A. The presence of either of the following symptoms and experience on almost all or all
(approximately 75–100%) occasions of sexual activity (in identified situational
contexts or, if generalized, in all contexts):
1. Marked delay in, marked infrequency of, or the absence of orgasm
2. Markedly reduced intensity of orgasmic sensations
B. The symptoms in criterion A have persisted for a minimum duration of approximately 6 months
C. The symptoms in criterion A cause clinically significant distress in the individual
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition
Specify whether:
Lifelong: The disturbance has been present since the individual became sexually active
Acquired: The disturbance began after a period of relatively normal sexual function
Specify whether:
Generalized: Not limited to certain types of stimulation, situations, or partners
Situational: Only occurs with certain types of stimulation, situations, or partners
Specify if:
Never experienced an orgasm under any situation
Specify current severity:
Mild: Evidence of mild distress over the symptoms in criterion A
Moderate: Evidence of moderate distress over the symptoms in criterion A
Severe: Evidence of severe or extreme distress over the symptoms in criterion A
In the DSM-5 discussion of the diagnosis, reference is also made to some cultural prohibitions against pleasure. The common occurrence of comorbidity of female orgasmic disorder with sexual interest and arousal disorders is appropriately noted.
Some of the statements in the DSM-5 criteria and related diagnostic discussion do not reflect best evidence but instead reflect common biases. The need for clinically significant distress to qualify for a diagnosis, the assertion that orgasm is not strongly correlated with sexual satisfaction, the use of an “always” criterion in mentioning supposedly infrequent orgasm from penile–vaginal intercourse, and the dismissiveness of lack of intercourse orgasm being important are all at odds with best evidence.
Rather than being a valuable index of clinical significance or even seemingly a reaction to a condition, distress might constitute an enduring composite of anxiety and depression that approximates a disorder in itself [101, 102]. In a large sample of Czech women, biological as well as developmental and psychological factors were found to be associated with difficulties in being coitally orgasmic, but it was also found that being sexually distressed reflects a different group of psychological problems [11]. Other developmental factors, early experience, and trauma can strongly shape the likelihood of experiencing sexual distress , as is evidenced by the finding that women who report a history of being sexually abused in childhood do not manifest as clear an inverse association between better sexual function and less distress as women without a history of such abuse (women who report a history of being sexually abused in childhood also have poorer orgasmic function as measured by the FSFI orgasm domain, with no difference between penetrative and non-penetrative abuse) [13]. Similarly, the correlates of female sexual arousal disorder symptoms differ when a distress criterion is required (those differences include the significant predictors: history of no vaginal orgasm but a history of having engaged in masturbation). However, in cases of female sexual arousal disorder both with and without distress, there is an association of female sexual arousal disorder with lack of attention to vaginal sensations during penile–vaginal intercourse [101]. A focus group with women having difficulties experiencing orgasm found that “distress” was a term rarely used and that the more common term was “frustrated” [103]. This is an important contrast between women’s actual experience and the words used in the DSM-5 criteria for female orgasmic disorder. By requiring the presence of a term not best reflecting the experience of women, there is a risk of failing to help women with orgasm problems. An interesting twin study that examined genetic and environmental factors revealed that sexual distress has little to do with sexual dysfunction but a great deal to do with the factors (including obsessive–compulsive symptoms and general anxiety sensitivity) associated with general anxiety in women [104].
There is a curious exceptionalism that applies to DSM-5 diagnosis of many sexual disorders. By requiring the presence of “distress,” the clinician risks reinforcing patient denial of a problem, a process that is not routinely promoted for other psychological or medical problems (with the possible exception of overweight).
In contrast to the assertions in DSM-5, research in multiple countries has shown that women’s orgasm is indeed associated with women’s sexual satisfaction [105, 106].
Unfortunately, DSM-5 is not the only example of consensus guidelines deviating sharply from best evidence regarding female orgasmic disorder evaluation and treatment [4]. Professional resistance to appreciation of the unique role of the vagina in women’s orgasm does a disservice to women whose sexual, interpersonal, and global psychological functioning might benefit from more specific education and treatment, rather than the denial of differences between vaginal and clitoral stimulation and corresponding orgasm. Given the associations between better penile–vaginal intercourse (including frequency, vaginal orgasm, and simultaneous orgasm) and multiple measures of women’s psychological health, psychophysiological health, and intimate relationship function, the insistence on a distress criterion and the common denial of the special value of penile–vaginal intercourse and vaginal orgasm amount to harm to women’s health by many health professionals [4].
