Cognitive-behavioral therapy for female orgasmic disorder aims at promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. Traditionally, the behavioral exercises used to induce these changes include directed masturbation, sensate focus, and systematic desensitization. Sex education, communication skills training, and Kegel exercises are also often included in cognitive-behavioral treatment programs for anorgasmia.
Masturbation exercises are believed to benefit women with orgasm difficulties for a number of reasons. To the extent that focusing on nonsexual cues can impede sexual performance (70), masturbation exercises can help the woman to direct her attention to sexually pleasurable physical sensations. Because masturbation can be performed alone, any anxiety that may be associated with partner evaluation is necessarily eliminated. Relatedly, the amount and intensity of sexual stimulation is directly under the woman's control and therefore the woman is not reliant upon her partner's knowledge or her ability to communicate her needs to her partner. Research that shows a relation between masturbation and orgasmic ability provides empirical support for this treatment approach. Kinsey et al. (1) reported that the average woman reached orgasm 95% of the time she engaged in masturbation compared with 73% during intercourse. More recently, in a random probability sample of 682 women, Laumann et al. (60) reported a strong relation between frequency of masturbation and orgasmic ability during masturbation. Sixty-seven percent of women who masturbated one to six times a year reported orgasm during masturbation compared with 81% of women who masturbated once a week or more.
LoPiccolo and Lobitz (71) were the first to outline a program of directed masturbation (DM). Since then, several other researchers have provided variations (72,73). The first step of DM involves having the woman visually examine her nude body with the help of a mirror and diagrams of female genital anatomy. During the next stage she is instructed to explore her genitals tactually as well as visually with an emphasis on locating sensitive areas that produce feelings of pleasure. Once pleasure-producing areas are located, the woman is instructed to concentrate on manual stimulation of these areas and to increase the intensity and duration until "something happens" or until discomfort arises. The use of topical lubricants, vibrators, and erotic videotapes are often incorporated into the exercises. Once the woman is able to attain orgasm alone, her partner is usually included in the sessions in order to desensitize her to displaying arousal and orgasm in his presence, and to educate the partner on how to provide her with effective stimulation.
DM has been used to effectively treat female orgasmic disorder in a variety of treatment modalities including group, individual, couples therapy, and bibliotherapy. A number of outcome studies and case series report DM is highly successful for treating primary anorgasmia. Heinrich (74) reported a 100% success rate for treating primary anorgasmia using therapist DM training at 2 month follow-up. The study was a controlled comparison of therapist-directed group masturbation training, self-directed masturbation training (bibliotherapy), and wait-list control. Forty-seven percent of the bibliotherapy subjects reported becoming orgasmic during masturbation compared with 21% of wait-list controls. In a randomized trial comparing written vs. videotaped masturbation assignments, the effects of self-directed masturbation training were further investigated (75). Sixty-five percent of women who used a text and 55% of women who used videotapes had experienced orgasm during masturba ion and 50% and 30%, respectively, were orgasmic during intercourse after 6 weeks. None of the control women had attained orgasm. Few controlled studies have examined the exclusive effects of DM for treating secondary anor-gasmia. Fichen et al. (76) compared minimal therapist contact bibliotherapy with a variety of techniques including DM and found no change in orgasmic ability. Hurlbert and Apt (77) recently compared the effectiveness of DM with coital alignment technique in 36 women with secondary anorgasmia. Coital alignment is a technique in which the woman assumes the supine position and the man positions himself up forward on the woman. After only four 30-min sessions, 37% of women receiving instructions on coital alignment technique vs. 18% of those receiving DM reported substantial improvements (>50% increase) in orgasmic ability during intercourse. The benefits of this technique are due to the fact that clitoral contact, and possibly paraurethral, stimulation are maximized.
In summary, DM has been shown to be an empirically valid, efficacious treatment for women diagnosed with primary anorgasmia. For women with secondary anorgasmia, who are averse to touching their genitals, DM may be beneficial. If, however, the woman is able to attain orgasm alone through masturbation but not with her partner, issues relating to communication, anxiety reduction, trust, and ensuring the woman is receiving adequate stimulation either via direct manual stimulation or engaging in intercourse using positions designed to maximize clitoral stimulation (i.e., coital alignment technique) may prove more beneficial.
Anxiety could feasibly impair orgasmic function in women via several cognitive processes. Anxiety can serve as a distraction that disrupts the processing of erotic cues by causing the woman to focus instead on performance related concerns, embarrassment, and/or guilt. It can lead the woman to engage in self-monitoring during sexual activity, an experience Masters and Johnson (78) referred to as "spectatoring". Physiologically, for many years it was assumed that the increased sympathetic activation that accompanies an anxiety state may impair sexual arousal necessary for orgasm via inhibition of parasympathetic nervous system activity. Meston and Gorzalka (79-81), however, have noted that activation of the sympathetic nervous system, induced via means such as 20 min of intense stationary cycling or running on a treadmill actually facilitates genital engorgement under conditions of erotic stimulation.
