CSIRO PUBLISHING & MINNIS COMMUNICATIONS Review

www.publish.csiro.au/journals/sh Sexual Health, 2006, 3, 143–153

A general look at female orgasm and anorgasmia

Margaret Redelman MBBS, MPsychotherapy

Sydney Centre for Sexual and Relationship Therapy, Bondi Junction, NSW 2022, Australia.
Email: redels@medemail.com.au

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.

Introduction normal? What is socially normal (Table 1)? What is merely

Humans seem to be the first species to elevate sexual activity
to a recreational form. The female orgasm, however, is an
intensely personal experience, and whether other female
animals experience similar degrees of pleasure during sex is
uncertain. Reproductive physiologists have not been able to
identify in other species all the physiological changes that
occur in human females during orgasm, although female
mammals do have a clitoris, which seems to suggest that
orgasm is a potential for them. Masturbation-like behaviour
can be observed in many species. In the usual primate
position, the female presents her rear to the male and
intercourse is brief and purposeful; on the other hand, the
human experience has the potential to be vastly different.
Why the biological ability to achieve orgasm varies
between women with the same cultural and social background
is not known, and the variable factors are not clearly
understood. There is not a clear understanding of what
is biologically or socially normal for female orgasmic
behaviour. Should all women be orgasmic within a specific
time and/or stimulation framework, much the same as large
numbers of men are? Male orgasm has a clear biological
imperative; what is the benefit of female orgasm? Why is
it that millions of species function very well reproductively
without female orgasm? Why evolve now? Is the female
orgasm ‘a work in progress’? If so, what standard of function
should therapists apply to it? In other words, what is medically
commercially desirable? These considerations impact on
our definitions of normal and dysfunctional and guide our
attitudes to therapy.
Normal female genital anatomy and physiology are
still being studied and no doubt our present level of
knowledge will be updated in the coming years. However,
lack of definitive knowledge has not been an impediment to
developing theories and treatment strategies for anorgasmia
or hypo-orgasmia. Many of the strategies are highly
successful. What is now causing problems for many
women, social scientists and researchers is the quest for
pharmacological treatments for female sexual conditions.1,2
The desire for ‘the best sex life’ possible abides in our society.
Men have been hugely helped with erectile difficulties by
the development of the PDE5 (phosphodiesterase type 5
inhibitors) class of drugs. Is it ethical to deny women
medical help, if drugs equally beneficial for women
can be discovered?
Along with increasing longevity, there are increasing
expectations for a continuing good sex life beyond
menopause, which is reflected in increased research into the
sex life of post-menopausal women.
What is an orgasm?
The word ‘orgasm’ comes from the Greek òργ ασµóγ
‘orgasmos’, meaning lustful excitement. Generally, we use

