Sexual Dysfunction: Libidinal and Orgasmic Dysfunction (Anorgasmia)

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Chapter 44 Sexual Dysfunction: Libidinal and Orgasmic Dysfunction (Anorgasmia)

INTRODUCTION

Description: Sexual dysfunction/anorgasmia is a lack of interest in sexual expression or sexual contact or the inability to achieve orgasm. Most studies indicate that only 30% to 40% of women are able to experience orgasm during intercourse and up to 15% of sexually active women have never experienced sexual release.
Genetics: No genetic pattern.
Prevalence: Most experience libidinal dysfunction episodically. Of sexually active women, 10% to 15% experience orgasmic failure; most experience it episodically. In “happy” or “very happy” marriages, sexual dysfunction occurs in almost two thirds of women, with three fourths reporting sexual difficulties that fall short of true dysfunction (such as lack of interest or inability to relax). In one survey, almost one half the women reported trouble becoming sexually excited, one third had trouble maintaining excitement, and one third were completely disinterested in sex. Almost half of the women reported difficulties in achieving orgasm, and 15% had never been able to have an orgasm at all.
Predominant age: Reproductive and beyond.
Genetics: No genetic pattern.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Libidinal dysfunction:

• Disinterest in or avoidance of sexual expression
• Lack of pleasure from sexual encounters

• Orgasmic dysfunction:

• Failure to obtain sexual release through any means.

Causes: The most common causes of sexual dysfunction are relationship problems, intrapsychic factors, and medical factors. Relationship problems are an obvious source for sexual problems, but both the patient and her doctor often overlook them. Marital or relationship stresses may be acted out by sexual distancing, orgasmic failure, or exploitation. Anger, hidden agendas, lack of trust, or infidelity may be expressed through the withdrawal of intimacy. Libidinal mismatches are common, but when combined with poor communication, they lead to dysfunction. Dual-income families may not realize the impact fatigue and a fast-paced lifestyle may be having on their ability to express warmth and be sexually expressive. Medical factors that influence sexual performance include drug and alcohol use, depression, anxiety, chronic illness, pregnancy, untreated menopause, and the effects of surgical therapies.
Once proximation (the process of courting, flirting, and desire that begins progress toward physical sexual expression) and arousal have occurred, orgasmic success requires effective stimulation, of a sufficient quality over a sufficient time, provided in a supportive environment. Failures in any of these areas may present as orgasmic problems. Medical factors that influence sexual performance include drug and alcohol use, depression, anxiety, chronic illness, pregnancy, untreated menopause, and the effects of surgical therapies.
Risk factors: Abuse, restrictive rearing, depression, fatigue, sleep disorders

DIAGNOSTIC APPROACH

Differential Diagnosis

• Depression and affective disorders
• Relational stress
• Physical or sexual abuse (current or past)
• Alcohol or drug use or abuse
• Conditioning (repeated orgasmic failure, restrictive rearing)
• Inappropriate expectations (inaccurate perception of “normal,” “correct,” or “expected”)
• Multiple sclerosis or other neurologic process
• Other sexual dysfunction (arousal, lubrication, dyspareunia, etc.) presenting as orgasmic failure

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: No imaging indicated.
Special Tests: None indicated.
Diagnostic Procedures: History.

Pathologic Findings

None.

MANAGEMENT AND THERAPY

General Measures: Reassurance, evaluation, stress reduction, relaxation training, encourage communication, sensate focusing (pleasuring). One of the simplest models for sexual therapy is the PLISSIT model. This model is made up of four levels of intervention: Permission, Limited Information, Specific Suggestions, and Intensive Therapy. These steps are applied in order. At each step a large number of dysfunctions will be resolved, leaving few patients who require referral for intensive or specialized therapy.

• Permission: Many patients only need permission for what they are doing or want to do.
• Limited Information: When permission is not enough, providing limited information often will be the solution to the problem.
• Specific Suggestion: These do not have to be exotic, complex, or imaginative. In most cases, they will be obvious and suggested by the situation.
• Intensive Therapy: When the problem is more complex, or deep seated, the intensive, specialized therapy of a trained sexual therapist, psychiatrist, psychologist, or other specialist should be considered.

