Redelman 2006
Redelman 2006
Sydney Centre for Sexual and Relationship Therapy, Bondi Junction, NSW 2022, Australia.
Email: [email protected]
Abstract. Male and female genital anatomy evolves from the same embryonic tissue. Is it therefore possible
that males and females have the same potential for orgasmic response? Have forces external to a woman’s biology
influenced her potential enjoyment of this bodily function, or is female orgasm a by-product of that early sameness
and variable because it has no or very little functional or evolutionary benefit? In modern times, we continue to
study the anatomy and physiology of female sexual responses. The journey now is to understand the similarities and
differences between the male and female sexual responses and be respectful of both. Female sexual response models
and the classification of female sexual dysfunctions direct the thoughts and treatments of sexual and relationship
therapists. The ultimate aim is to allow each woman to have the best possible sex life and orgasm, namely the one she
wants. The psychophysiological treatments for female orgasmic dysfunction are on the whole successful. However,
in anorgasmia proven to be biological in aetiology, following menopause for example, physiological changes occur
that cannot be resolved by these strategies alone. We need to be supportive of the pharmaceutical industry finding
medication that we can appropriately and responsibly use for the good of women with sexual difficulties, because
good sexuality is a very important quality of life issue for very many women.
Table 1. Differences in sexual difficulties between European– sperm time to reach the egg. The Upsuck Theory argues
American and African–American women that fertility is increased by enhanced sperm retention and
From Laumann et al. (1994)58
facilitation to the ovum by the angle and contractions of
European–American African–American the uterus during and after orgasm. The Cuddles Theory
women (%) women (%) states that female orgasm developed to help couples bond.
Unable to reach orgasm 23.2 29.2
Lloyd argues that the female orgasm has no evolutionary
Lack of interest in sex 30.9 44.5 function and proposes that the theory put forward by Symons
Sex not pleasurable 19.7 30.0 (1979),7 that the female orgasm is a by-product of the
common origin of male and female sexual development
(another example of which is nipples in men), is probably
most relevant.
it to describe the sudden release of muscular and nervous More recently, a plethora of Health Benefit Theories
tension at the climax of the sexual experience. The experience have been put forward. The endorphin release of orgasm
is difficult to describe in subjective detail, especially for has been touted as beneficial for mental health (sexually
women, because there is wide inter- and intra-person active people are less vulnerable to depression and suicide),
variation. Women also have a potential to experience multiple pain management (oxytocin causes release of endorphins,
orgasms within a short time without a refractory period given which act as analgesics, ref. 8), immunity (frequent sexual
appropriate mental and physical stimulation. activity boosts levels of white cells, ref. 9), cancer resistance
Meston et al. (2004) defined orgasm as ‘a sensation (oxytocin and dehydroepiandrosterone (DHEA) levels affect
of intense pleasure creating an altered consciousness breast cancer), heart disease (good aerobic exercise and burns
state accompanied by pelvic striated circumvaginal 200 calories) and others.
musculature and uterine/anal contractions and myotonia that Most of these ‘theories’ are the result of small,
resolves sexually induced vasocongestion and induces unvalidated studies or clinical observations, and there
well being/contentment’.3 However, this does not are as many arguments for as there are against each
define the experience of women who become aroused, idea. Certainly, many women who don’t enjoy sex have
experience contractions, but do not experience the ‘well orgasms, many who dislike their partner have sex and
being/contentment’ of this definition. become pregnant, and women with good sex lives become
ill. However, our quest for understanding and explaining
What is anorgasmia?
is interesting.