© CSIRO 2006 10.1071/SH06005 1448-5028/06/030143

144 Sexual Health
Table 1. Differences in sexual difficulties between European–
American and African–American women
From Laumann et al. (1994)58
European–American African–American
women (%) women (%)
Unable to reach orgasm 23.2 29.2
Lack of interest in sex 30.9 44.5
Sex not pleasurable 19.7 30.0
it to describe the sudden release of muscular and nervous
tension at the climax of the sexual experience. The experience
is difficult to describe in subjective detail, especially for
women, because there is wide inter- and intra-person
variation. Women also have a potential to experience multiple
orgasms within a short time without a refractory period given
appropriate mental and physical stimulation.
Meston et al. (2004) defined orgasm as ‘a sensation
of intense pleasure creating an altered consciousness
state accompanied by pelvic striated circumvaginal
musculature and uterine/anal contractions and myotonia that
resolves sexually induced vasocongestion and induces
well being/contentment’.3 However, this does not
define the experience of women who become aroused,
experience contractions, but do not experience the ‘well
being/contentment’ of this definition.
What is anorgasmia?
Anorgasmia is a primary or secondary situation where a
woman experiences a persistent or recurrent absence of
sexual orgasm following a normal excitement/arousal phase
with adequate stimulation. The label ‘anorgasmic’ when
applied to a woman can be quite pejorative, and Hite (1976)
coined the much kinder descriptor ‘preorgasmic’ with its
implication of potential.4 It has been estimated that only
about 10% of women are never, or will never be, orgasmic.5
Primary anorgasmia occurs when a woman has never been
able to achieve an orgasm either alone or with a partner by
any means. Secondary anorgasmia occurs when a woman
has been able to achieve orgasms by any means in the past,
but is no longer able to. Diagnostic and Statistical Manual
of Mental Disorders published by the American Psychiatric
Association (DSM IV) classification requires the subjective
distress about the anorgasmia by the women. Hypo-orgasmia
is where there is infrequent climaxing or the orgasms are of
weak intensity.
Evolutionary theories for female orgasm
Lloyd (2005) looked at the twenty leading theories for
the evolution of female orgasm.6 For example, the Poleax
Theory postulates that the female orgasm (with release of
the hormone oxytocin) evolved to flatten the woman with
post-coital lassitude and stop rising after intercourse to allow
M. Redelman
sperm time to reach the egg. The Upsuck Theory argues
that fertility is increased by enhanced sperm retention and
facilitation to the ovum by the angle and contractions of
the uterus during and after orgasm. The Cuddles Theory
states that female orgasm developed to help couples bond.
Lloyd argues that the female orgasm has no evolutionary
function and proposes that the theory put forward by Symons
(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.
More recently, a plethora of Health Benefit Theories
have been put forward. The endorphin release of orgasm
has been touted as beneficial for mental health (sexually
active people are less vulnerable to depression and suicide),
pain management (oxytocin causes release of endorphins,
which act as analgesics, ref. 8), immunity (frequent sexual
activity boosts levels of white cells, ref. 9), cancer resistance
(oxytocin and dehydroepiandrosterone (DHEA) levels affect
breast cancer), heart disease (good aerobic exercise and burns
200 calories) and others.
Most of these ‘theories’ are the result of small,
unvalidated studies or clinical observations, and there
are as many arguments for as there are against each
idea. Certainly, many women who don’t enjoy sex have
orgasms, many who dislike their partner have sex and
become pregnant, and women with good sex lives become
ill. However, our quest for understanding and explaining
is interesting.
Female orgasms during history
Before written history, we can only surmise that in
matriarchal societies women’s sexuality was unfettered.
It would make sense that physically observant people would
discover the arousal potential of the clitoris and freely enjoy
the pleasure of orgasm. However, once man understood his
role in paternity and issues of wealth and ownership arose,
written sources show a definite shift to male control of
women’s sexuality and fertility. The influence of organised
religion and the Church is also very significant, with its
negative or ambivalent portrayal of woman’s sexuality. The
full implication of this control is not clearly understood
across all cultures; for example many women in cultures
where they are considered little more than chattel are
orgasmic and many women in sexually open cultures
have difficulties.
Certainly, in Anglo-Saxon cultures, by the mid-1800s the
orgasm was seen as unnecessary, unseemly, or perhaps even
unhealthy for women. Freud added a new dimension in 1905
with his ‘New Introductory Lectures on Psychoanalysis’:
‘With the change to femininity the clitoris should wholly
or in part, hand over its sensitivity and at the same time its
importance to the vagina’. This idea had a very significant
impact on female orgasmic potential in the Western world.
Female orgasm and anorgasmia
For a long time, orgasmic difficulties were thought to be
caused primarily by psychological and interpersonal issues,
and women were told they needed to climax primarily through
intercourse or be ‘dysfunctional’.
The book ‘Human Sexual Response’ from Masters and
Johnson (1966) made the scientific study of female sexuality
more acceptable, and the clitoris re-entered the arena.10
Nevertheless, the dilemma of the clitoral versus the vaginal
orgasm persisted for many years.
Ladas et al. (1982) re-described the G-spot orgasm,
and other scientists have since labelled other areas in the
genital tract as having increased erotic sensation capable
of orgasmic potential in some women.11 Levin (2003)
postulated that it is more sensible to call the whole area
(urethra–clitoral–G-spot area–Halban’s fascia) the ‘anterior
wall erogenous complex’.12
Female genital anatomy
The scientific study of anatomy started during the
Renaissance and, of necessity, focussed on males. Although
the discipline developed, Victorian morality did not
allow for the study of female sexuality and genitalia. ‘Gray’s
Anatomy’, the standard medical anatomical handbook, hardly
mentioned the clitoris and the vaginal opening was depicted
as a round hole. O’Connell et al. (1998) presented a
a b
mons pubis
front commissure
shaft of clitoris (hidden)
hood
glans
frenulum
urethra
vagina
labium minorum
labium majorum
fourchette
perineum
anus
Fig. 1. Female genital anatomy: (a) external and (b) internal views of the vulva. From Kerner (2004: pp. 42 and 48).61
Sexual Health 145
fuller understanding of the true size and distribution
of the clitoris (Fig. 1).13 This fuller understanding of
the extent of clitoral and pelvic nerve distribution is
particularly important because it impacts on women’s
orgasmic potential with genital or pelvic surgery and post-
menopausal changes.
Evolution of models about female sexual
response and orgasm
Masters and Johnson’s linear sexual response model
Masters and Johnson (1966) focussed on genital and
peripheral physiological changes and on the classification
of sexual dysfunctions based on these stages.10 Interest and
desire were not included. The conclusion was that sexual
desire and arousal correlated with orgasmic frequency for
men and women. Orgasm was thought to be so intensely
pleasurable and self-reinforcing that it maintained the cycle
for repetition of sexual activity. In hindsight, this model is
more sympathetic to male sexual functioning.
Kaplan’s triphasic model of human sexuality
Kaplan’s linear model introduced desire as the lead-in
to sexual behaviour.14 Although more female-sympathetic,
it is still linear, with orgasm as the desired successful
outcome. However, Kaplan did note that frequency or ease
mons pubis
suspensory ligament
shaft of clitoris
glans
leg of clitoris
urethra
bulb of clitoris
clitoral cluster
vagina
labium minorum
labium majorum
perineal sponge
anus
146 Sexual Health M. Redelman

of women achieving orgasm was often uncorrelated with the

degree of physiological arousal or subjective pleasure. Garde Minimal
and Lunde (1980) showed that roughly 30% of women never Sexual
Neither emotional motivation
experience spontaneous desire, despite adequate arousal nor physical Willingness to
and orgasm.15 satisfaction find / be receptive