The most notable anxiety reduction techniques for treating female orgasmic disorder are systematic desensitization and sensate focus. Systematic desensitization for treating sexual anxiety was first described by Wolpe (82). The process involves training the woman to relax the muscles of her body through a sequence of exercises. Next, a hierarchy of anxiety-evoking stimuli or situations is composed and the woman is trained to imagine the situations while remaining relaxed. Once the woman is able to imagine all the items in the hierarchy without experiencing anxiety, she is instructed to engage in the activities in real life.
Sensate focus was originally conceived by Masters and Johnson (78). It involves a step-by-step sequence of body touching exercises, moving from nonsexual to increasingly sexual touching of one another's body. Components specific for treating anorgasmic women often include nondemand genital touching by the partner, female guidance of genital manual, and penile stimulation and coital positions designed to maximize pleasurable stimulation. Sensate focus is primarily a couple's skills learning approach designed to increase communication and awareness of sexually sensitive areas between partners. Conceptually, however, the removal of goal-focused orgasm, which can cause performance concerns, the hierarchical nature of the touching exercises, and the instruction not to advance to the next phase before feeling relaxed about the current one, suggest sensate focus is also largely an anxiety reduction technique and could be considered a modified form of in vivo desensitization.
The success of using anxiety reduction techniques for treating female orgasmic disorder is difficult to assess because most studies have used some combination of anxiety reduction, sexual techniques training, sex education, communication training, bibliotherapy, and Kegel exercises, and have not systematically evaluated the independent contributions to treatment outcome. Moreover, even within specific treatment modalities, considerable variation between studies exists. For example, systematic desensitization has been conducted both in vivo and imaginal, has used mainly progressive muscle relaxation but also drugs (83) and hypnotic techniques (84) to induce relaxation, and has varied somewhat in the hierarchical construction of events. Furthermore, the relative contribution of factors such as individual vs. group treatment, patient demographics (age, marital status, education, religion), precise diagnosis and severity of presenting sexual concerns, therapist characteristics (sex, theoretical orientation and training), treatment settings (private, hospital, university clinics), and length of treatment sessions and duration are often reported but systematic evaluation of many of these factors is missing from the literature. Finally, of the controlled studies that have included anxiety reduction techniques, few have differentiated between treatment outcomes for primary and secondary anor-gasmic women. Across studies, women have reported decreases in sexual anxiety and, occasionally, increases in frequency of sexual intercourse and sexual satisfaction with systematic desensitization, but substantial improvements in orgasmic ability have not been noted. Similarly, of the few controlled studies that have included sensate focus as a treatment component, none have reported notable increases in orgasmic ability. These findings suggest that, in most cases, anxiety does not appear to play a causal role in female orgasmic disorder and anxiety reduction techniques are best suited for anorgasmic women only when sexual anxiety is coexistant.
As noted earlier, many treatment outcome studies for anorgasmia include a variety of treatment components, and the relevant individual contributions they make to treatment outcome success cannot be effectively evaluated. With this in mind, a number of additional treatment techniques warrant mention. Since Masters and Johnson's pioneering work (78), sex education has been a component of many sex therapy programs. Ignorance about female anatomy and/ or techniques for maximizing pleasurable sensations can certainly contribute to orgasm difficulties. Jankovich and Miller (85) noted increases in orgasmic ability following an educational audiovisual presentation in seven of 17 women with primary anorgasmia. Kilmann et al. (86) compared the effectiveness of various sequences of sex education and communication skills vs. wait-list control on orgasmic ability in women with secondary anorgasmia. The authors found sex education to be beneficial for enhancing coital ability at posttest but not at 6 month follow-up. In a comparison study of the effectiveness of sex therapy vs. communication skills training for secondary anorgasmia, Everaerd and Dekker (87) found both treatments were equally effective in improving orgasmic ability. Kegel (88) proposed that conducting exercises that strengthen the pubo-coccygeous muscle could increase vascularity to the genitals and, in turn, facilitate orgasm. Treatment comparison studies have generally found no differences in orgasmic ability between women whose therapy included using Kegel exercises vs. those whose therapy did not. To the extent that Kegel exercise may enhance arousal and/or help the woman become more aware and comfortable with her genitals, these exercises may enhance orgasm ability (69). In summary, sex education, communication skills training, and Kegel exercises may serve as benefical adjuncts to therapy. Used alone, they do not appear highly effective for treating either primary or secondary anorgasmia.
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