Anorgasmia is a primary or secondary situation where a
woman experiences a persistent or recurrent absence of Female orgasms during history
sexual orgasm following a normal excitement/arousal phase Before written history, we can only surmise that in
with adequate stimulation. The label ‘anorgasmic’ when matriarchal societies women’s sexuality was unfettered.
applied to a woman can be quite pejorative, and Hite (1976) It would make sense that physically observant people would
coined the much kinder descriptor ‘preorgasmic’ with its discover the arousal potential of the clitoris and freely enjoy
implication of potential.4 It has been estimated that only the pleasure of orgasm. However, once man understood his
about 10% of women are never, or will never be, orgasmic.5 role in paternity and issues of wealth and ownership arose,
Primary anorgasmia occurs when a woman has never been written sources show a definite shift to male control of
able to achieve an orgasm either alone or with a partner by women’s sexuality and fertility. The influence of organised
any means. Secondary anorgasmia occurs when a woman religion and the Church is also very significant, with its
has been able to achieve orgasms by any means in the past, negative or ambivalent portrayal of woman’s sexuality. The
but is no longer able to. Diagnostic and Statistical Manual full implication of this control is not clearly understood
of Mental Disorders published by the American Psychiatric across all cultures; for example many women in cultures
Association (DSM IV) classification requires the subjective where they are considered little more than chattel are
distress about the anorgasmia by the women. Hypo-orgasmia orgasmic and many women in sexually open cultures
is where there is infrequent climaxing or the orgasms are of have difficulties.
weak intensity. Certainly, in Anglo-Saxon cultures, by the mid-1800s the
orgasm was seen as unnecessary, unseemly, or perhaps even
Evolutionary theories for female orgasm unhealthy for women. Freud added a new dimension in 1905
Lloyd (2005) looked at the twenty leading theories for with his ‘New Introductory Lectures on Psychoanalysis’:
the evolution of female orgasm.6 For example, the Poleax ‘With the change to femininity the clitoris should wholly
Theory postulates that the female orgasm (with release of or in part, hand over its sensitivity and at the same time its
the hormone oxytocin) evolved to flatten the woman with importance to the vagina’. This idea had a very significant
post-coital lassitude and stop rising after intercourse to allow impact on female orgasmic potential in the Western world.
Female orgasm and anorgasmia Sexual Health 145
For a long time, orgasmic difficulties were thought to be fuller understanding of the true size and distribution
caused primarily by psychological and interpersonal issues, of the clitoris (Fig. 1).13 This fuller understanding of
and women were told they needed to climax primarily through the extent of clitoral and pelvic nerve distribution is
intercourse or be ‘dysfunctional’. particularly important because it impacts on women’s
The book ‘Human Sexual Response’ from Masters and orgasmic potential with genital or pelvic surgery and post-
Johnson (1966) made the scientific study of female sexuality menopausal changes.
more acceptable, and the clitoris re-entered the arena.10
Nevertheless, the dilemma of the clitoral versus the vaginal Evolution of models about female sexual
orgasm persisted for many years. response and orgasm
Ladas et al. (1982) re-described the G-spot orgasm, Masters and Johnson’s linear sexual response model
and other scientists have since labelled other areas in the Masters and Johnson (1966) focussed on genital and
genital tract as having increased erotic sensation capable peripheral physiological changes and on the classification
of orgasmic potential in some women.11 Levin (2003) of sexual dysfunctions based on these stages.10 Interest and
postulated that it is more sensible to call the whole area desire were not included. The conclusion was that sexual
(urethra–clitoral–G-spot area–Halban’s fascia) the ‘anterior desire and arousal correlated with orgasmic frequency for
wall erogenous complex’.12 men and women. Orgasm was thought to be so intensely
pleasurable and self-reinforcing that it maintained the cycle
Female genital anatomy for repetition of sexual activity. In hindsight, this model is
The scientific study of anatomy started during the more sympathetic to male sexual functioning.