Schnarch’s quantum model of sexual function Minimal

and dysfunction Minimal “Spontaneous Sexual stimuli
arousal Desire” avoided - proven
Schnarch’s model possesses two dimensions: arousal and No responsive desire ineffective
orgasm thresholds.16 This model was significant for the
introduction of ‘meanings and feelings for and about’ sexual Pr
Minimal af oce
activity, partner and context, and how this biofeedback Arousability lo fe
arousal w ct ssi
impaired an ed ng
can increase or decrease ability to reach these thresholds. dr by
og
Emotional satisfaction rather than orgasm could motivate en
for more sexual behaviour. The stimulus thresholds are very
individual and vary over time and with intra and extra-person Fig. 2. Sex response cycle, showing the effect of androgen on a
changes such as health or partner behaviour. Conscious or woman’s sexual response. From Basson (2003).18
hormonally driven sexual hunger, possibly very important in
masturbation, becomes only one factor for engaging in couple and World Health Organization (WHO) International
sexual behaviour. Classification of Diseases (ICD)-10 classification of
Basson’s human sex response cycle diseases; Table 3).
Women meeting the criteria for the FOD described by
Basson’s ‘intimacy’ driven model of sexuality is more DSM-IV experience delay in, or absence of, sexual orgasm.
applicable to many women (Fig. 2) and integrates The Consensus Classification still presents a linear biological
‘spontaneous’ and ‘responsive’ desire.17,18 This model progression to orgasm based on an assumed universal
addresses ways in which women enter the sexual arena physiological sexual response pattern (‘normal function’)
and how sexual incentives and disincentives arise. The originally described by Masters and Johnson in the 1960s.
physiological sexual health and adequate total sexual However, does this truly reflect the diversity of women’s
stimulation for orgasm is still needed, but orgasm itself is sexual experiences?
not the only or main incentive to be sexual. The issue of distress can also be problematic — if a woman
is not distressed, is there a problem? What if the partner is
Classification of female sexual dysfunction/female
distressed? Does classifying something as a problem take
orgasmic disorder
away personal decision of whether there is a problem for the
Classification is important for defining what is a individual, and whether to act on it?
problem, for allowing consistency and comparability
in research and to help guide management and/or Neurophysiology of female desire, arousal and orgasm
treatment strategies. The classification of female sexual
dysfunctions (FSD) and female orgasmic disorder (FOD) Sexual desire pathophysiology
has undergone radical rethinking in recent years and It is self-evident that without the desire or willingness
is still ongoing. Two such classifications are listed — to participate in sexual activity or to be receptive to a
the DSM diagnostic criteria (ref. 19; Table 2) and the partner’s initiation, arousal and orgasm will be affected.
Consensus Classification (1999, drawn from the DSM-IV Libido represents the core of sexual behaviour (except for

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
Table 3. Consensus classification of female sexual dysfunction
From Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) and the World Health Organization’s International Classification of
Diseases (ICD)-10 classification
I Sexual desire disorders A Hypoactive sexual
desire disorder
B Sexual aversion
disorder
II Sexual arousal disorder
III Orgasmic disorder
IV Sexual pain disorders
those women who can orgasm without positive feelings for
partner or the sexual context).
There are three major dimensions of desire.
(1) Biological — centred in the rhinencephalic and limbic
brain and strongly hormone-dependent. However, this is
further modulated by mood states and is neurochemically
driven.
(2) Motivational — it may be that over a lifespan and
depending on life situations of women, the motivation for
sexual activity may shift from the primary reproductive
biological goal, to recreational sex and to instrumental
sex, where it becomes the vehicle to obtain advantages
(for example bonding) and express other motivations
(for example intimacy).
(3) Cognitive — wishes, fears and knowledge about sexual
behaviour.
Sexual arousal pathophysiology
Mental arousal is triggered biologically by androgens
and by psychologically meaningful interactions, such as
bonding. There is a biofeedback interaction in which 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
are all important factors in reaching biological thresholds
of function.
Genital arousal results in the production of vaginal
transudate. This is mediated by the neurotransmitter
vasointestinal peptide (VIP) under the ‘permitting’ influence
of oestrogens. Nitric oxide (NO) stimulates the neurogenic
congestion of the clitoris and vestibular bulb corpora
cavernosa. Androgens are potentiating factors for NO.
Sexual Health 147
Persistent or recurrent deficiency or absence of sexual
fantasies/thoughts and/or of desire for or receptivity
to sexual activity that causes personal distress.
Persistent or recurrent phobic aversion to and avoidance
of sexual contact with a sexual partner that causes
personal distress.
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.
Persistent or recurrent loss of orgasmic potential after
sufficient sexual stimulation and arousal, which causes
personal distress. Can be primary or secondary.
Dyspareunia.
Vaginismus.
Other sexual pain disorders.
Orgasm pathophysiology
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, and 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 five to eight
seconds, starting with intervals less than one second (0.8 s)
and then, as they become weaker, at longer intervals.20
Almost at the same time, the uterus begins to contract.
These weak contractions start at the top and progress
down the uterus. The sphincter muscles of the rectum
may also contract. However, there are different patterns
between women.
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. 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. A few women
have ‘female ejaculation’ of what appears to be prostate-
like fluid.11 Continued sexual stimulation may lead to a
repeat of the orgasmic response if the woman desires this.
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.
148 Sexual Health M. Redelman

Prevalence of orgasm difficulties Hunt (1974)24 reported that:

