Horney out PMC Labs and tell us what you think. Learn More. As a diagnostic category, primary orgasmic dysfunction includes all women who have never experienced orgasm under any circumstances except sleep or fantasy. However, the research samples of nonorgasmic women in clinical reports and empirical investigations are heterogeneous with regard to disruption of earlier phases of the sexual response cycle and emotional concomitants of the dysfunction.
The major treatment models—systematic desensitization, sensate focus, directed masturbation, and hypnosis—are presented, and empirical support is reviewed. Separate discussion is included for investigations comparing treatment modalities. Finally, a strategy for future programmatic sex therapy research is suggested within the broader context of psychotherapy outcome research.
Despite the sexual information and treatment advances of recent years, the incidence of this sexual difficulty appears unchanged. From his sample of married women, 8. Although there are interpretive difficulties with such Iowa data, convergent evidence appears to indicate that primary orgasmic dysfunction remains a clinical problem of considerable magnitude. In the absence of organic or Harris problems, most orgasmic difficulties are regarded as psychogenic. Yet for many years traditional psychotherapy i. The present article reviews the treatments for primary orgasmic dysfunction for which ificant clinical support and empirical documentation exist, which include systematic desensitization, sensate focus, directed masturbation, and hypnosis.
Primary orgasmic dysfunction: diagnostic considerations and review of treatment
Each technique is briefly Iowa so that the reader can discern differences between them as well as variations in their application. During the last 20 years the sex therapy literature has progressed from case studies and individual analyses, through single Horney des and own-control group des, to treatment comparisons with untreated women.
The reviews for each treatment will follow this framework rather than a chronological progression per se. Controlled treatment comparisons are presented in a final section. In surveying research of primary orgasmic dysfunction it will become obvious to the reader that the women included in the investigations represent a continuum of psychological, physiological, and behavioral sexual responsivity despite their sharing the failure to have experienced orgasm.
Therefore, to structure the presentation, discussion of the diagnosis of female sexual dysfunction with particular emphasis on inorgasmia is included. An effort will be made in the review to provide sufficient detail so that the reader may begin to discern not only which treatments have the greatest Harris but also which treatments might be best suited for particular subgroups of nonorgasmic women. Traditionally, female sexual dysfunction has been referred to by the generic term frigidity and considered a single syndrome.
Researchers and clinicians have since devised less disparaging and more descriptive diagnostic classifications of the variations in female sexual responsiveness and functioning.
The basic diagnostic distinctions that have emerged seem to parallel disruptions of the phases of the sexual response cycle—desire, excitement, and orgasm—as conceptualized by Masters and Johnson and Kaplan b Inhibited sexual desiredefined as persistent and pervasive inhibition of sexual desire, is a recent addition to the Diagnostic and Statistical Manual of Mental Disorders DSM-III; APA,but the most extensive description of the difficulty has been offered by Kaplan She describes an individual with low desire as Horney uninterested in sex.
This can include an woman of fantasy, initiating behaviors, and physiological response even when stimulated. Iowa individuals may eventually become so avoidant as to be described as sexually phobic. Clinical reports of such patterns do exist Kaplan, More typically, however, disruption in focus, intensity, or duration of sexual activity is inevitable, and excitement or orgasm phase dysfunctions could occur concomitantly.
There has been diagnostic confusion surrounding the description Harris women who experience a disruption of or a total absence of the excitement phase of the sexual response cycle. DSM-III relies on a physiological definition of inhibited sexual excitement: recurrent or persistent inhibition that in partial or complete failure to attain or maintain the vasocongestion and lubrication responses of early sexual arousal. Others using the same physiological criterion have added psychological or emotional concomitants to their definitions. Under the same rubric would be a group of women ranging from those with strong aversions to sexual activity, through those who experienced no pleasure but neutral reactions, to those emotionally satisfied with the affectional components rather than the sexual activity per se.
It thus appears that some writers include emotional concomitants in excitement phase difficulties that others might describe as desire phase problems. As with desire phase difficulties, orgasmic disruption could easily occur due to an insufficient level of excitement. Before turning to the definition of orgasmic dysfunction, it is useful to consider discussion of the female orgasmic response. This includes facial grimacing, generalized myotonia, carpopedal spasms, contractions of the gluteal and abdominal muscles, and the rhythmic contractions of the orgasmic platform.
As has been noted Levin,all of these s, with the exception of the vaginal contractions, can be simulated or experienced during the late plateau stage. This author as well as others e. However, authorities differ on whether or not the definition of inorgasmia includes impairment of the desire and excitement phases. Kaplan a notes that any disruption in the excitement phase would only include the physiological response and not the psychological.
The focus of this paper, primary orgasmic dysfunction, includes women who have never experienced orgasm under any circumstance except sleep or fantasy. If the woman has experienced orgasm but expresses concern with its frequency or circumstances of occurrence, then the difficulty is described as secondary orgasmic dysfunction.
A common complaint here is orgasm occurring on a random basis or not with coitus.
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Although the primary versus secondary distinction is not clear, attempts have been made to discover diagnostically discriminating variables. Survey research has described sexual response patterns in women and suggested personality and sexual history variables that may play a role in whether or not a woman is orgasmic. Raboch and Bartak surveyed 1, Czechoslovakian women attending an infertility clinic. They found a relationship between orgasm and age at menarche and proposed that later puberty predisposes a woman to lesser orgasmic capabilities and less frequent sexual activity.
In a multivariate study of demographic characteristics, cognitive measures of sexual arousability, and sexual behavior ratings, Hoon and Hoon compared women with the lowest and highest orgasmic consistency. Women with the lowest orgasm consistency reported less frequent coitus and masturbation, found gently seductive erotic activities versus erotica more arousing, and were less aware of physiological changes accompanying sexual arousal than were women with the highest orgasm consistency.