Renaissance and, of necessity, focussed on males. Although
the discipline developed, Victorian morality did not Kaplan’s triphasic model of human sexuality
allow for the study of female sexuality and genitalia. ‘Gray’s Kaplan’s linear model introduced desire as the lead-in
Anatomy’, the standard medical anatomical handbook, hardly to sexual behaviour.14 Although more female-sympathetic,
mentioned the clitoris and the vaginal opening was depicted it is still linear, with orgasm as the desired successful
as a round hole. O’Connell et al. (1998) presented a outcome. However, Kaplan did note that frequency or ease
a b
mons pubis
suspensory ligament
mons pubis
shaft of clitoris
front commissure
shaft of clitoris (hidden) glans
leg of clitoris
hood urethra
labium majorum
vagina
labium minorum perineal sponge
labium majorum
fourchette anus
perineum
anus
Fig. 1. Female genital anatomy: (a) external and (b) internal views of the vulva. From Kerner (2004: pp. 42 and 48).61
146 Sexual Health M. Redelman
Table 2. Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) classification of female sexual dysfunction
From DSM-IV diagnostic criteria 302.7319
A Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability
in the type or intensity of stimulation that triggers orgasm. The diagnosis of female orgasmic disorder should be based on the
clinician’s judgment that the woman’s orgasmic capacity is less than would be reasonable for her age, sexual experience and the
adequacy of sexual stimulation she receives.
B The disturbance causes marked distress or interpersonal difficulty.
C The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due
exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.
Specify Lifelong or acquired type. Generalised type or situational type. Due to psychological factors or due to combined factors.
Female orgasm and anorgasmia Sexual Health 147
I Sexual desire disorders A Hypoactive sexual Persistent or recurrent deficiency or absence of sexual
desire disorder fantasies/thoughts and/or of desire for or receptivity
to sexual activity that causes personal distress.
B Sexual aversion Persistent or recurrent phobic aversion to and avoidance
disorder of sexual contact with a sexual partner that causes
personal distress.
II Sexual arousal disorder Persistent or recurrent inability to attain or maintain
sufficient sexual excitement, causing personal
distress. It may be expressed as a lack of subjective
(central mental) excitement or a lack of genital or
other somatic responses.
III Orgasmic disorder Persistent or recurrent loss of orgasmic potential after
sufficient sexual stimulation and arousal, which causes
personal distress. Can be primary or secondary.
IV Sexual pain disorders Dyspareunia.
Vaginismus.
Other sexual pain disorders.
those women who can orgasm without positive feelings for Orgasm pathophysiology
partner or the sexual context).
At the genital end, orgasm is a sensorimotor response that
There are three major dimensions of desire.
can be triggered by physical and/or mental stimuli. In order
(1) Biological — centred in the rhinencephalic and limbic to enable a genital orgasm, four structures and processes
brain and strongly hormone-dependent. However, this is need to be intact: pudendal nerve fibres S2, 3, and 4 and
further modulated by mood states and is neurochemically corticomedullary fibres; cavernosal structures with intact
driven. nerves; adequate pelvic floor muscle strength; and adequate
(2) Motivational — it may be that over a lifespan and genital arousal and congestion.
depending on life situations of women, the motivation for The orgasmic response begins with strong rhythmic
sexual activity may shift from the primary reproductive contractions of the outer one-third of the vagina (the
biological goal, to recreational sex and to instrumental orgasmic platform). These contractions last five to eight
sex, where it becomes the vehicle to obtain advantages seconds, starting with intervals less than one second (0.8 s)
(for example bonding) and express other motivations and then, as they become weaker, at longer intervals.20
(for example intimacy). Almost at the same time, the uterus begins to contract.
(3) Cognitive — wishes, fears and knowledge about sexual These weak contractions start at the top and progress
behaviour. down the uterus. The sphincter muscles of the rectum
may also contract. However, there are different patterns
between women.