Data suggest that sexual difficulties are very common in 53% of married women are orgasmic almost all the time.
women but many people question the appropriateness of the 7% of married women are never orgasmic.
dysfunction labels because up to 30–50% of the population
is classified as having a dysfunction (Table 4). Once again, Hite (1976) surveyed 3000 women and concluded that
the yardstick for what is normal over a lifespan needs to be ‘most’ women do not reach orgasm during intercourse
established. Presumably it may be normal to have a sexual and masturbation is more effective than intercourse for
difficulty at some time over a lifespan when conditions orgasm.4 The Redbook Report surveyed 100 000 women and
for good sex are not met or when hormonal levels drop reported that most of their subjects reached orgasm through
below physiological levels necessary to maintain function. intercourse and 63% reach coital orgasm all or most of time.25
However, what is normal may not be what is desirable
Effects of menopause
or desired.
Laumann et al. (1999) reported that 24% of his study As we have an increasing healthy aging female population
population of women reported orgasmic difficulties.21 Apart in the Western world who frequently want to maintain the
from their report on frequency of orgasmic difficulties, sexual pleasure they enjoyed in younger years and maintain
Richters and Rissel (2005) also reported on statistics with their quality of life, the study and treatment of menopausal
combinations of activities leading to orgasm (Table 5).22 This consequences and age-related changes has flourished.
confirmed Hite’s (1976) finding that intercourse is not the best Menopause is defined by the WHO and the National
way for women to reach orgasm.4 Institute of Health (NIH) Stages of Reproductive Health
Kinsey et al. (1965)23 reported that: Workshop as the permanent cessation of menstrual periods
that occurs naturally or is induced by surgery, chemotherapy
25% of women are totally anorgasmic in first year of or radiation.26 Natural menopause is recognised after twelve
marriage. consecutive months without menstrual periods that are not
10% of women are never orgasmic with intercourse associated with a physiologic or pathologic cause. The
throughout marriage. menopausal transition is the time of an increase in follicle-
39% of women married less than 12 months are almost stimulating hormone and increased variability in cycle
always orgasmic during intercourse. length, two skipped menstrual cycles with 60 or more
47% of women married 20 years are almost always orgasmic days of amenorrhea, or both. The menopausal transition
during intercourse. concludes with final menstrual period and the beginning
of post-menopause. The post-menopause is recognised after
12 months of amenorrhea.
Table 4. Prevalence of sexual difficulties
Australian data from Richters and Rissel (2005);22 Japanese data from Iatrogenic menopause, which is brought on by pelvic
Hisasue et al. (2005)59 surgery, cancer treatment and conditions or medications that
increase sex hormone binding globulin (such as thyroxine,
Difficulty (%)
oral oestrogens and pregnancy), seems to have a greater
Orgasm Desire Arousal
impact on testosterone levels than natural menopause
Australia Pre-menopause 29 55 (Table 6). Oxytocin (the ‘cuddle hormone’) is another
Post-menopause 42 55 very important neurochemical involved in moderating
Japan Pre-menopause 15.2 27.7 29.7 interpersonal bonding behaviour and is released with orgasm.
Post-menopause 32.2 57.9 57.9 Endorphins may certainly be very important in perception of
pleasure and the motivation to repeat sexual activity.
Table 5. Combinations of sexual practices and orgasm at woman’s Female androgen insufficiency syndrome
most recent sexual encounter with a male partner
The female androgen insufficiency syndrome (FAIS,
Practice Who did Who reached defined by the Princeton Consensus Statement, ref. 27)
this (%) orgasm (%) includes: diminished sense of well being, dysphoric mood
Vaginal intercourse only 20 50
and/or blunted motivation; persistent unexplained fatigue;
Vaginal plus manual 53 71 sexual function changes, including deceased libido, sexual
Vaginal plus oral 3 73 receptivity and pleasure; and (potential) bone loss, decreased
Vaginal plus oral plus manual 21 86 muscle strength and changes in cognition/memory.
Manual only 2 79 However, there is no reason why the ‘age-related’ changes
Manual plus oral 1 90 that occur in men should not also occur in women. Vascular
Oral only <1 79
problems with aging may reduce blood flow to the female
Any combination including anal 1 71
genital region so that tissues and structures become less
Female orgasm and anorgasmia Sexual Health 149

Table 6. Hormones involved in female sexuality

Adapted from Lobo (1999)60

Hormone Action Hormone level (pg mL−1 ) Consequences

Fertile Post-menopause Iatrogenic menopause
Androgens Central initiators Testosterone, Testosterone, Testosterone, Female androgen insufficiency
peripheral 400 <290 110 syndrome
conditioners Decreased sensitivity of clitoris
and nipples
Decreased capacity for arousal
and orgasm
Changes labia
Loss of pubic hair, dry skin
Oestrogens Cental and peripheral 100–150 <15 10 Vasomotor symptoms
conditioners Atrophy genitourinary tract
Decreased vaginal lubrication
and congestion
Loss of pelvic floor muscle tone,
leads to decreased orgasmic
contraction strength
Decreased vaginal sensitivity
Altered sense of smell
Touch aversion
Reduced sensitivity to touch
Progestins Mild cental inhibitors
(unless androgenic)
type
Prolactin Central inhibitor
at high levels
Thyroid hormones Inhibitors at low levels Inhibits sexual desire