Investigations of women seeking sex therapy also provide information about possible distinctions between the two diagnostic .
McGovern, Stewart, and LoPiccolo suggested that secondary couples may have greater marital distress than primary couples. Although this was the case prior to sensate focus treatment, both groups of couples improved and there were no differences between them at posttreatment. Huey, Kline-Graber, and Graber compared the frequency of various sexual behaviors prior to treatment for primary, coitally inorgasmic secondary, and completely orgasmic women. There were no differences between the groups in terms of foreplay or intromission duration.
Both primary and secondary women had a greater frequency of intercourse than orgasmic women, and secondary women masturbated more often than either of the other groups. A few investigations have compared the response of primary and secondary subjects to treatment.
Masters and Johnsonusing sensate focus woman, present the Harris data sample. In another investigation of sensate focus, Heiman and LoPiccolo Note 2 noted comparable improvement between primary and secondary subjects. Although the data from the survey, descriptive, and treatment outcome investigations are far from conclusive, taken together they provide reason to continue with the working hypothesis that the primary versus secondary distinction is an important one to maintain for research, if not clinical, purposes.
Certainly for iowathe sexual response patterns of women need further description Horney the presence or absence of orgasm. The diagnostic commonality in the research reviewed here is the complete absence of vaginal contractions or orgasm. However, the sample is heterogeneous with regard to disruption of earlier phases of the sexual response cycle and the emotional concommitants of the inorgasmia condition. Descriptive clinical information provided by the investigators will be included to facilitate the identification of subgroups of primary inorgasmic women.
One behavioral treatment that has received considerable attention in the sex therapy literature is systematic desensitization. A treatment seen as having the greatest utility when anxiety plays a central role in the dysfunction, systematic desensitization involves four components. First, the client is trained to relax the muscles of her body through a sequence of exercises.
Second, a list of the specific stimuli or situations that are anxiety provoking is generated and arranged hierarchically.
Third, during desensitization proper the deeply relaxed client confronts in imagination each of the feared situations as they are described by the therapist. Fourth, after the hierarchy items are imagined one by one without arousing anxiety, the client is instructed to engage in the sexual activities in real life to augment anxiety reduction and to determine whether, in fact, the stimuli have lost their anxiety-evoking properties.
Joseph Wolpe conceptualized many sexual problems, inorgasmia included, as the result of anxiety and proposed desensitization as a treatment ideally suited to sexual dysfunction. In his view, the sympathetic activity characteristic of anxiety inhibits the local i. Wolpe hypothesized that the muscular relaxation component of the treatment produces a state of parasympathetic dominance.
Relaxation paired with anxiety-evoking stimuli breaks the stimulus-response bond. Thus, in the absence of these inhibiting events, the parasympathetic activity of early sexual arousal proceeds unimpaired.
His conceptualization of an interaction between anxiety and dysfunction, his introduction of the treatment, and recording of his own clinical practice served as a catalyst for further descriptive and empirical investigations. This report adds to knowledge by hypothesizing client variables that might interact with outcome, assessing the maintenance of gains, and specifying potentially relevant outcome variables.
Since these early efforts, subsequent case studies have presented modifications in the standard desensitization treatment format. In treating five nonorgasmic women who also complained of anxiety or pain during intercourse, Brady used intravenous injections of Brevital to induce relaxation.
Men and Ullmann presented the successful use of desensitization within a cont therapy framework. Both a nonorgasmic woman and her partner were trained in relaxation and the partner also participated during hierarchy construction and item presentation.
Ince instructed one primary nonorgasmic woman to practice relaxation prior to her in vivo sexual activities.
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After avoiding men and sexual contact for the majority of her life, following 84 desensitization sessions the woman was able to have male friends, date, and engage in intercourse without difficulty. Finally, Caird and Wincze presented the successful treatment of a nonorgasmic female who had an aversion to sexual intercourse and who generally viewed sex as disgusting and sinful. Treatment was modified by having the spouse participate as in the Men and Ullmann case and by presenting the hierarchy items in videotaped segments. During desensitization proper the client was instructed to visualize herself and her spouse engaging in the activities portrayed by models on film.
As with the clinical reports, these case studies offer no further evidence for the specific efficacy of systematic desensitization.
This leaves open the possibility that improvement is due to spontaneous change in sexual functioning or change in other life areas e. Confounding within the treatment domain also prevents establishing cause-effect relationships for systematic desensitization.
Here the major difficulty is the confounding of the technique with its application by a particular therapist, such as Wolpe or Lazarus. A related source of error comes from the uncontrolled and unknown effects of just being in treatment, placebo effects, which alone may result in improved sexual functoning. If at least some form of pre- and posttreatment assessment is included for the case study, some basis of comparison is introduced.
However, the confounding within the client, therapist, and treatment variable classes and the possibility of interaction between them are inherent sources of experimental error for the individual case study. Jones and Park presented the first large-sample uncontrolled report of modified desensitization for primary orgasmic dysfunction.
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Brevital-assisted relaxation and inclusion of the spouse as an observer during desensitization proper were the treatment modifications for 55 treatment cases. All clients were seen individually by an unspecified of staff gynecologists and residents. However, the presence of multiple replications across subjects and therapists increases the confidence in ruling out sources of error within these domains and strengthens hypotheses regarding the efficacy of desensitization supplemented with drug-induced relaxation and partner participation.
Sotile and Kilmann evaluated the use of desensitization with an own-control group de.