The scientific study of anatomy started during the Renaissance and of necessity focused on males. Although the discipline developed, Victorian morality did not allow for the study of female sexuality/genitalia. The anatomy bible for medical students Gray’s Anatomy [42] hardly mentioned the clitoris and the vaginal opening was mostly depicted as a round hole. The result was that women seeing the diagram expected the penis to fit into the “hole”. In 1998 O’Connell [13] and subsequently others [43] have presented a fuller understanding of the true size and distribution of the clitoris. The visible glans of the clitoris was shown to be a very small part of the whole clitoris with its two crura running along both sides of the vaginal vault. The fuller understanding of the extent of the clitoral and the pelvic nerve distribution is particularly important in understanding women’s orgasmic potential with genital/pelvic surgery such as hysterectomy and post menopausal changes . It also highlights how direct clitoral glans stimulation by mouth, fingers or vibrator, and vaginal penetration with fingers, dildo or penis can lead to stimulation and sexual arousal. It is not possible to have vaginal penetration without clitoral stimulation.

Classification is important for defining what is a problem; for allowing consistency and comparability in research; and to help generate and guide management/treatment strategies. The classification of female sexual dysfunctions has undergone rethinking in recent years and is still ongoing. Women with FOD experience delay in or absence of sexual orgasm. The woman has to be distressed by her situation before it can be labelled a dysfunction. DSM-V has included an experiential component with “reduced intensity of orgasm”. The difficulty needs to be persistent for some period of time (Table 15-2).

Arousal and orgasm are attained when thresholds of stimulation are reached from a variable combination of mental and physiological stimulation. At one end of the spectrum are mental/fantasy/dream orgasms with no body/genital stimulation [44] and at the other end of the spectrum are vibrator on clitoris orgasms while having totally non-sexual thoughts. Most women employ a combination of mental and physical stimulation. One of the difficulties experienced by many women is the gradual change post “honeymoon phase” of their sexual relationship when decrease in spontaneous mentally driven sexual arousal needs to be compensated for by improved sexual technique and physical stimulation. In consensual sexual activity there is the presumption of willingness to engage in the process. Without the willingness to participate in sexual activity or to be receptive to a partner’s initiation, arousal and orgasm will be affected. However, due to anxiety driven activation of brain centres, nonconsensual sexual behaviour (overt as in rape or more subtle as in pressured or obligatory) can also result in orgasm.

Mental arousal (desire) is triggered biologically by androgens and by psychologically meaningful interactions e.g. bonding. There is a bio-feedback interaction so that mental arousal may trigger genital and non-genital peripheral arousal and in turn be triggered by those activities . The quality, quantity and meaningfulness of erotic stimulation is important to reach biological thresholds of arousal and orgasm. Brain studies show increased activation in the paraventricular nucleus of the hypothalamus, periaquaductal gray of the midbrain, hippocampus and the cerebellum at orgasm.

Genital arousal results in the production of vaginal transudate. This is mediated by the neurotransmitter vasointestinal peptide under the “permitting” influence of estrogens. Nitric oxide stimulates the neurogenic congestion of the clitoris and vestibular bulb corpora cavernosa. Androgens are potentiating factors for nitric oxide. At the genital end orgasm is a sensorimotor response that can be triggered by physical and/or mental stimuli. In order to enable a genital orgasm four structures and processes need to be intact: pudendal nerve fibres S2, 3 & 4 and corticomedullary fibres; cavernosal structures with intact nerves; adequate pelvic floor muscle strength; and adequate genital arousal and congestion.

The orgasmic response begins with strong rhythmic contractions of the outer one third of the vagina (the orgasmic platform). These contractions last 5–8 s starting with intervals less than 1 s [45] and then as they become weaker at longer intervals. However, there are different patterns, between women and for women depending on the levels of mental and physical stimulation. Some examples of orgasmic patterns include several small contractions of equal intensity that feel like “a flutter”, several stronger contractions of equal intensity and small contractions ending in a strong contraction. Almost at the same time, the uterus begins to contract. The weak contractions start at the top and progress down the uterus. The sphincter muscles of the rectum may also contract.