Sexual arousal pathophysiology The ‘sex flush’ on the neck and upper chest becomes
Mental arousal is triggered biologically by androgens more pronounced, especially in fair-skinned women, and may
and by psychologically meaningful interactions, such as cover a greater percentage of the body. Myotonia may be
bonding. There is a biofeedback interaction in which mental evident throughout the body, especially in the face, hands
arousal may trigger genital and non-genital peripheral and feet. A facial rictus is usual. At the peak of orgasm, the
arousal and in turn be triggered by those activities. The entire body may become momentarily rigid. The breathing
quality, quantity and meaningfulness of erotic stimulation rate, pulse rate and blood pressure increase and there is a
are all important factors in reaching biological thresholds positive Babinski reflex and dilated pupils. A few women
of function. have ‘female ejaculation’ of what appears to be prostate-
Genital arousal results in the production of vaginal like fluid.11 Continued sexual stimulation may lead to a
transudate. This is mediated by the neurotransmitter repeat of the orgasmic response if the woman desires this.
vasointestinal peptide (VIP) under the ‘permitting’ influence Although each woman has a pattern of orgasm usual for her,
of oestrogens. Nitric oxide (NO) stimulates the neurogenic the intensity, pleasure and meaningfulness will vary with each
congestion of the clitoris and vestibular bulb corpora experience, depending on the context, quality and quantity of
cavernosa. Androgens are potentiating factors for NO. the sexual stimulation.
148 Sexual Health M. Redelman
engorged during sexual arousal. This may feed into the menopause.34 In fact, initially with the fall in oestrogens and
negative biofeedback loop through decreased perception of sex hormone binding globulin (SHBG) there was a slight
arousal and increased anxiety, or less nerve stimulation so increase in testosterone.
that the orgasmic threshold is not reached. Sarrel (1990)
showed that levels of oestradiol below 50 pg mL−1 resulted Diagnosis
in decreased genital blood flow, sensation and sex drive.28
Irrespective of the classification used, the first step in
Berman and Goldstein (2001) showed that genital changes
diagnosing a sexual dysfunction needs to be a very extensive
of arousal diminish in older women.29 Decreased pelvic
psychosociosexual and medical history. Not only does this
blood flow leads to vaginal wall and clitoral smooth muscle
give information to the clinician for best treatment but it also
fibrosis.30 Labial swelling and clitoral engorgement are
usually gives insight into the difficulty to the woman and her
uncommon after age 60. Vaginal lubrication slows from
partner, so that co-operation and shared responsibility are
seconds to minutes in women after 40 and the ability
achieved. The burden of ‘craziness or abnormality’ is also
of the vagina to elongate, widen and expand is reduced.
removed when people see that it makes sense for there to be
Berman (2000) found that any condition or event that affects
a difficulty given the conditions involved. In women, good
the nerves or blood supply to the genitals could have a
sexual function is more than a simple biologic response to
direct local affect on orgasmic potential.31 Rako (1999)
sexual or tactile stimulus, so a multifactorial aetiology is to
found that ovarian atrophy and fibrosis of the vagina and
be expected and more than a simple solution is needed.
clitoris could occur after disruption of the uterine vessels.32
The order of questioning should be as follows (from the
Hysterectomy is a relatively common procedure in Australia.
least threatening and intrusive).
The prevalence for having a hysterectomy in Australia in the
1980s for women 55 to 59 years was 24%, so the potential (1) Medical history includes general medical (especially
consequences for FAIS are there due to vascular and cardiovascular), surgical, endocrine, gynaecological and
nerve disruption.33 urinary tract related questions. Other important issues
However, the Melbourne Women’s Midlife Health Project include medication history, drug (tobacco, alcohol,
found no significant change in total testosterone levels with non-prescribed drugs) usage, other chronic, debilitating
150 Sexual Health M. Redelman
and painful conditions, menopausal status and symptoms, severe psychological distress, personality disorder or a
any pregnancies, terminations, and nature of deliveries highly stressed relationship, this treatment strategy may be
and contraceptive history. inappropriate. In post-menopausal situations, a return to pre-
(2) Social history includes family information, position menopausal orgasmic function may not be possible despite
in family, siblings, family traumas (violence, divorce, various cognitive–behavioural treatment and/or medication
deaths), a history of relationships including the present regimes and counselling to accept the best possible outcome
relationship and communication patterns and skills. may be needed. Grief counselling for the loss of the past
(3) Psychological history includes general emotional sexual function may need to be undertaken before the patient
robustness and coping skills (including emotional and or client can move forward.