Another potential concern in DSM-5 criteria is the presence of other mental disorder being an exclusion criterion. Given that depression is common among sexual disorders [107], and in some cases the pharmacological interventions for depression might be at least as sexually impairing as the depression the medications are intended to treat, one should consider the merit in diagnosing and treating both depression and orgasmic disorder. The fact that the personality features which can predispose to depression also predispose to some orgasmic impairment [12, 40, 45, 63, 66, 71] also argues against at least depression being a simple exclusion criterion. Of note, even within the normal (nonclinical) range of depression scores, Beck Depression Inventory scores were inversely associated with women’s orgasm frequency and intensity [44]. In some cases, especially milder forms of depression might reflect personality influences, rather than disease processes.
Members of the DSM-V sexual dysfunctions working group responded [108] to some of the published criticisms on the changes they made from the previous edition of DSM (Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision; DSM-IV-TR). However, the serious problems noted in this chapter regarding the DSM-V diagnostic criteria for female orgasmic disorder were not among the issues that they addressed.
Although DSM-5 is widely used (especially in the United States, where its use might be required for insurance claims or to comply with other administrative demands), it is important to understand not only the shortcomings of DSM-5 but also the existence of the much more straightforward diagnosis of female orgasmic dysfunction found in the tenth edition (2016 version) of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10), under the category of sexual dysfunction not caused by organic disorder or disease [109]. The criterion is refreshingly clear: “Orgasm does not occur or is markedly delayed” (http://apps.who.int/classifications/icd10/browse/2016/en#/F52.3).
Implications for Treatment
As the evidence briefly reviewed above indicates, distress is not a legitimate requirement (scientifically or clinically) for men or women to qualify for diagnosis and treatment of their sexual dysfunctions. Obtaining information about other disorders also requiring treatment is important, as is obtaining information regarding medications and physiological states that might be causing or contributing to sexual dysfunction, lifestyle factors, and characteristics of the partner and the partnership.
Many studies have found that vaginal orgasm is associated with indices of better psychological and psychophysiological function, but other orgasm triggers (including masturbation during penile–vaginal intercourse) are associated with poorer psychological and psychophysiological function [3, 64]. These differential findings (multivariate analyses allow for concurrent statistical control of other sexual behaviors, so that observed adverse correlates of masturbation are not simply due to lack of penile–vaginal intercourse) speak not only to differences between sexual behaviors but also raise serious questions regarding the usual approach to treating female orgasmic dysfunction with directed masturbation. It has been noted that for some women, repeated orgasm from clitoral stimulation can interfere with the development of pathways leading to vaginal orgasm [110, 111]. A large representative study of Swedish women found that penile–vaginal intercourse orgasm is inversely associated with masturbation frequency [27], and some smaller studies found no correlation between orgasm consistency triggered by penile–vaginal intercourse and triggered by masturbation [89, 90]. In a large representative sample of women in the Czech Republic, vaginal orgasm consistency was associated with a variety of factors that make vaginal stimulation during penile–vaginal intercourse more thorough or more psychologically salient. These factors include women having been educated in their youth that the vagina is a source of women’s orgasm, being mentally focused on vaginal sensations during penile–vaginal intercourse, greater duration of penile–vaginal intercourse, and sufficient male partner penis length [5]. The authors of that study observed that a purely clitoral focus can undermine the capacity for vaginal orgasm. It should be noted that there are effective penile–vaginal intercourse-based treatments for female orgasmic dysfunction [112] and that women should not be directed away from penile–vaginal sensations in the hope that would develop the ability to respond orgasmically to penile–vaginal intercourse. A penile–vaginal intercourse-based treatment that has been shown to be effective at improving women’s penile–vaginal intercourse orgasm is the coital alignment technique (also known by its acronym CAT) developed by Eichel. The coital alignment technique involves a synchronized rocking movement by the man and woman during penile–vaginal intercourse, with a riding high variant of the missionary position [112].