The “sex flush” on the neck and upper chest becomes more pronounced especially in fair skinned women and may cover a greater percentage of the body. Myotonia may be evident throughout the body, especially in the face, hands and feet and arching of the back. A facial rictus is usual. At the peak of orgasm the entire body may become momentarily rigid. The breathing rate, pulse rate and blood pressure increase and there is a positive Babinski reflex and dilated pupils. Some women hold their breath. There may be involuntary sounds or speech. A few women have “female ejaculation” of what appears to be prostate-like fluid [34, 46]. Continued sexual stimulation may lead to a repeat of the orgasmic response if the woman desires this [47, 48]. Although each woman has a pattern of orgasm usual for her, the intensity, pleasure and meaningfulness will vary with each experience depending on the context, quality and quantity of the sexual stimulation.

The data suggests that sexual difficulties are very common in women but many question the appropriateness of a dysfunction label when 10–42% [49, 50] of the population is classified as having the dysfunction. The older studies did not use clinical diagnoses, validated questionnaires or measures to assess women’s function or distress. Hayes [51] showed how the prevalence of sexual dysfunction declined when validated questionnaires including distress and persistence of the difficulty beyond 6 months were included. The effects of co-morbid conditions also has a significant effect on the prevalence rates of FOD, arousal and desire [52] and need to be included before a sexual dysfunction is diagnosed.

The yardstick for what is normal over a woman’s lifespan has yet to be established. Presumably it may be normal to have a sexual difficulty at some time over the lifespan when conditions for good sex are not met or when hormonal levels drop below the physiological levels necessary to maintain function. The element of distress experienced by the woman herself over the difficulty in not achieving orgasms or having orgasms different from those she previously had, needs to be factored into the assessment before applying diagnostic labels. However, the issue of “distress” is itself not without contention as women may accommodate to a “non-distressed” state about no or inconsistent orgasms as a coping mechanism to avoid ongoing anxiety, upset or anger. When “distress” is factored in, the numbers drop very significantly especially in older women. Around 60–80% of women do not reach orgasm reliably during intercourse and approximately 10% of women do not experience orgasm by any means over their lifetime [4, 7, 39, 53].

Richters ([54], page 88) from Australian data reported that 29% premenopausal women experienced FOD and 42% postmenopausal women. Hisasue [55] in Japan reported that 15.2% premenopausal women experienced FOD and 32.2% postmenopausal women. Laumann [49] in USA reported that 24% of his study population of women reported orgasmic difficulties.

Richters [54] also looked at combinations of activities that resulted in orgasms for women. The statistics on the combinations of sexual behaviours and success in terms of orgasm success highlight the fact that intercourse alone may be a more useful activity for achieving pregnancy and stimulating the penis than helping women achieve orgasm. Richter’s results showed that only 20% of her sample restricted themselves to intercourse only and of these 50% reached orgasm. Fifty-three percent practiced intercourse and manual stimulation and here 71% reached orgasm. A combination of intercourse, oral and manual stimulation was practiced by 21% and now 86% of women reached orgasm. This confirmed Hite’s [56] finding that intercourse is not the most efficient way for women to reach orgasm. Hite [56] surveyed 3000 women and concluded that “most” women do not reach orgasm during intercourse and masturbation is more effective than intercourse for orgasm.

Kinsey [57] reported that 25% of women are totally anorgasmic in the first year of marriage, 10% are never orgasmic with intercourse throughout marriage, that 39% married less than 12 months are almost always orgasmic during intercourse and that 47% women married 20 years are almost always orgasmic during intercourse. Morton Hunt [58] reported that 53% of married women are orgasmic almost all the time and 7% of married women are never orgasmic.