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
and painful conditions, menopausal status and symptoms,
any pregnancies, terminations, and nature of deliveries
and contraceptive history.
(2) Social history includes family information, position
in family, siblings, family traumas (violence, divorce,
deaths), a history of relationships including the present
relationship and communication patterns and skills.
(3) Psychological history includes general emotional
robustness and coping skills (including emotional and
psychiatric problems), use of medication, and depression
history including post-natal depression.
(4) Sexual history includes detailed history of the specific
presenting sexual difficulty (onset gradual or rapid,
situational or generalised, and any specific pertinent event
around the time of onset), a detailed history of personal
sexual learning and experiences (including feelings about
these, for example a parent’s sexual behaviour), history
and style of masturbation, history of sexual trauma,
and a detailed history of how the couple actually make
love and level of partner’s lovemaking skills and/or
sexual difficulties. Sexual orientation and content of
sexual fantasies may be relevant. Co-morbidity with more
than one sexual dysfunction being present should be
looked for.
Asking the woman or couple what they think is causing
the difficulty, what they have tried in the past and what
they think will help is important. It is pertinent to enquire
how much energy is available to apply to efforts to change
the situation.
Management of anorgasmia
The reality is that sexual desire disorders and arousal
disorders are often precursors to orgasmic disorders,
as can be seen from the circular models of female sexual
function, with feedback loops involving meaning, emotion
and biological/medical functions. Treatment of orgasmic
difficulties of necessity often involves treatment of desire
and/or arousal difficulties.
The success rate for treating anorgasmia with cognitive–
behavioural treatment is very good, although the success
is higher in primary than secondary anorgasmia with
organic factors. LoPiccolo and Stock (1986) 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
a partner and 40% could reach orgasm during coitus.35
Combining direct clitoral stimulation with coitus improves
the rate for coital orgasms. The cognitive–behavioural
treatment approach incorporating sensate focus, systematic
desensitisation and directed masturbation has received the
greatest amount of empirical support for treating FOD,
with reported success rates between 88 and 90%.36,37
However, where orgasmic difficulties occur alongside with
M. Redelman
severe psychological distress, personality disorder or a
highly stressed relationship, this treatment strategy may be
inappropriate. In post-menopausal situations, a return to pre-
menopausal orgasmic function may not be possible despite
various cognitive–behavioural treatment and/or 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
or client can move forward.
The most successful treatment outcome will result from
the sexual health consultant listening well to the history,
conducting appropriate physical examinations and blood tests
and constructing an individualised treatment program.
Relationship counselling may be very relevant and
especially the teaching of intimate communication skills,
because it is very difficult for many women to say ‘I love
you and want to make love with you, but the way you rub my
clitoris is irritating for me’. Many men feel threatened when
a woman tries to teach what she needs to be orgasmic.
Primary anorgasmia
A history will give insight into whether a low biological
sex drive, timid personality, repressive sexual environment
in conjunction with poor sexual knowledge, abusive
experiences, poor lovemaking style, troubled relationship/s,
or medical problems are major factors in the anorgasmia.
Psychological factors, including sexual inexperience, lack of
sexual knowledge of how to achieve sufficient stimulation
and sexual shyness, are more common than medical factors
in primary anorgasmia.
Management of primary anorgasmia includes:
(1) Assessment and treatment of co-morbid factors where
possible.
(2) Education about sexual anatomy and function.
(3) Improvement of self-confidence and assertiveness.
(4) Entitlement to adult sexuality.
(5) Encouragement of self-exploration of whole body and
genitals.
(6) Permission to be sexually selfish (the woman is allowed
to consider herself and her sexual needs first some of
the time).
(7) Acceptance and appreciation of genitals (become
‘friends’ so can ‘play’ together).
(8) Dealing with specific sexual fears or fears of orgasm.
(9) Pelvic floor exercises (daily, lifelong asset for good
sexuality).
(10) Reducing spectatoring (critically observing oneself is
not an erotic activity).
(11) Enhancement of mental arousal (use senses to create
sensual ambiance and variety).
(12) Improvement of sexual focussing skills (fantasy, reading
erotica).
Female orgasm and anorgasmia
(13) Directed masturbation exercises, as per a masturbation
program (ref. 38) and using lots of lubricant.
(14) Vibrator use if more stimulation is needed.