Best Practice or Evidence-Based Approach to Diagnosis Including Diagnostic Tests, Instruments, or Rating Scales
Scales
The Female Sexual Function Index (FSFI) [113] might be the most commonly used female sexual function scale. It has one question each (rated on a six-point scale) inquiring about frequency of orgasm, difficulty in reaching orgasm, and satisfaction from the ability to reach orgasm. A serious problem with the FSFI is that it explicitly asks women to not differentiate between penile–vaginal intercourse and other sexual activity. As with some other scales, the use of several conceptually related questions leads to internal statistical consistency (technically termed reliability), but ultimately, the data from the FSFI and similar scales might not be as useful and differentially valid as more objective measures of sexual behaviors and corresponding orgasm frequencies (see below).
The Golombok Rust Inventory of Sexual Satisfaction (GRISS) has one question each (rated on a five-point scale) inquiring about ability to have an orgasm with a partner, finding it impossible to have an orgasm, orgasm from partner stimulating the clitoris during foreplay, and failure to reach orgasm during intercourse [114].
The Arizona Sexual Experience Scale (ASEX) was developed to measure various adverse sexual effects of medication, and the single item for women’s orgasm function is rating on a six-point scale how easily one reaches orgasm [115].
The Changes in Sexual Functioning Questionnaire (CSFQ) was also developed to measure medication (or illness)-induced changes in sexual function [116]. It has one question each (rated on a five-point scale) inquiring about frequency of orgasm, ability to reach orgasm when the respondent wants to have an orgasm, and degree of pleasure from orgasm (there is also a question on painful orgasms).
The Sexual Functioning Questionnaire by Quirk et al. [105] was developed for use in clinical trials of treatments of female sexual dysfunctions. It has one question each (rated on a five-point scale plus an option of no activity during the 4-week queried period) inquiring about frequency of orgasm, ease of reaching orgasm, and pleasure experienced from orgasms.
The Patient-Reported Outcomes Measurement Information System (PROMIS) Sexual Function and Satisfaction Measures Version 2.0 [117] has many items on aspects of sexual behavior for both sexes, but only two items on female orgasmic function. One item is how relatively often in the past 30 days the woman has been able to have an orgasm when she wanted an orgasm, and the other is how satisfying her orgasms have been. Both items are rated on a five-point scale from never to always (plus the respective options of not attempted and no orgasm in the past 30 days). Although the overall scale benefitted from several useful methodological features in the course of its development, the authors of the report on the scale observed that additional work is required in the orgasm domain of the scale.
An alternative approach is found in the Sexual Behavior Questionnaire developed by Brody and colleagues [66, 69, 88]. Women report how many days in a recent representative month they (1) engaged in and (2) had an orgasm from various specific sexual activities. The specific sexual activities in the scale typically include penile–vaginal intercourse without additional simultaneous clitoral stimulation, penile–vaginal intercourse with additional simultaneous clitoral stimulation, clitorally focused masturbation (further differentiated as with or without a vibrator), vaginally focused masturbation (further differentiated as with or without a vibrator), clitorally focused manual stimulation by a partner, vaginally focused manual stimulation by a partner, cunnilingus, and receptive anal intercourse [88]. The scale can also include a further differentiation of partnered noncoital sexual behaviors as occurring with or without penile–vaginal intercourse on the same day. The Sexual Behavior Questionnaire items are usually presented in a matrix format for completion (with instructions to the respondent including that if the answer for an item is either never or zero, to write 0 rather than leaving any item blank). The sexual behavior items can be expanded or reduced as needed. The validity of the Sexual Behavior Questionnaire has been demonstrated both in its associations with various psychological and psychophysiological measures in several of the studies reviewed in this chapter, as well as examination of the role of social desirability response bias, a consideration not often examined in research on sexual behavior. Additional columns can be added to measure age at first engaging in each activity (or indicating that the specific sexual activity was never tried) and age at first having an orgasm from each activity. The approach of the Sexual Behavior Questionnaire provides not only more precise information on specific sexual behaviors and orgasm than more common scales, but the numerator (orgasm) and denominator (times tried in the month) provide additional useful information, as do the ratio (orgasm consistency from the specific activity). This specific quantitative approach is in contrast to the vague relative terms used in other scales. Each of the items in the Sexual Behavior Questionnaire can provide useful information. For example, if the number of days per month of penile–vaginal intercourse is low, the interview can include further questions on what factors led to the low number of days per month (such as partner availability, lack of interest by the woman and/or her partner, illness, etc.). The presence of masturbation, especially if a high number of days per month, can also be examined, as it might suppress pursuit of and/or full response to penile–vaginal intercourse in some cases. Additional subcategories of activities can also be added, such as vaginal orgasm occurring at the same time as male penile–vaginal intercourse orgasm (simultaneous orgasm; in a nationally representative survey of 35–65-year-old Czechs, simultaneous penile–vaginal orgasm was associated with better sexual satisfaction, relationship satisfaction, personal mental health satisfaction, and life satisfaction [6]). The Sexual Behavior Questionnaire also has a version for use with men, in which an item for fellatio is substituted for the cunnilingus item, all references to clitoral stimulation are removed, and an item for insertive anal intercourse is added [88].