The figures vary depending on the decade at time of research and criteria used. More research is needed over a lifespan and including co-morbid conditions so that normal (albeit undesired states) are not pathologized. This does not mean that women with these normal states should not be helped.

Worldwide there is an increasing, healthy aging female population who want to maintain the sexual pleasure they enjoyed in younger years and maintain their quality of life. Menopause is a given for all women, usually occurring between the ages of 45–55 years. Menopause is the permanent cessation of menstrual periods that occurs naturally or induced by surgery, chemotherapy or radiation leading due to loss of ovarian follicular activity resulting in a drop in oestrogen and progesterone levels. Most women approaching menopause will have some of the following symptoms: hot flashes, mood swings, fatigue, depression, irritability, sleep disturbances, altered urinary and bowel function, vulval irritation and vaginal dryness. The pelvic changes due to oestrogen loss include reduced pelvic floor tone leading to incontinence and laxity, reduced lubrication and vulval and vaginal dryness causing dyspareunia and possibly secondary vaginismus.

Oestrogen and testosterone have been linked with the physical experience of orgasm [59]. There is usually no significant change in testosterone levels during the menopausal transition. Testosterone and dehydroepiandrosterone sulphate levels fall between the ages of 20 and 45 years [60] but testosterone then shows little further change while dehydroepiandrosterone sulphate continues to fall with age [61]. Lobo [62] presents a full account of the hormones involved in the human female sexual response.

Iatrogenic menopause brought on by pelvic surgery, cancer treatment and conditions/medications that increase Sex Hormone Binding Globulin such as Thyroxine, oral estrogens and pregnancy, seems to have a greater impact on testosterone levels than natural menopause. Oxytocin is another very important neurochemical, involved in moderating interpersonal bonding behaviour and is released with orgasm. Endorphins may certainly be very important in perception of pleasure and the motivation to repeat sexual activity (Table 15-3).

However, there is no reason why the same age related changes that occur in men should not also occur in women. Vascular problems with aging may reduce blood flow to the genital region so that tissues and structures become less engorged during sexual arousal. This may feed into the negative biofeedback loop through decreased perception of arousal and increased anxiety, or less nerve stimulation so that the orgasmic threshold is not reached. Sarrel [63] showed that levels of oestradiol below 50 pg/ml resulted in decreased genital blood flow, sensation and sex drive. Berman [50] showed that genital changes of arousal diminish in older women. Park [64] showed that decreased pelvic blood flow leads to vaginal wall and clitoral smooth muscle fibrosis. Labial swelling and clitoral engorgement are uncommon after age 60. Vaginal lubrication slows from seconds to minutes in women after 40 and the ability of the vagina to elongate, widen and expand is reduced. Berman [50] found that any condition or event that affects the nerves or blood supply to the genitals can have a direct local affect on orgasmic potential. Rako [65] found that ovarian atrophy and fibrosis of the vagina and clitoris can occur after disruption of the uterine vessels.

There are real physiological changes that do occur with menopause and aging, both of which are normal events. Does a pathological classification need to be given so that medical insurance can be claimed? Or can help just be given because the natural outcome is not desirable?

The first step in diagnosing a sexual dysfunctional is a very extensive medical and psycho-socio-relational-sexual history. Not only does this give information to the clinician for best management but it also usually gives insight into the difficulty to the woman and her partner, so that co-operation and shared responsibility are achieved. The burden of “craziness or abnormality” is also removed when people see that it makes sense for there to be a difficulty given the conditions involved. Ultimately, the diagnosis of FOD is based on the clinician’s judgement that the woman’s orgasmic capacity is less than would be reasonable for her age, sexual experience and adequacy of the sexual stimulation she has received within the context of her sexual situation. The main criterion for FOD is that there has been a normal sexual excitement phase and whether the woman’s self report of this occurring is correct. This subjective experience is difficult to quantify and convey to another person. This can be especially difficult for women with primary anorgasmia who do not know what they need or how that should feel. Clinicians need to be patient with women struggling to explain their feelings and physiological experiences.

