Female Sexual Arousal Disorder and Female Orgasmic Disorder Introduction

A substantial amount has been written on female sexual arousal disorder and female orgasmic disorder, yet there has been little empirical investigation of the causes or most effective treatment for these disorders. In terms of the presentation of both female sexual arousal disorder and female orgasmic disorder, they may be lifelong or acquired, and they may occur in all situations or be situation-specific (e.g., with a spouse but not with a different partner). The length of time the disorder has been in place and the extent to which it is partner- or situation-specific, as opposed to occurring in all situations, may be determined by different etiological factors and may influence the intervention strategy chosen to treat the disorder. These issues will be discussed and illustrated with case examples later in the chapter.

Diagnostic Features

Female Sexual Arousal Disorder
The DSM-IV (American Psychiatric Association 1994) diagnostic criteria for female sexual arousal disorders are outlined in

Table 65-1. Female sexual arousal disorder is defined as “persistent or recurrent inability to attain, or maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement” (American Psychiatric Association 1994, p. 502). This condition needs to cause “marked distress or interpersonal difficulty” (p. 502). Difficulties arise with this definition in terms of what constitutes an adequate lubrication-swelling response. There is no “gold standard” regarding the length of time it should take to become aroused or the level of arousal that should be achieved. These responses may vary from one woman to another and are dependent on a range of factors, which include her general mood when sexual stimulation commences and her partner’s skill in stimulating her. There may also be differences in physiological and subjective levels of arousal, with some women reporting no feelings of sexual arousal despite evidence of vaginal vasocongestion and others reporting arousal in the absence of such evidence. The expectations and past experiences of clinicians and clients may also lead them to classify the same symptoms as female sexual arousal disorder in one woman but not in another. As with the other sexual dysfunctions, the clinician must be aware of his or her own biases in making diagnostic decisions.

Female Orgasmic Disorder
The DSM-IV diagnostic criteria for female orgasmic disorder are outlined in

Table 65-2. Female orgasmic disorder is classified as “persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase” (American Psychiatric Association 1994, p. 506). Again, it is necessary for the disorder to cause “marked distress or interpersonal difficulty” (American Psychiatric Association 1994, p. 506). The major problem a clinician may experience in operationalizing this definition is in determining what constitutes “delay” and what may be interpreted as a “normal sexual excitement phase.” Important considerations in the interpretation of these terms are whether they refer to time since commencement of sexual stimulation or to the nature of the stimulation. Given that there are wide differences among women regarding the types of sexual stimulation that they consider to be sexually arousing, it would seem to be more appropriate for this judgment to be made by the client rather than the clinician.

DSM-IV implies that the diagnosis of female orgasmic disorder is made by the clinician based on his or her “...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” (American Psychiatric Association 1994, p. 506). Given that few data are available on this topic and that women vary substantially in their needs for stimulation to experience orgasm, the clinician’s biases may have a significant impact not only on which clients are classified as having this disorder but also on what treatments they receive. Furthermore, it is not clear how a woman’s orgasmic response would be expected to vary according to her age and sexual experience. Studies examining whether or how sexual response changes with increasing age are contaminated by cohort effects and social expectations of the sexuality of older women (e.g., Hallstrom and Samuelsson 1990; Mansfield et al. 1995). Also, these studies have not specifically examined orgasmic response. It is unclear how age is expected to affect sexual experience and orgasmic response, and no empirical data are available to guide the clinician in his or her judgment about this relationship in making a diagnosis of orgasmic disorder.