(15) Encouragement of patience and persistence with at least
thrice-weekly sessions in a good setting.
(16) Transferring masturbation skills to couples situation.
(17) Treatment of couple relationship/communication
dynamics.
(18) Learning lifelong erotic and romance skills.
Secondary anorgasmia
Once again, a history will highlight possible causes for the
loss of orgasmic potential.
In younger women, the causes are more likely to be due
to lifestyle issues, relationship difficulties and health issues,
such as depression or infections. Anger and/or resentment
at a partner are especially common around negotiating
equitable domestic and child-care roles or career decisions.
Contraceptive dilemmas or fears of pregnancy may also
inhibit sexual expression.
In older women, health issues, medications and
menopause are more often responsible. Entrenched
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
with life-stage changes, affecting sexuality. However, the
treatment for depression can also compound or create a
sexual difficulty.
Management of secondary anorgasmia includes:
(1) Addressing any treatable medical condition.
(2) Addressing relationship issues.
(3) Addressing co-morbid sexual difficulties.
(4) Explaining need for change in lovemaking pattern and
need for more intense stimulation (lots of lubricant,
manual stimulation, vibrator).
(5) Treatment of any hormone imbalance with systemic or
local hormone replacement therapy as appropriate and
acceptable to the woman.
(6) Encouragement of daily pelvic floor exercises for life.
(7) Monitoring medications and adjusting or replacing as
appropriate.
(8) Addressing partner health and sexual problems.
(9) Giving permission and encouragement.
(10) Treatment of the couple.
(11) Teaching acceptance of things that can’t or don’t want
to be changed.
Medical management of secondary anorgasmia includes:
(1) Hormone replacement therapy (HRT) with or without
testosterone.39
(2) Oestrogens to improve clitoral and vaginal sensitivity,
vaginal lubrication and sexual desire.40
Sexual Health 151
(3) Testosterone (‘Androfeme gel’ available in Western
Australia, intramuscular injections, transdermal parches)
to increase clitoral sensitivity,41 sexual arousal, mental
arousal and emotional receptivity.42
(4) Tibolone, a synthetic steroid with oestrogenic,
androgenic and progestagenic properties.43
(5) Lubricants.
(6) PDE5 drugs for post-menopausal FOD for poor-arousal
couples with good libido.44–46
(7) Bupropion, a dopamine agonist, which may have a
centrally acting mode of action for stimulating sexual
thoughts, increasing orgasm potential, and reversing the
inhibitory side effects of selective serotonin re-uptake
inhibitors (SSRIs).47,48
(8) Transdermal delivery of oestrogens and testosterone
gives best results.49,50 With transdermal oestrogens
the first hepatic pass is avoided, which avoids
the increase in SHBG that binds with serum
testosterone to lower available free testosterone.
Sherwin (2002) and Alexander et al. (2004), in reviews
of randomised controlled trials, found that adding
androgens to oestrogens replacement had added
sexual benefits.39,51
The women in the above Berman et al. 2003 study
showed improved sensation and ability to reach orgasm
with increased blood flow following Viagra (Pfizer) use
(Table 7).46 However, the PDE5 female trials are often
ambivalent or neutral,52 but that could be because only a
specific population of women benefits from increased genital
blood flow, given that other factors are not an issue.
The rising incidence of depressive disorders worldwide
and the increased use of antidepressants, especially SSRIs,
has resulted in an increase in iatrogenic loss of desire
and difficulty with achieving orgasm. This SSRI effect is
useful for men with premature ejaculation but not so helpful
for depressed women struggling to regain control of their
lives. Changing the antidepressant medication, changing the
dose, having medication holidays, and improving sexual
techniques and quality of the relationship are all strategies.
The PDE5 drugs may help women with antidepressant-
associated arousal or orgasm difficulties.53,54
Table 7. Impact of Viagra on the post-hysterectomy sexual
complaints of women
From Berman (2000)31
Before (%) After (%)
Low sexual sensations 100 22
Inability to reach orgasm 100 18
Little or no desire 52 45
Little or no lubrication 67 40
Pain or discomfort during sex 68 33
152 Sexual Health
Conclusions
Having orgasms can be a very enjoyable, healthy and
free activity for all women who want them. It seems that
all women, excluding those with certain medical (severe
diabetes, multiple sclerosis) or surgical conditions, are
capable of having orgasms. Perhaps labelling women ‘pre-
orgasmic’ rather than anorgasmic may be more appropriate.
The past focus on ‘non-organic’ aspects of FOD has
perhaps reflected our past level of knowledge of female sexual
function and physiology, and the availability of medical
solutions. It is not so long ago that we were telling men that
erectile dysfunction was mostly a psychological problem.10
Hormone replacement therapy has not had an easy time of late
(see refs 55, 56) and, in Australia, testosterone replacement