The boundary between female sexual arousal disorder and FOD is difficult and there can be a case made for FOD being the extreme end of an arousal disorder. The determination that adequate sexual stimulation has been given is subjective both on the part of the woman and on the clinician.

The order of questioning when taking a history should be from the least threatening and intrusive to the more personal, embarrassing and threatening.

The woman/couple should be given the opportunity to elucidate what they think is causing the difficulty, what they have tried in the past and what they think will help. It is pertinent to enquire how much energy is available for effort to change the current situation. Change requires effort and energy from both the woman and the couple and is never achieved without some struggle.

Physical examination may reveal infection, dermatological changes, atrophy, anatomical variations and the woman’s attitude to her genitals. If the woman cannot accept her “playground” then relaxed, engaged, enjoyable genital play, arousal and orgasm become difficult to achieve.

It is important to accept that the management of sexual difficulties is not an exact science. There is no ‘best practice’ recommendation for the management of FOD. There is ‘art’ involved on the part of the clinician. The ‘fit’ in personality and style of practice is often the only difference between two clinicians with the same scientific knowledge. The fit may also include age, gender, race and even qualifications so that individuals who prefer alternate health care may prefer to go to a counsellor or therapist rather than a doctor. However, the high prevalence of FOD and the significant negative effect it has on the quality of life of the woman and possibly the partner and relationship means that it should have enough gravitas for health professional attention and research.

The starting point for management of sexual difficulties is the formation of a therapeutic alliance between the woman, her male or female partner and the Clinician/Therapist. Individuals who come for help with sexual agenda are usually anxious, embarrassed, shy, feel guilty, and generally feel that that is something very wrong with them and that they are defective in a way that most people are not. If the woman is in a relationship then engagement of the partner in the therapeutic situation is very important. Many partners are angry, disappointed or frustrated by the time the woman comes to therapy. Sabotage can occur, especially at home where previously established patterns of interaction are likely to reassert themselves when the situation becomes stressful or change is slow in coming. The change process is difficult for most people, even if they sincerely want the outcome and they understand the processes and changes that must take place to achieve it. Two individuals will see and experience any given situation differently and in order to achieve success, conscious cognitive understanding and alliance to work supportively must be gained. The clinician needs to maintain a position of empathy i.e. understanding that the situation is difficult but must push gently or not so gently for the homework exercises to be done and reluctance overcome if change is to occur. The partner must be factored in and supported through the process. The partner’s sexual needs need to be acknowledged and factored into the therapy. Empathy and forward encouragement rather than sympathy are needed.

The homework exercises offered must be within the comfort frame of the woman and she must understand that the rate of change is under her control. Encouragement of self exploration may be repugnant for some women and needs empathic discussion. Religious and cultural constraints have to be respected and somehow incorporated and reframed to be part of the homework. It is important to explore the source of beliefs about genitals being unclean, unsafe, not belonging to the woman like other parts of her body, ugly etc. so that they can be worked with and hopefully gradually changed into beliefs that are more helpful to good sexuality. Masturbation, likewise, may be rejected on religious or other personal grounds and needs to be presented as a learning/training exercise and not a goal in itself that takes the woman away from sexuality with her partner or makes her self-reliant sexually. Engagement of a religious cleric important to the woman/couple , who is educated and empathic about sexuality, may be helpful.

Sexual desire disorders and arousal disorders are often precursors to orgasmic disorders. This can be understood from the circular models of female sexual function, with feedback loops involving meaning and emotion and biological/medical functions. Treatment of orgasmic difficulties of necessity often involves treatment of desire and/or arousal difficulties. However, it is pertinent not to over focus on desire or libido as a prerequisite for engaging in sexual behaviour, as waiting for desire to strike, is unpredictable. Rather, it is better to create the best possible sensual, relaxing, exciting and erotic context/environment for the sexual homework i.e. actively make changes and thereby provide the context within which desire may evolve. Desire is not a prerequisite for achieving orgasms.

