Orgasmic Disorder
Orgasmic disorder, now referred to as female orgasmic disorder, is the difficulty or inability for a woman to reach orgasm during sexual stimulation. This disturbance must cause marked distress or interpersonal difficulty for it to be diagnosed. The diagnosis for men is erectile dysfunction, premature ejaculation, or delayed ejaculation.
Women show wide vari­ability in the type or intensity of stimulation that elicits orgasm. Similarly, subjective descriptions of orgasm are varied, suggesting that it is experienced in different ways. For a woman to have a diagnosis of female orgasmic disorder, clinically significant distress must accompany the symptoms. If interpersonal or significant contextual factors, such as severe relationship distress, intimate partner violence, or other significant stressors, are present, then a diagnosis of female orgasmic disorder would not be made.
Most women require clitoral stimulation to reach orgasm, and a relatively small number of women report that they always experience orgasm during intercourse. It's also important to consider whether orgasmic difficulties are the result of inadequate sexual stimulation and not related to female orgasmic disorder.
Signs and symptoms as cataloged by the DSM-5:
Presence of either of the following symptoms and experienced on almost all or all occasions (approximately 75 percent to 100 percent) of sexual activity:
- Marked delay in, marked infrequency of, or absence of orgasm
- Markedly reduced intensity of orgasmic sensations
The symptoms have persisted for a minimum duration of approximately six months.
The symptoms cause clinically significant distress in the individual.
The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (partner violence) or other significant stressors and is not attributable to the effects of a substance, medication, or another medical condition.
The distress associated with orgasmic disorder can manifest in many different ways, research suggests. Women may feel disappointed to be missing out on a pleasurable and important life experience. They may compare themselves negatively to other women who can orgasm. They may feel like their body is inadequate or that something is “wrong” with them. Or they may worry that their partner is disappointed by their inability to orgasm. Working with a therapist can help women navigate these difficult emotions.
People who are concerned about their inability to orgasm can visit their doctor, who will perform a physical examination and ask questions about medical history, sexual history, and current or past relationships. This may be followed by a referral to a gynecologist for further examination or a mental health professional to address psychological, social, and relational factors related to orgasm.
A range of factors can contribute to orgasmic disorder, according to the DSM-5. Psychological factors include stress, anxiety, and potential concerns about pregnancy. Biological factors include genetics, medical conditions such as multiple sclerosis, pelvic nerve damage from radical hysterectomy, and spinal cord injury, and medications such as antidepressants. Environmental factors include relationship problems and attitudes toward gender roles and religion. All of these factors likely interact with one another in unique ways to give rise to the disorder.
The DSM-5 characterizes orgasmic disorder as lifelong or acquired. Lifelong female orgasmic disorder indicates that orgasmic difficulties have always been present, whereas the acquired subtype applies to or­gasmic difficulties that developed after a period of normal functioning.
A woman's first experience of orgasm can occur any time from prepuberty to well into adulthood. Women show a more variable pattern in age at first orgasm than do men, and women's reports of having had orgasms increase with age. Many women learn to experience orgasm as they explore a wide variety of stimulation and acquire more knowledge about their bodies. Women's rates of orgasm consistency (defined as "usually or always" experiencing orgasm) are higher during masturbation than during sexual activity with a partner.
Difficulty achieving orgasm is very common—and it’s often not indicative of a mental disorder. Studies indicate that orgasmic difficulty affects 16-28 percent of women in the United States, Europe, Central and South America, and Mainland China and up to 46 percent in other Asian countries. Only some of these women experience clinically significant distress, so the prevalence of those who meet the diagnostic criteria for the disorder is much lower.
Many factors can disrupt the ability to orgasm. These include hormonal status, lack of sexual desire or arousal, pain during intercourse, relationship quality, mental health conditions such as anxiety or PTSD, and social stigmas around sex. One study asked women what caused their severe difficulty with experiencing orgasms. The most common reasons were stress and anxiety, insufficient arousal or stimulation, and lack of time. Other reasons included negative body image, pain during sex, insufficient lubrication, and medication-related problems.
To treat orgasmic dysfunction, the underlying medical condition, medication, or mood disorder needs evaluation and treatment. The role of hormone supplementation in treating orgasmic dysfunction is controversial and the long-term risks remain unclear. If other sexual dysfunctions (such as lack of interest and pain during intercourse) co-occur, these need to be addressed as part of the treatment plan.
Relationship difficulties sometimes play a role; treatment may sometimes need to include communication training and relationship enhancement work. A series of exercises to practice communication, more effective stimulation, and playfulness can help.
Incorporating clitoral stimulation into sexual activity may be all that is necessary for a woman to experience orgasm. Masturbation when the partner is not present (which could cause inhibition) usually results in success. Working with a partner to decrease performance anxiety and maximize communication can make it possible for a woman to achieve orgasm with a partner.
It is also important to ascertain that the problem is only one of orgasmic disorder, and not a coexisting problem with inhibited sexual desire.
Some women with low sexual desire may struggle with a disconnect between the mind and body. Mindfulness programs can help women tune out potential detractors such as negative body image and household responsibilities and tune in to physical sensations and feelings of desire.
Data on success rates in sex therapy indicates that these interventions are helpful in 65 to 85 percent of cases. In primary orgasmic dysfunction, treatment is usually successful in 75 to 90 percent of cases. A positive prognosis is usually associated with being younger, emotionally healthy, and having a loving, affectionate relationship with a partner.
If talking about sex feels uncomfortable or difficult, it can be easy to shy away from it. But discussing sex openly is the first step to solving problems or achieving greater pleasure. Couples should begin talking about sex more frequently and in greater detail. They can discuss what each person wants, what feels good and doesn’t feel good, likes, dislikes, fantasies, and the best times for sex. Taking a positive, affirming approach can help partners feel supported and keep the door open to continue the conversation.