therapy for women is only approved in Western Australia.
The importance of better surgical techniques to spare pelvic
nerves (in line with nerve-sparing prostatectomies) needs
to be stressed to surgeons and gynaecologists. However, all
solutions do not have to come from pills. Basson’s (2002)
circular biofeedback interactive model clearly shows how
important the psychosocio-relational aspects of a woman’s
sex life are.57 The best results will be gained by seeing
the whole picture affecting any one individual woman and
tailoring a program for her from all available treatment
modalities. However, our expectations for good healthy
sexual functioning are perhaps unrealistic if we are obese,
smoke, don’t exercise, don’t do pelvic floor exercises every
day, are ignorant of how to get the best out of our bodies and
do nothing to make sexual activity ‘fun’.
References
1 Moynihan R. J Sex Med 2003; July 66–68.
2 Tiefer L, Hall M, Travis C. Beyond dysfunction: a new view
of women’s sexual problems. J Sex Marital Ther 2002; 28(s):
225–232.
3 Meston CM, Hull E, Levin RJ, Sipski M. Disorders of orgasm
in women. J Sex Med 2004; 1: 66–8. doi: 10.1111/j.1743-
6109.2004.10110.x
4 Hite S. The Hite Report. New York: Macmillan; 1976.
5 Spector IP, Carey MP. Incidence & prevalence of sexual
dysfunctions: A critical review. Arch Sex Behav 1990; 19:
389–408. doi: 10.1007/BF01541933
6 Lloyd EA. The case of the female orgasm: bias in the science of
evolution. Cambridge, MA: Harvard University Press; 2005.
7 Symons D. The evolution of human sexuality. Oxford, UK: Oxford
University Press; 1979.
8 Komisaruk BR, Whipple B. The suppression of pain by genital
stimulation in females. Annu Rev Sex Res 1996; 6: 151–84.
9 Kellogg-Spadt S. Demystifying female sexual response: the best is
yet to come. In ‘Program and abstracts of the National Association
of Nurse Practitioners in Women’s Health 7th Annual Conference;
13–16 October 2004; Chicago, IL’.
10 Masters EH, Johnson VE. Human sexual response. Boston, MA:
Little Brown; 1966.
11 Ladas AK, Whipple B, Perry JD. The G-spot and other discoveries
about human sexuality. New York: Holt, Rinehart & Winston;
1982.
M. Redelman
12 Levin R. The G spot-reality or illusion? Sex Relationship Ther
2003; 18(1): 117–9. doi: 10.1080/1468199031000064487
13 O’Connell HE, Hutson JM, Anderson CR, Plenter RJ. Anatomical
relationship between the urethra and clitoris. J Urology 1998; 159:
1892–7. doi: 10.1016/S0022-5347(01)63188-4
14 Kaplan KS. Hypoactive sexual desire. J Sex Marital Ther 1979;
3: 3–9.
15 Garde I, Lunde I. Female sexual behaviour—a study in a
random sample of 40-year-old women. Maturitas 1980; 2:
240–55.
16 Schnarch DM. Constructing the sexual crucible – an integration
of sexual and marital therapy. New York: Norton; 1991.
17 Basson R. Using a different model for female responses to address
women’s problematic low sexual desire. J Sex Marital Ther
2001a; 27(5): 395–403.
18 Basson R. Biopsychosocial models of women’s sexual response:
applications to the management of ‘desire disorders’. Sex
Relationship Ther 2003; 18(1): 107–115. doi: 10.1080/
1468199031000061308
19 DSM-IV. Diagnostic and statistical manual of mental disorders
(4th edn). Washington, DC: American Psychiatric Association;
1994.
20 Reinisch JM. The Kinsey Institute New Report on Sex. New York:
The Kinsey Institute; 1990.
21 Laumann EO, Paik A, Rosen RC. Sexual dysfunctions in the
United States: prevalence and predictors. JAMA 1999; 281:
537–44. doi: 10.1001/jama.281.6.537
22 Richters J, Rissel C. Doing it down under – the sexual lives of
Australians. Sydney: Allen & Unwin; 2005.
23 Kinsey AC, Wardell BP, Martin CE. Sexual behaviour in the human
female. New York: Pocket Books Inc.; 1965.
24 Hunt M. Sexual behaviour in the 1970’s. New York: Dell
Publishing Co.; 1974.
25 Tavris C, Sadd S. The redbook report on female sexuality.
New York: Delacorte Press; 1975.
26 STRAW, NIH Consensus Development Program. State of
Science Statement on Management of Menopause Related
Symptoms. March 2005. (Bethesda, MD: National Institute
of Health.)
27 Bachmann GA, Bancroft J, Braunstein G, Burger H, Davis S,
Dennerstein L, Goldstein I, Guay A, Leiblum S, Lobo R,
Notelovitz M, Rosen R. Female androgen insufficiency: The
Princeton consensus statement on definition, classification and
assessment. Fertil Steril 2002; 77(4): 660–5. doi: 10.1016/S0015-
0282(02)02969-2
28 Sarrel PM. Sexuality and menopause. Obstet Gynaecol 1990; 75:
26S–30S.
29 Berman JR, Goldstein I. Female sexual dysfunction. Urol
Clin North Am 2001; 28: 405–16. doi: 10.1016/S0094-
0143(05)70148-8
30 Park K, Goldstein I, Andry C, Siroky MB, Krane RJ,
Azadzoi KM. Vasculogenic female sexual dysfunction: the
hemodynamic basis for vaginal engorgement insufficiency and
clitoral erectile insufficiency. Int J Impot Res 1997; 9: 27–37.
doi: 10.1038/sj.ijir.3900258
31 Berman L. Women too may benefit from Viagra. Presented
at the American Urological Association Meeting, Atlanta, GA,
29 April–4 May 2000.
32 Rako S. Testosterone deficiency and supplementation for
women: matters of sexuality and health. Psychiatry Annu 1999;
29: 23–6.
33 Santow G, Bracker M. Correlates of hysterectomy in
Australia. Soc Sci Med 1992; 34: 929–42. doi: 10.1016/0277-
