Although the way in which female sexual arousal disorder and female orgasmic disorder are expressed shows a wide degree of variation, there is no evidence to suggest either that different factors contribute to the two disorders or that different treatment strategies should be used. In fact, the same treatment strategies are generally applied for both disorders. These strategies may need to be supplemented with additional techniques to resolve specific problems for individual women, but they are generally good starting points for resolving the issues that contribute to the development and maintenance of the sexual problem. Because the relationship between the woman and her partner has been shown to play a significant role in both the development and the maintenance of sexual problems, most programs are designed to be implemented by the couple, although there may also be additional strategies that focus on the individual.

If the woman is in a relationship, it is important that both partners be involved in the treatment process. Even if difficulties in the relationship were not initially responsible for the development of the orgasmic or arousal problems, once the sexual problem has developed, the relationship between the partners is influenced by the sexual disorder. Furthermore, once the woman begins to address (within the treatment process) issues related to her sexual dysfunction, changes occur in the sexual aspects of the relationship, and this, in turn, influences other areas of the relationship. Unless the partner is involved in this process of change, he (or she, for homosexual relationships) may act in ways that impede the therapeutic process. Strategies for treating orgasmic or arousal problems in women who are not involved in relationships are covered later in this chapter.

Sensate Focus
The first comprehensive treatment program for sexual dysfunction was developed by Masters and Johnson (1970). This program was implemented on a residential basis for men and women who were experiencing problems in their sexual functioning. To be eligible for treatment, people needed to be in a relationship, and both partners were required to attend the treatment program. The same treatment strategies were used for all female sexual disorders.

The essential ingredient of the Masters and Johnson program was sensate focus. Sensate focus is a useful strategy for overcoming the anxiety associated with the need to perform well. Women often feel under pressure to become aroused and to have an orgasm during intercourse as a means of proving their sexual adequacy. Sensate focus is designed to help the woman learn a wide range of touching and sexual skills that are enjoyable in themselves and thus remove the feeling of being under pressure to prove herself in intercourse. Sensate focus also helps in building communication between partners so that they can give each other clear directions (both verbally and nonverbally) with regard to methods of touching, so as to enhance the arousal of both partners. Finally, sensate focus may allow the woman to become more open and creative about exploring her sexual self and offer an opportunity to challenge some of her attitudes about sex that have come from her upbringing or previous experience.

Sensate focus exercises are useful in relieving a wide range of difficulties, including performance anxiety and anxieties associated with engaging in sexual interaction. By applying these techniques, women can distract themselves from performance concerns and are better able to enjoy and function in the sexual interaction. Through this process of desensitization, it is also possible to address guilt and other negative feelings associated with sexual expression.

Masters and Johnson’s research has received a great deal of criticism, specifically with regard to their evaluation of the outcome of therapy, their description of the therapeutic techniques, their selection of subjects, and their follow-up procedures. Despite its inadequacies, however, Masters and Johnson’s program provided a model for treatment that has been subsequently modified by other clinicians and researchers to improve its effectiveness. In fact, sensate focus, one of the essential elements of the Masters and Johnson program, remains an important component of many current treatments for sexual dysfunction.

Other Treatment Strategies
As discussed previously, intergenerational, individual, and relationship problems contribute to the development of sexual arousal or orgasmic dysfunction in women. Treatment strategies must directly address these problems. Alternatively, such problems can be indirectly addressed through the use of imagery, a technique shown to be particularly effective among women experiencing sexual arousal disorders (Purcell and McCabe 1992). Imagery appears to be effective for a number of reasons: it grants the woman permission to be sexual, it provides a sexually arousing stimulus, and it helps the woman to distract herself from any concerns she may have about her performance.

Relationship Problems
Relationship problems can be expressed in many forms: anger, the need for control or power over the partner, or a lack of intimacy with the partner. These difficulties in the relationship may result in the development of sexual problems among women. The sensate focus exercises are useful in resolving some of these difficulties. Spending time with one’s partner as well as communicating honestly about one’s feelings also seems to be useful in the resolution of female sexual dysfunction. We have found that communication exercises can help couples to identify and address these relationship difficulties (Delaney and McCabe 1988). Difficulties or resistances in these communication exercises may identify the presence of anger, control, power, or intimacy concerns, which can then be discussed in the therapy sessions.

Intergenerational and Individual Problems
Not all problems can be resolved with couple exercises. Sometimes it is necessary for a woman to address guilt or anxiety that stems from her own attitudes and experiences. For women who are not in a relationship, clear resolution of individual problems is the only option. Once the woman is in a relationship, other problems may appear that also need to be discussed. This particularly applies if the problem results from the way in which the woman interacts with her partner - that is, if the problems stem from the fears and anxieties that relationships generate.

Sexual fantasy is another technique that may be useful in helping women resolve their sexual problems (Delaney and McCabe 1988; Purcell and McCabe 1992). Fantasy may serve a number of important functions for women. If the woman is experiencing guilt or anxieties regarding her sexuality, permission to use sexual fantasy, and the pleasure associated with such fantasy, may allay these negative feelings. Sexual fantasy may also act to distract the woman from her performance concerns and enhance her sexual arousal. For women who monitor their levels of arousal, sexual fantasy may perform a positive function in terms of providing a focus to increase levels of sexual desire, arousal, and orgasm.