psychiatric problems), use of medication, and depression The most successful treatment outcome will result from
history including post-natal depression. the sexual health consultant listening well to the history,
(4) Sexual history includes detailed history of the specific conducting appropriate physical examinations and blood tests
presenting sexual difficulty (onset gradual or rapid, and constructing an individualised treatment program.
situational or generalised, and any specific pertinent event Relationship counselling may be very relevant and
around the time of onset), a detailed history of personal especially the teaching of intimate communication skills,
sexual learning and experiences (including feelings about because it is very difficult for many women to say ‘I love
these, for example a parent’s sexual behaviour), history you and want to make love with you, but the way you rub my
and style of masturbation, history of sexual trauma, clitoris is irritating for me’. Many men feel threatened when
and a detailed history of how the couple actually make a woman tries to teach what she needs to be orgasmic.
love and level of partner’s lovemaking skills and/or
sexual difficulties. Sexual orientation and content of
Primary anorgasmia
sexual fantasies may be relevant. Co-morbidity with more
than one sexual dysfunction being present should be A history will give insight into whether a low biological
looked for. sex drive, timid personality, repressive sexual environment
in conjunction with poor sexual knowledge, abusive
Asking the woman or couple what they think is causing experiences, poor lovemaking style, troubled relationship/s,
the difficulty, what they have tried in the past and what or medical problems are major factors in the anorgasmia.
they think will help is important. It is pertinent to enquire Psychological factors, including sexual inexperience, lack of
how much energy is available to apply to efforts to change sexual knowledge of how to achieve sufficient stimulation
the situation. and sexual shyness, are more common than medical factors
in primary anorgasmia.
Management of anorgasmia Management of primary anorgasmia includes:
The reality is that sexual desire disorders and arousal
disorders are often precursors to orgasmic disorders, (1) Assessment and treatment of co-morbid factors where
as can be seen from the circular models of female sexual possible.
function, with feedback loops involving meaning, emotion (2) Education about sexual anatomy and function.
and biological/medical functions. Treatment of orgasmic (3) Improvement of self-confidence and assertiveness.
difficulties of necessity often involves treatment of desire (4) Entitlement to adult sexuality.
and/or arousal difficulties. (5) Encouragement of self-exploration of whole body and
The success rate for treating anorgasmia with cognitive– genitals.
behavioural treatment is very good, although the success (6) Permission to be sexually selfish (the woman is allowed
is higher in primary than secondary anorgasmia with to consider herself and her sexual needs first some of
organic factors. LoPiccolo and Stock (1986) found that the time).
95% of 150 previously anorgasmic women were able to (7) Acceptance and appreciation of genitals (become
achieve orgasm through a directed masturbation program, ‘friends’ so can ‘play’ together).
85% could reach orgasm through manual stimulation by (8) Dealing with specific sexual fears or fears of orgasm.
a partner and 40% could reach orgasm during coitus.35 (9) Pelvic floor exercises (daily, lifelong asset for good
Combining direct clitoral stimulation with coitus improves sexuality).
the rate for coital orgasms. The cognitive–behavioural (10) Reducing spectatoring (critically observing oneself is
treatment approach incorporating sensate focus, systematic not an erotic activity).
desensitisation and directed masturbation has received the (11) Enhancement of mental arousal (use senses to create
greatest amount of empirical support for treating FOD, sensual ambiance and variety).
with reported success rates between 88 and 90%.36,37 (12) Improvement of sexual focussing skills (fantasy, reading
However, where orgasmic difficulties occur alongside with erotica).
