The following case example illustrates the use of some of the treatment strategies discussed above. Techniques of therapy and treatment outcome for a woman with secondary orgasmic disorder are presented.

Presentation and Etiology
Mr. and Mrs. D, aged 51 and 48 years, respectively, were referred by a family planning agency. Mrs. D described difficulties in her sexual functioning that suggested secondary orgasmic dysfunction. The couple had been married for 25 years, having lived together for 12 months prior to marriage. Mr. and Mrs. D were tertiary-educated professional people who had met and become friends while working together. At that time, Mrs. D was just emerging from a broken first marriage and subsequent divorce. Although the sexual relationship in this first marriage had not been good, Mrs. D had had several affairs in which she had enjoyed sex, become sexually aroused, and experienced orgasm most times during intercourse. At the time the couple presented for treatment, it had been 2 years since Mrs. D had achieved orgasm during intercourse, and the frequency with which she experienced orgasm during other sexual activity had fallen to 25%. As a consequence, she claimed that she was beginning to lose interest in sex, and came to therapy looking for more enjoyment for herself. She reported her loss of interest in sex as beginning when the couple’s second child left home, which meant that for the first time in 24 years they had no children living at home. Up until then, their sexual relationship had been satisfactory from both their points of view. She also reported no anxiety about sex and a rather neutral attitude toward it in the original family home, with no other repressive influences. There was no evidence that she was starting to experience physiological or psychological changes associated with menopause.

Summary of Treatment Program
The program used to treat Mrs. D focused on dealing with performance anxiety and enhancing communication between the partners. Sensate focus homework exercises, in conjunction with bans on intercourse and orgasm, were explained, with Mrs. D commencing to engage in general body pleasuring with her husband. Mrs. D was seen weekly by the therapist for 6 weeks, and Mr. D was also seen by the therapist on two occasions. To improve communication between the partners, communication homework exercises were developed to parallel the sensate focus assignments.

A major feature of the program also entailed the use of erotic fantasy within therapy sessions by the therapist, and at home by Mrs. D. She was encouraged to use fantasy, either self-generated or from other sources, during sexual interaction with her husband, incorporating whatever stimulation she was giving or receiving into her fantasy. She could share the fantasy with Mr. D or keep it to herself. She was also encouraged to use whatever themes that she might find sexually exciting and was reassured of the normative and nonpathological nature of such fantasizing. Fantasy was being used primarily to distract from performance concerns during sexual interaction and to enhance arousal. Imaginative involvement in the program’s fantasies brought to the surface Mrs. D’s ambivalence about her own sexuality and her anxiety about being perceived as a sexual person.

Another aspect of Mr. and Mrs. D’s relationship that was clearly evident in the treatment sessions was the influence of nonsexual issues on the sexual relationship. Mrs. D felt indebted to her husband for the support, friendship, and love he had given her during the difficult time after her first marriage ended. She also feared, quite correctly, that Mr. D would interpret any rejection of his sexual advances as rejection of himself. Mr. D, being aware of his wife’s declining interest in sex, feared that the day would come when she might not need him any longer. This was a major concern for him, particularly since their children had left home.

Outcome
By the end of therapy, Mrs. D was achieving orgasm during intercourse 50% of the time, and this level was unchanged at the follow-up session 4 months after the completion of therapy. Orgasm during masturbation by the partner was stable at 25% between the intake and pretherapy sessions, rose to 50% at the posttherapy session, and was reported as 75% at the follow-up session. Telephone contact 4 months after the follow-up session revealed that these frequencies were being maintained.

Mrs. D also showed substantial increases - both over the course of therapy and at the follow-up sessions - in positive feelings about her relationship, sexual satisfaction, and sexual communication, as well as decreases in performance anxiety. Whereas erotic fantasy during sexual interaction was reported as being present only “occasionally” at intake and pretherapy, it was present “frequently” at posttherapy and “almost always present” at follow-up.

As Payne and Wakefield (1982) observed, attention to sexual problems can bring marital issues to the surface to such an extent that the marital relationship deteriorates. This certainly happened for Mr. D in this case. The communication exercises enabled the couple to air their individual differences and concerns about the relationship. Initially this led to some disappointment and disillusion with the relationship, mainly for Mr. D. However, further use of exercises enabled each to better understand the other’s perspective. The result at follow-up appeared to be an integration of the marital relationship at a deeper level than had existed at the start of therapy. At the end of therapy, Mr. and Mrs. D possessed the tools and techniques to achieve further improvement in their sexual and marital relationship. This conclusion was borne out by further improvement in both marital and sexual functioning at the time of follow-up.