Specific Measures: Specific suggestions for scheduled time together (including nonsexual time), sexual counseling as needed. Many patients who do not achieve orgasm during intercourse are fully orgasmic with additional manual stimulation, oral–genital stimulation, a vibrator, or masturbation. (About 30% to 40% of women require concurrent clitoral stimulation to achieve orgasm.) This is common enough that it should be viewed as a problem only if it is a source of concern for the patient or her partner.
Diet: No specific dietary changes indicated. (There are no true aphrodisiacs, but if the patient believes a food will enhance sexuality, it should not be denied.)
Activity: No restriction.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Booklet AP042 (Your and Your Sexuality), AP072 (Sexuality and Sexual Problems)
Bacos CS: The sex bible: The complete guide to sexual love. Beverly, MA, Quiver, 2006.
Comfort A: The new joy of sex. New York, Crown Publishers, Inc, 2002.
Keeling B: Sexual healing: The complete guide to overcoming common sexual problems. Alameda, CA, Hunter House Publishing, 2006.

Drug(s) of Choice

None. (Hormone replacement therapy for postmenopausal women may improve sexual function, especially if vaginal dryness or atrophy play a role in the dysfunction. Testosterone treatment improves libido but does not result in improved sexual functioning and is generally not indicated as a treatment for sexual dysfunction except in women who are surgically menopausal.)

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Alternative Therapies

Biofeedback, relaxation therapy, marital or psychological counseling as needed.
Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: Communication, maintenance of general health, adequate rest and exercise. Many patients who do not achieve orgasm during intercourse are fully orgasmic with additional manual stimulation, oral–genital stimulation, a vibrator, or masturbation. (About 30% to 40% of women require concurrent clitoral stimulation to achieve orgasm.) This is common enough that it should be viewed as a problem only if it is a source of concern for the patient or her partner.
Possible complications: Social withdrawal, depression, marital discord.
Expected outcome: Generally good with a mixture of reassurance, sexual counseling, stress reduction, and graded exercises as appropriate.

Associated Conditions: Orgasmic dysfunction, dyspareunia, depression.
Pregnancy considerations: No effect on pregnancy.
Synonyms: Inhibited desire.
ICD-9-CM Codes: 302.71 (Libidinal dysfunction), 302.73 (Orgasmic dysfunction)

REFERENCES

Level III

Alexander B. Disorders of sexual desire: diagnosis and treatment of decreased libido. Am Fam Physician. 1993;47:832.

Amato P. Categories of female sexual dysfunction. Obstet Gynecol Clin North Am. 2006;33:527.

Carey JC. Disorders of sexual desire and arousal. Obstet Gynecol Clin North Am. 2006;33:549.

Duddle M, Brown ADG. The clinical management of sexual dysfunction. Clin Obstet Gynecol. 1980;7:293.

Goldstein I, Meston CM, Davis S, Trais A. Women’s sexual function and dysfunction: study, diagnosis and treatment. London: Informa Healthcare, 2005.

Gracia CR, Freeman EW, Sammel MD, et al. Hormones and sexuality during transition to menopause. Obstet Gynecol. 2007;109:831.

Hatzimouratidis K, Hatzichristou D. Sexual dysfunctions: classifications and definitions. J Sex Med. 2007;4:241.

Kingsberg S. Testosterone treatment for hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2007;4:227.

Lentz GM. Emotional aspects of gynecology: sexual dysfunction, eating disorders, substance abuse, depression, grief, loss. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:184.

McGloin L, Carey JC. Orgasmic dysfunction. Obstet Gynecol Clin North Am. 2006;33:579.

Redelman M. A general look at female orgasm and anorgasmia. Sex Health. 2006;3:143.

Shen WW, Sata LS. Inhibited female orgasm resulting from psychotropic drugs. J Reprod Med. 1983;28:497.

Smith RP. Gynecology in primary care. Baltimore: Williams & Wilkins, 1997;193. 517.

Stimmel GL, Gutierrez MA. Counseling patients about sexual issues. Pharmacotherapy. 2006;26:1608.

Zeiss AM, Rosen GM, Zeiss RA. Orgasm during intercourse: a treatment strategy for women. J Consult Clin Psychol. 1977;45:89.

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