Interview and Best Practice
Many patients do not spontaneously report sexual problems, and many general clinicians do not spontaneously enquire about patient sexual function. Even if one does not have time or need to use a scale, a few minutes of direct calm questioning can elicit some important information. The Sexual Behavior Questionnaire (see above) can save time in gathering quantitative details of specific sexual behavior history and frequency and corresponding orgasm consistency, but further questions regarding medical conditions and the sexual function of partners are also suggested, even in the course of a nonspecialist anamnesis. Although multi-item satisfaction (intimate relationship, sexual, life, mental health, etc.) scales exist, a clinician or even researcher can also simply ask for a rating of the specific domain of satisfaction on a scale from one to six, providing the anchors of one = very unsatisfying and six = very satisfying (such scales are not only time-efficient but valid as well [25]). Information on the degree to which the woman feels sexual desire and experiences sexual arousal and lubrication before and during sex can also provide useful information (even if pre-existing desire is not essential for orgasm), as can information on the degree to which she is able to focus her attention on vaginal sensations during penile–vaginal intercourse [5].
It is important to query women about the sexual function of their partner, because in quite a few cases, the woman’s seemingly impaired function might be due to the premature ejaculation or inadequate erectile function of their partner. Similarly, the possibility should also be considered that a woman with a chronic sexual dysfunction (or negative attitude toward sex) might adversely affect the function of their partner. Chronic sexual dysfunction of one partner can create adverse expectations for sexual interaction with at least that partner, which can affect sexual function. Information on partners can include an assessment of intimate relationship satisfaction with their partner, sexual desire for their partner, the presence of premature ejaculation or erectile dysfunction, and whether the woman’s orgasm problem also existed earlier in the same intimate relationship or in other intimate relationships. Although scales for the ascertainment of premature ejaculation and erectile dysfunction exist, the clinician might begin assessment of partner sexual function by simply asking the woman if her male partner(s) ejaculate earlier than what might make for an optimal opportunity for her orgasm and if her male partner(s) have difficulty maintaining a sufficiently hard erection during intercourse.
After the diagnosis of female orgasmic disorder is made and the essential aspects of history are obtained (including asking the patient what they have already tried to overcome their orgasm difficulty), one of the first places to start treatment planning is considering whether relatively simple solutions are available. These include evaluating whether any medications or health habits might be changed and evaluating whether the male partner needs an evaluation for his sexual dysfunction. In some cases, assessment of the woman’s hormone levels might be indicated. Intimate relationship quality issues might in some cases respond to couples counseling but in other cases might not. Similarly, in some cases, psychological or psychiatric problems might respond to psychological treatment, but in other cases, one might proceed to more direct sexological interventions. At the very least, a woman with orgasmic disorder might benefit from discussion of her focusing attention on vaginal sensations during intercourse and scheduling sex sufficiently frequently (preferably at a time and with an ambience that is optimal for her). As noted above, there are effective penile–vaginal intercourse-based (non-masturbatory) treatments for female orgasmic disorder.
References
1.
IsHak WW, Bokarius A, Jeffrey JK, Davis MC, Bakhta Y. Disorders of orgasm in women: a literature review of etiology and current treatments. J Sex Med. 2010;7:3254–68.PubMed
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McCool ME, Zuelke A, Theurich MA, Knuettel H, Ricci C, Apfelbacher C. Prevalence of female sexual dysfunction among premenopausal women: a systematic review and meta-analysis of observational studies. Sex Med Rev. 2016;4:197–212.PubMed
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Brody S. The relative health benefits of different sexual activities. J Sex Med. 2010;7:1336–61.PubMed
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