9536(92)90261-N
Female orgasm and anorgasmia
34 Burger HG, Dudley EC, Cui JS, Dennerstein L, Hopper JL.
A prospective longitudinal study of serum testosterone,
dehydroepiandroosterone sulfate and sex hormone binding
globulin levels through the menopause transition. J Clin
Endocrinol Metab 2000; 85: 2832–8. doi: 10.1210/jc.85.8.2832
35 LoPiccolo J, Stock WE. Treatment of sexual dysfunction.
J Consult Clin Psychol 1986; 54: 158–67. doi: 10.1037/0022-
006X.54.2.158
36 Heiman JR, Meston CM. Empirically validated treatment for
sexual dysfunction. Annu Rev Sex Res 1997; 8: 148–94.
37 Meston CM, Frolich PF. Update on female sexual function.
Curr Opin Urol 2001; 11: 603–9. doi: 10.1097/00042307-
200111000-00008
38 Heiman J, LoPicollo J. Becoming orgasmic: a sexual and personal
growth program for women. New York: Prentice Hall; 1988.
39 Sherwin BB. Randomised clinical trials of combined androgen–
androgen preparations: effects on sexual functioning. Fertil Steril
2002; 77(suppl. 4): 49–54. doi: 10.1016/S0015-0282(02)03002-9
40 Collins A, Landgren BM. Reproductive health, use of estrogens
and experience of symptoms in postmenopausal women:
a population based study. Maturitas 1994; 20: 101–11.
doi: 10.1016/0378-5122(94)90005-1
41 Goldstat R, Briganti E, Tran J, Wolfe R, Davis SR. Transdermal
testosterone therapy improves well being, mood and sexual
function in premenopausal women. Menopause 2003; 10: 390–8.
doi: 10.1097/01.GME.0000060256.03945.20
42 Basson R. Female sexual response: the role of drugs in the
management of sexual dysfunction. Obstet Gynecol 2001b; 98:
350–3. doi: 10.1016/S0029-7844(01)01452-1
43 Davis SR. The effects of tibolone on mood and libido. Menopause
2002; 9: 162–70. doi: 10.1097/00042192-200205000-00004
44 Fourcroy JL. Female sexual dysfunction: potential for
pharmacotherapy. Drugs 2003; 63: 1445–57. doi: 10.2165/
00003495-200363140-00002
45 Kaplan SA, Reis RB, Kohn IJ, Ikeguchi EF, Laor E, Te AE,
Martins ACP. Safety and efficiency of sildenafil in postmenopausal
women with sexual dysfunction. Urology 1999; 53: 481–6.
doi: 10.1016/S0090-4295(98)00633-5
46 Berman JR, Berman LA, Toler SM, Gill J, Haughie S. Safety and
efficacy of sildenafil citrate for the treatment of female sexual
arousal disorder: a double blind, placebo controlled study. J Urol
2003; 170: 2333–8. doi: 10.1097/01.ju.0000090966.74607.34
47 Clayton AH, Warnock JK, Kornstein SG, Pinkerton R,
Sheldon-Keller A, McGarvey EL. A placebo controlled trial of
bupropion SR as an antidote of SSRI induced sexual dysfunction.
J Clin Psychiatry 2004; 65(1): 62–7.
48 Ginzburg R, Wong Y, Fader JS. Effect of bupropion on sexual
function. Ann Pharmacother 2005; 39(12): 2096–9. doi: 10.1345/
aph.1G275
http://www.publish.csiro.au/journals/sh
Sexual Health 153
49 Simon JA, Mazer NA, Wekselman K. Safety profile: transdermal
testosterone treatment of women after oophorectomy. Obstet
Gynecol 2001; 97: S10–1. doi: 10.1016/S0029-7844(01)01154-1
50 Simon JA, Nachtigal LE, Davis SR, Utian WH, Lucas JD,
Braunstein GD. Obstet Gynecol 2004; 103: S64.
51 Alexander JL, Kotz K, Dennerstein L, Kutner SJ, Wallen K,
Notelovitz M. The effects of menopausal hormone therapies
on female sexual functioning: review of double-blind
randomized controlled trials. Menopause 2004; 11(6): 749–795.
doi: 10.1097/01.GME.0000142887.31811.97
52 Walton B, Thorton T. Female sexual dysfunction. Curr Womens
Health Rep 2003; 3: 319–26.
53 Shen WW, Urosevich Z, Clayton DO. Sildenafil in the treatment
of female sexual dysfunction induced by SSRI’s. J Reprod Med
1999; 44(6): 535–42.
54 Nurnberg HG, et al. Sildenafil for selective reuptake inhibitor
associated female sexual dysfunction (abstract) presented 155th
Annual Meeting of the American Psychiatric Association,
Philadelphia, PA, 2002.
55 Anderson GL, Limacher M, Assaf AR, Bassford T,
Beresford SAA, Black H, Bonds D, Brunner R, Brzyski R,
Caan B, Chlebowski R, Curb D. Effects of estrogens plus
progestin on gynaecologic cancers and associated diagnostic
procedures: The Women’s Health Initiative Randomised Trial.
JAMA 2003; 290: 1739–48. doi: 10.1001/jama.290.13.1739
56 Lobo RA. Evaluation of cardiovascular event rates with hormone
therapy in healthy, early postmenopausal women: results from
2 large clinical trials. Arch Intern Med 2004; 164: 482–4.
doi: 10.1001/archinte.164.5.482
57 Basson R. Are our definitions of women’s desire, arousal
and pain disorders too broad and our definition of orgasmic
disorder too narrow? J Sex Marital Ther 2002; 28: 289–300.
doi: 10.1080/00926230290001411
58 Laumann EO, Gagnon JH, Michael RT, Michaels S. The social
organization of sexuality: sexual practices in the United States.
Chicago, IL: University of Chicago Press; 1994.
59 Hisasue S, Kumamoto Y, Sato Y, Masumori N, Horita H, Kato R,
Kobayashi K, Hashimoto K, Yamashita N, Itoh N. Prevalence of
female sexual dysfunction symptoms and its relationship to quality
of life: a Japanese female cohort study. Urology 2005; 65(1):
143–8. doi: 10.1016/j.urology.2004.08.003
60 Lobo RA. Treatment of postmenopausal women. Boston, MA:
Lippincott; 1999.
61 Kerner I. She comes first. New York: Harper Collins; 2004.
Received 18 January 2006, accepted 24 May 2006