor these sensations.
Currently, no data suggest that any drug is efficacious in the treatment of female orgasmic disorder.
- Diagnose orgasmic disorder based on DSM-5 clinical criteria.
- Treat with directed masturbation, usually as first-line therapy.
- Recommend sex therapy and other psychologic therapies to help women identify and manage factors that contribute to orgasmic disorder.