Female orgasm and anorgasmia Sexual Health 151
(13) Directed masturbation exercises, as per a masturbation (3) Testosterone (‘Androfeme gel’ available in Western
program (ref. 38) and using lots of lubricant. Australia, intramuscular injections, transdermal parches)
(14) Vibrator use if more stimulation is needed. to increase clitoral sensitivity,41 sexual arousal, mental
(15) Encouragement of patience and persistence with at least arousal and emotional receptivity.42
thrice-weekly sessions in a good setting. (4) Tibolone, a synthetic steroid with oestrogenic,
(16) Transferring masturbation skills to couples situation. androgenic and progestagenic properties.43
(17) Treatment of couple relationship/communication (5) Lubricants.
dynamics. (6) PDE5 drugs for post-menopausal FOD for poor-arousal
(18) Learning lifelong erotic and romance skills. couples with good libido.44–46
(7) Bupropion, a dopamine agonist, which may have a
Secondary anorgasmia centrally acting mode of action for stimulating sexual
thoughts, increasing orgasm potential, and reversing the
Once again, a history will highlight possible causes for the inhibitory side effects of selective serotonin re-uptake
loss of orgasmic potential. inhibitors (SSRIs).47,48
In younger women, the causes are more likely to be due (8) Transdermal delivery of oestrogens and testosterone
to lifestyle issues, relationship difficulties and health issues, gives best results.49,50 With transdermal oestrogens
such as depression or infections. Anger and/or resentment the first hepatic pass is avoided, which avoids
at a partner are especially common around negotiating the increase in SHBG that binds with serum
equitable domestic and child-care roles or career decisions. testosterone to lower available free testosterone.
Contraceptive dilemmas or fears of pregnancy may also Sherwin (2002) and Alexander et al. (2004), in reviews
inhibit sexual expression. of randomised controlled trials, found that adding
In older women, health issues, medications and androgens to oestrogens replacement had added
menopause are more often responsible. Entrenched sexual benefits.39,51
lovemaking patterns sometimes limit people when life,
health or relationship changes occur and help needs to be
given to expand sexual repertoires. Depression can occur The women in the above Berman et al. 2003 study
with life-stage changes, affecting sexuality. However, the showed improved sensation and ability to reach orgasm
treatment for depression can also compound or create a with increased blood flow following Viagra (Pfizer) use
sexual difficulty. (Table 7).46 However, the PDE5 female trials are often
Management of secondary anorgasmia includes: ambivalent or neutral,52 but that could be because only a
specific population of women benefits from increased genital
(1) Addressing any treatable medical condition. blood flow, given that other factors are not an issue.
(2) Addressing relationship issues. The rising incidence of depressive disorders worldwide
(3) Addressing co-morbid sexual difficulties. and the increased use of antidepressants, especially SSRIs,
(4) Explaining need for change in lovemaking pattern and has resulted in an increase in iatrogenic loss of desire
need for more intense stimulation (lots of lubricant, and difficulty with achieving orgasm. This SSRI effect is
manual stimulation, vibrator). useful for men with premature ejaculation but not so helpful
(5) Treatment of any hormone imbalance with systemic or for depressed women struggling to regain control of their
local hormone replacement therapy as appropriate and lives. Changing the antidepressant medication, changing the
acceptable to the woman. dose, having medication holidays, and improving sexual
(6) Encouragement of daily pelvic floor exercises for life. techniques and quality of the relationship are all strategies.
(7) Monitoring medications and adjusting or replacing as The PDE5 drugs may help women with antidepressant-
appropriate. associated arousal or orgasm difficulties.53,54
(8) Addressing partner health and sexual problems.
(9) Giving permission and encouragement.
(10) Treatment of the couple. Table 7. Impact of Viagra on the post-hysterectomy sexual
(11) Teaching acceptance of things that can’t or don’t want complaints of women
to be changed. From Berman (2000)31
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aph.1G275 Received 18 January 2006, accepted 24 May 2006
http://www.publish.csiro.au/journals/sh