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Response:
Through the first window (the "current situation"), the clinician considers to what extent various factors in the woman's current relationship and life might be relevant to the orgasmic difficulty. Are there circumstances present that would be expected to have an impact on the woman's ability to experience orgasm? If so, then this may suggest the presence of an adaptive inhibition of sexual response (Bancroft et al., 2003) rather than a sexual "dysfunction." Amanda, a 35-year-old married woman with three young children, including 18-month-old twins, came to therapy with problems reaching orgasm, Although she had been able to experience orgasm throughout most of her 10-year marriage to Tim, a 40-year-old lawyer, she had found it increasingly difficult to do so over the past 6 months. Initial assessment uncovered a number of factors that might be relevant. After almost 2 years on maternity leave, Amanda had recently returned to work full time. Tim contributed little to the child-care and the housework, and Amanda had become increasingly resentful about this, particularly as her job, as a marketing manager in a bank, was quite stressful and she often returned home exhausted. Two months before attending therapy, Tim's parents had come to stay with the couple for an extended (4-week) visit, which increased the workload for Amanda (as well as her resentment and fatigue).

Through the second window ("vulnerability of the individual"), the woman's sexual history is examined, as well as her propensity to become sexually inhibited. There is 95

considerable individual variation in the extent to which women's ability to experience sexual arousal and pleasure is affected by factors such as negative sexual experiences, anxiety, and other factors. Although inhibition of sexual response is most often adaptive, high levels of sexual inhibition may be associated with increased vulnerability to experiencing sexual problems (Bancroft, 2009). There is some evidence that women who score high on measures of inhibition "proneness" are more likely to report orgasm difficulties (Sanders, Graham, & Milhausen, 2008). Other relevant factors to assess through this second window are the need to maintain self-control (e.g., a fear of "letting go" sexually), negative attitudes toward sexuality and/or about one's body, and the presence of dysfunctional sexual beliefs (Nobre & Pinto-Gouveia, 2006). A woman's feelings about her body and about her genitals should be explored. There is evidence that a more positive genital self-image is positively associated with a woman's having ever experienced orgasm, both during masturbation and from receiving cunnilingus (Herbenick & Reece, 2010). Returning to the case of Amanda, assessment through the second window revealed another possible etiological factor underlying her orgasm difficulties. She had long-standing issues with her body image, dating back to adolescence when she was diagnosed with bulimia nervosa. Although she was now a normal weight, she still had a fear of becoming overweight and had found the weight gain during her last pregnancy difficult to cope with. She also mentioned that during sexual activity, she was quite self-conscious about her stretch marks and avoided certain positions in which she felt that she looked "fat."

Finally, through the third window ("health-related factors") the clinician considers various health-related factors that can influence sexual functioning. These include current mental and physical health and sexual side effects of medication. In the case of Amanda, the clinician needed to consider whether another relevant factor might have been the initiation of oral contraceptives (OC) 6 months before she presented for therapy. Although most of the research on OC-related sexual side effects relates to sexual interest, there is some evidence that orgasm frequency might decline in women using OCs (Battaglia et al., 2012).

**Diagnostic Issues**

The first inclusion of FOD in the DSM was in the third edition of the manual (DSM-III; American Psychiatric Association, 1980), in which it was labeled "inhibited female orgasm." In DSM-IV and DSM-IV-TR (American Psychiatric Association, 1994, 2000), the disorder was renamed FOD, but the essential feature of the disorder remained a recurrent and persistent delay in or absence of orgasm following a normal sexual excitement phase. The major change from DSM-III to DSM-IV was the inclusion of the distress criterion, by which the symptoms were required to cause marked distress or interpersonal difficulty.

Regarding FOD, there are two substantive changes in the DSM-5 criteria (American Psychiatric Association, 2013) compared with DSM-IV-TR (American Psychiatric Association, 2000). The first change is that specific cutoff criteria for both duration and 96

frequency of symptoms are provided. "Recurrent and persistent" were not clearly operationalized in DSM-IV-TR, and, as discussed previously, the prevalence of mild, transient orgasmic difficulties is considerably higher than that of persistent, severe problems (Graham, 2010). To avoid pathologizing normal variations in orgasmic functioning, the DSM-5 criteria (for all of the sexual dysfunctions) include the requirement that symptoms be present for a minimum duration of approximately 6

months and be experienced on all or almost all (approximately 75–100%) occasions of sexual activity. The second change relates to Criterion A, which now requires a marked degree of at least one of two symptoms: delay in, or absence of, orgasm or reduced intensity of orgasmic sensations. The justification for the addition of the intensity symptom is that clinically it is not uncommon to find women reporting reduced orgasmic intensity, particularly in association with some types of neurological disease or medication use (Basson, 2002). The revised criteria reflect the fact that orgasm is not an

"all or nothing" phenomenon and that diminished intensity of orgasm may be a problem for some women (Graham, 2010). When Jennifer, a 50-year-old woman, had completed a course of chemotherapy treatment for breast cancer, she was relieved to discover that her interest in, and overall enjoyment of, sexual activity with her husband had not diminished. She did, however, notice a marked reduction in the intensity of the orgasms she experienced and presented for therapy with this complaint.

