Female Orgasmic Disorder

Female orgasmic disorder (FOD) involves difficulty in achieving orgasm, substantially decreased intensity of orgasm, or both. ^[1]

Female orgasm itself has been comprehensively defined as "a variable, transient peak sensation of intense pleasure creating an altered state of consciousness, usually accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions and myotonia that resolves the sexually-induced vasocongestion (sometimes only partially), usually with an induction of well-being and contentment." ^[2]

Particular attention should be paid to the terms "variable," "usually," "often," "sometimes," and "partially" in this definition. The use of such terms in a statement presumably meant to be precise and specific may indicate that the subject being defined is in fact highly variable, that there is little agreement on its objective characteristics, or both.

The traditional view promoted by Masters and Johnson is that male and female sexual response is characterized by a gradual, sequential progression of events starting with sexual interest and culminating with orgasm. ^{[3, 4]} However, this linear model has proved to be only marginally useful for assessing and treating women’s sexual difficulties. Accordingly, the current view incorporates the idea that female sexual responses of the mind and body may follow more than 1 set pattern.

With regard to sexual motivation, most authorities agree that awareness of sexual desire at the outset of a wanted sexual experience is not required for orgasm to occur, particularly in women. Either sexual or nonsexual erotic stimulation may result in orgasms. Furthermore, despite sexual satisfaction, orgasms may occur in multiples or not at all.

Authorities increasingly accept that the traditional view of a simple, gradual, linear progression through the stages of desire, excitement, orgasm, and resolution probably oversimplifies and possibly mystifies evaluation of the sexual response. Advances in the field over the past few decades suggest that adequate evaluation of the sexual response must account for many variables and possible outcomes, especially in women. ^[5]

Diagnostic criteria (DSM-5-TR)

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), classifies FOD as belonging to a group of sexual dysfunction disorders that are typically characterized by a clinically significant inability to respond sexually or to experience sexual pleasure. ^[1]

Sexual functioning involves a complex interaction among biologic, sociocultural, and psychological factors, and the complexity of this interaction makes it difficult to ascertain the clinical etiology of sexual dysfunction. Before any diagnosis of sexual dysfunction is made, problems that are explained by a nonsexual mental disorder or other stressors must first be addressed. Thus, in addition to the criteria for FOD, the following must be considered:

• Partner factors (eg, partner sexual problems or health issues)

• Relationship factors (eg, communication problems, differing levels of desire for sexual activity, or partner violence)

• Individual vulnerability factors (eg, history of sexual or emotional abuse, existing psychiatric conditions such as depression, or stressors such as job loss)

• Cultural or religious factors (eg, inhibitions or conflicted attitudes regarding sexuality)

• Medical factors (eg, an existing medical condition or the effects of drugs or medications)

The specific DSM-5-TR criteria for FOD are as follows: ^[1]

• In almost all or all (75-100%) sexual activity, the experience of either (a) markedly delayed, markedly infrequent, or absent orgasms or (b) markedly less intense orgasms

• The symptoms above have persisted for approximately 6 months

• The symptoms above cause significant distress to the individual

• The dysfunction cannot be better explained by nonsexual mental disorder, a medical condition, the effects of a drug or medication, or severe relationship distress or other significant stressors

The severity of female orgasmic disorder is specified as mild, moderate, or severe on the basis of the level of distress the patient exhibits over the symptoms. The duration of the dysfunction is specified as follows:

• Lifelong (present since first sexual experience)

• Acquired (developing after a period of relative normal sexual functioning)

In addition, the context in which the dysfunction occurs is specified as follows:

• Generalized (not limited to certain types of stimulation, situations, or partners)

• Situational (limited to specific types of stimulation, situations, or partners)

The female sexual response is mediated primarily via spinal cord reflexes under the tonic descending inhibitory control of the brainstem. Afferent signals from clitoral stimulation are transmitted via the pudendal nerve. Signals from vaginal stimulation are transmitted via the pelvic nerve alongside the pudendal and hypogastric nerves.

The nucleus paragigantocellaris in the ventral medulla, which has direct projections to the pelvic efferent neurons and interneurons in the lumbosacral spinal cord, appears to be an important regulatory site mediating orgasm. ^[6] Sympathetic nervous system (SNS) activation facilitates the female sexual response. ^[7] This sympathetic dominance is reversed in men, in whom SNS activation inhibits the sexual response.

There is a relatively low correlation between psychophysiological measures of vaginal blood flow and verbal reports of sexual arousal. This indicates either that women are less sensitive than men to changes in the genital blood flow or, alternatively, that women value external stimulus information alongside internal physiologic changes in their assessment of sexual arousal. ^[8]

Erotic stimulation resulting in female orgasm can originate from a variety of genital and nongenital sites. Although the clitoris and vagina are the most common sites of stimulation that result in an orgasm, stimulation of other body sites (eg, periurethral glans, breast, nipple, or mons) can trigger an orgasm, as can mental imagery, fantasy, or hypnosis. ^[9]

Both estrogens and androgens have been implicated in the regulation of libido and sexual responsiveness. The role of testosterone in sexual dysfunction in women is not well established; decreased estradiol levels have been associated with decreased sexual interest and arousal. ^[10]

It is noteworthy that consciousness seems not to be an absolute requirement for orgasms to occur; orgasms in mature women have been reported to occur during sleep. ^[11] Polatin and Douglas also described the phenomenon of spontaneous orgasm for which no obvious sexual stimulus could be ascertained. ^[12]

The question of the underlying neurocircuitry of the orgasmic response has been addressed in animal studies and subsequently in functional neuroimaging studies using positron emission tomography (PET) and functional MRI (fMRI).