It is not uncommon for individuals with sexual difficulties, anxieties and insecurities to partner up with individuals who also have sexual difficulties or insecurities, even if they are not consciously aware that the other has issues. The partner’s sexual history must be taken to understand his or her function. The partner’s sexual script, their sexual responses and ability, their personality characteristics such as empathy, patience, enjoyment of sensuality, creativity will impact on the presenting patient.

Relationship dynamics impact significantly on sexual functioning especially in longer established relationships and this must be understood and included in the therapy management for the orgasmic difficulty. While some women will orgasm occasionally under stressful situations such as rape, the usual situation is that reasonable emotional and physical safety is needed to meet the conditions for arousal to orgasm. Conditions for good enough sexual functioning need to be met (Figure 15-1).

The success rate for treating anorgasmia with cognitive behavioural treatment (CBT) is very good. LoPiccolo [68] found that 95% of 150 previously anorgasmic women were able to achieve orgasm through a directed masturbation program (85% could reach orgasm through manual stimulation by partner and 40% could reach orgasm during coitus). Combining direct clitoral stimulation with coitus improved the rate for coital orgasms. The CBT approach incorporating sensate focus, systematic desensitisation and directed masturbation has received the greatest amount of empirical support for treating FOD. Reported success rates range between 88–90% [69, 70]. However, where orgasmic difficulties are part of severe psychological distress, personality disorder or highly stressed relationship, especially with violence being involved, this treatment strategy may be inappropriate. In post-menopausal situations return to pre-menopausal orgasmic function may not be possible despite various CBT/medication regimes, and counselling to accept the best possible outcome may be needed. Grief counselling for the loss of the past sexual function may need to be undertaken before the patient/client can move forward. No-one likes to lose something that was valued and the phrase “it’s not fair” is common.

The most successful treatment outcome will result from the clinician taking a detailed history, conducting appropriate physical examinations and blood tests and constructing an individualised treatment program. An eclectic approach using CBT, psychodynamic and relational strategies is likely to give the best outcome. Realistic outcomes and time frames should be given. Most individuals will respond with appreciation and gratitude to achieving their goals faster, rather than being given unrealistic expectations that are not achievable or not achievable in the time frame given. Engendering further feelings of failure is to be avoided.

If possible all medical treatments should be initiated before starting the CBT to set up the best chance of success . These may include treatment for depression, pain management, revision of episiotomy scars, change or modification of medication regime, hormone replacement therapy and so on. Individual psychopathologies and psychiatric conditions should be treated separately with medical treatment and psychotherapy either before couple’s work or concurrently as appropriate.

Relationship counselling may be very relevant to help resolve festering resentments and unresolved issues. Anger management for the partner may be necessary as freedom from fear is important for most women. The teaching of intimate communication skills needs to be included as it is very difficult for many women to say “I love you and want to make love with you, but the way my clitoris is being rubbed is causing irritation. I would love it if my clitoris could be touched this way … ”. Very few individuals are taught these intimate communication skills by their family of origin or educational institutions. (Table 15-4)

FOD has a very high likelihood of other sexual and non-sexual co-morbid conditions. Low sexual interest and/or arousal disorder will lead to an orgasmic difficulty unless the woman has a very low biological threshold for orgasm. Depression leading to low sexual interest and anhedonia is also commonly associated with FOD. There is a bio-feedback between all conditions that decrease the good conditions needed for orgasm and orgasmic potential. Laan [22] reported that 31% of women diagnosed with FOD also had an arousal disorder, 50% had problems with lubrication, desire, pain or vaginismus, 25% had anxiety and more than 50% met the criteria for depression (Tables 15-5 and 15-6).