Clinical studies have been conducted to study orgasmic responses in women with complete spinal cord injury at the level of T10 or higher. Such women were able to experience orgasms by means of vaginal-cervical mechanical self-stimulation (CSS). This finding suggests that the vagus nerve, bypassing the spinal cord, might provide the afferent pathway for orgasmic perception.

Additional evidence for this hypothesis comes from PET and fMRI studies, which show that CSS activates the region of the medulla oblongata to which the vagus nerves project (ie, the nucleus of the solitary tract). ^{[13, 14]} Brain regions activated during orgasm include the following:

• Hypothalamus

• Parts of the limbic system (medial amygdala, hippocampus, cingulate cortex, insular cortex, and the region of the nucleus accumbens−bed nucleus of the stria terminalis−preoptic area)

• Neocortex (including the parietal and frontal cortices)

• Basal ganglia (especially the putamen)

• Cerebellum

• Lower brainstem (central gray matter, mesencephalic reticular formation, and the nucleus of the solitary tract)

The fMRI data suggest that different brain regions are activated in sequence. The earliest activation in response to CSS occurs in the medial amygdala, the insula, the basal ganglia, and the cingulate cortex. At the time of orgasm, the nucleus accumbens, the paraventricular nucleus of the hypothalamus, and the hippocampus are also activated.

Some have suggested that the differences in the timing of regional activation (during as opposed to before or after orgasm) may reflect a relatively direct relation between some regions (eg, paraventricular area of the hypothalamus, medial amygdala, anterior cingulate region of the limbic cortex, and nucleus accumbens) and orgasm.

Although the fMRI findings are interesting, they do not help in differentiating between activation that may occur uniquely at orgasm and gradually increasing activity that exceeds an arbitrary detection threshold at orgasm.

In general, neuroimaging studies of female orgasm are limited by the small samples and the lack of control groups. Additional research is necessary to confirm the purported anatomic-physiologic substrate of female orgasm in heterogeneous populations and to facilitate additional state or group comparisons between brain activation during orgasm and sexual arousal without orgasm, as well as to assess orgasm associated with different eliciting mechanisms (eg, clitoral/vaginal stimulation vs imagery-based elicitation).

To the author’s knowledge, no researchers have yet performed neuroimaging studies of FOD.

Age, education, social class, religion, personality, and relationship issues have been studied in relationship to female orgasm. To date, no consistent, empirical findings substantiate the hypothesis that psychosocial factors alone can lead to FOD. ^[2] No substantial evidence links childhood sexual abuse to FOD.

DSM-5 lists the following risk factors for FOD ^[1] :

• Temperamental factors – These include various psychological factors, including pregnancy concerns and anxiety

• Environmental factors – Physical and mental health and relationship problems are strongly associated with orgasm difficulties in women; sociocultural factors such as religious norms and gender role expectations can also have an impact

• Genetic and physiologic factors – Multiple sclerosis, pelvic nerve damage, vulvovaginal atrophy, and spinal cord injury are all known to influence women’s orgasmic functioning; medications such as selective serotonin reuptake inhibitors (SSRIs) are also associated with orgasm difficulties; genetic factors may contribute as well

United States statistics

The reported prevalence of female orgasmic problems has ranged from 10% to 42%, depending on factors such as age, culture, and symptom duration and severity. However, these figures may not reflect the true prevalence of FOD, insofar as they do not take into account the diagnostic criterion of associated distress, which is not reported by all women experiencing orgasm difficulties. Variations in how symptoms are assessed also influence reported frequencies.

The largest US study of female sexual dysfunction, Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking (PRESIDE), including over 30,000 women who responded to standardized questionnaires, placed the prevalence of orgasm dysfunction at around 21%. ^[15]

Studies of women with FOD tend to reveal that female sexual interest/arousal disorder is also diagnosed in a high percentage. This observation suggests either (a) that clinicians often ignore the traditional criterion of an absence of orgasms after a normal sexual excitement phase or (b) that the difference between the 2 diagnoses is only illusory, in that they may in fact reflect a common underlying pathophysiologic pathway.

Furthermore, epidemiologic researchers in the field of orgasmic disorders among women must contend with the challenge of investigating outcomes based on subjective patient reports with poor collateral confirmatory evidence. This situation differs from that encountered with men, in whom equivalent pathology can easily be objectively quantified and verified by co-informers.

In view of the lack of well-controlled studies, the wide variability, and the lack of objective diagnostic markers for FOD, the available epidemiologic evidence is, at best, informative. Further epidemiologic research is needed to derive an accurate estimate of the incidence and prevalence of female orgasmic disorders across age groups, races, cultures, relationship status, and countries.

International statistics

The Global Study of Sexual Attitudes and Behaviors (GSSAB) found that for women aged 40–80 years, inability to achieve orgasm varies across world regions, with frequencies ranging from 10% in Northern Europe to 34% in South East Asia. ^[16] There is considerable variation in the prevalence rates of orgasmic dysfunction—from a 16–25% prevalence in Australia, Sweden, the United States, and Canada to 37% in Iran and 72.4% in Ghana. ^[17]

Little is known about the natural course of FOD or about the prognosis for women with untreated FOD. Some cases of the acquired and situational types seem likely to resolve spontaneously. Patients with lifelong and generalized types of FOD appear to have a good prognosis with treatment but an uncertain prognosis without treatment.

For patient education resources, see Female Sexual Problems.

The following Web sites may also be useful:

• Anorgasmia in women (Mayo Clinic)

• Orgasmic disorders (About.com)