The reference in DSM-IV-TR to the orgasm difficulty occurring following a normal excitement phase has not been retained in the DSM-5 criteria, for several reasons. First, this statement has caused considerable confusion among clinicians and researchers, as it suggested that a diagnosis of female sexual arousal disorder (FSAD) would preclude a diagnosis of FOD; in fact, the DSM-IV-TR text included a clear statement that both diagnoses can be made. Second, in practice clinicians (and indeed women themselves) find it difficult or even impossible to establish whether a "normal excitement phase" has occurred (Laan & Rellini, 2011). The phrase "normal excitement phase" also suggests a linear, universal model of sexual response in women, which recent research does not support (Graham, 2010).

The requirement that the orgasm problem cause distress was retained (Criterion B), as was Criterion C, which states that a diagnosis of FOD would be made only if the symptoms in Criterion A are not better explained by a nonsexual mental disorder, by the effects of a substance (e.g., a drug of abuse, a medication), by another medical condition, or by significant relationship distress or other significant stressors.

Regarding the possible impact of the changes in diagnostic criteria introduced in DSM-5, there has been little discussion in the literature about the likely impact of the changes in diagnostic criteria for FOD (in contrast with other diagnostic categories such as female sexual interest/arousal disorder (SIAD; DeRogatis et al., 2010). Because the major change for FOD is that specific duration and severity criteria are required for a diagnosis, one possible outcome is that fewer women will be diagnosed with acquired FOD (the severity and duration criteria would have no impact on lifelong FOD, given that women with this diagnosis have never experienced an orgasm). Given the evidence on the variability in women's experiences of orgasm and the high prevalence of short-term fluctuations in orgasmic functioning, raising the threshold for diagnosis of FOD

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seems justified. Although the impact of the DSM-5 changes for FOD will be apparent only after the criteria are in use by clinicians (unfortunately, American Psychiatric Association field trials for the sexual dysfunctions were not funded), the rationale for the changes was based on research evidence, as well as on long-standing critiques of the DSM-IV criteria (Graham, 2010).

**ETIOLOGY**

Many possible etiological factors are relevant to orgasmic dysfunction, but in many cases, the etiology remains unclear, even after detailed assessment. One likely reason for this is that we still have limited understanding of the mechanisms underlying female orgasm (Bancroft, 2009). In most women with FOD, the causes of orgasm difficulties are also likely to be multifactorial.

**Psychosocial Factors**

Although a wide range of psychological factors, such as anxiety and distraction, can all potentially influence women's experience of orgasm, there is a great deal of individual variability in the likelihood that women are affected by these. For example, although there is evidence that a history of sexual abuse or rape is associated with orgasmic difficulties, this is not always the case (Rellini & Meston, 2007), and we understand little about why individual women vary in this respect. One recent study has suggested that the tendency to avoid interpersonal closeness and emotional involvement may mediate the relationship between lower orgasmic functioning and a history of childhood sexual abuse (Staples, Rellini, & Roberts, 2012).

Although, historically, certain personality factors have been linked to orgasmic difficulties (e.g., "histrionic traits" in DSM-III; American Psychiatric Association, 1980), there is limited evidence for associations between orgasmic ability and personality traits (American Psychiatric Association, 2013; Mah & Binik, 2001). One U.K. twin study that investigated personality factors and their association with female coital orgasmic frequency reported that introversion, emotional instability, and "not being open to new experiences" were related to orgasmic infrequency (Harris, Cherkas, Kato, Heiman, & Spector, 2008). In contrast, in a recent study of Australian twins, although orgasm rates in women showed substantial heritability, they were phenotypically and genetically independent of 19 other traits assessed, including extraversion and neuroticism (Zietsch et al., 2011).

Communications about sex and communication deficits within couples have been suggested as etiological factors in the development of orgasm problems. Although some research has suggested problematic communication patterns in couples in which the female partner has FOD (Kelly et al., 2004), it is not clear whether the communication problems were a cause or an effect of the orgasmic difficulties.

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Fear of losing control is another oft-cited etiological factor for orgasmic difficulties.

Apart from Fisher's (1973) detailed early studies of women with low and high orgasmic

"attainment," however, there has been little empirical study of this. The need to maintain self-control may be particularly important in women with primary anorgasmia or those who are able to experience orgasm during masturbation but not during sexual activity with a partner.

**Physiological Factors**

A wide range of physical illnesses, neurological and gynecological conditions, and medications can impair orgasmic functioning (Basson & Weijmar Schultz, 2007; West, Vinikoor, & Zolhoun, 2004). Conditions such as multiple sclerosis, thyroid problems, arthritis, pelvic nerve damage from radical hysterectomy, and spinal cord injury have all been associated with FOD (Bancroft, 2009; Shifren et al., 2008). Women with vulvovaginal atrophy are more likely to report orgasm difficulties than women without this condition (Levine et al., 2008). Menopausal status has not been consistently associated with the likelihood of orgasm problems (Avis, Stellato, Crawford, Johannes,

& Longcope, 2000).

Selective serotonin reuptake inhibitors (SSRIs) are known to delay or inhibit orgasm in women, affecting between 30 and 60% of individuals taking them (Montgomery, Baldwin, & Riley, 2002). There have been many attempts to reverse these side effects using various other medications but with limited effectiveness, particularly for women (for a review, see Bancroft, 2009).

**APPROACHES TO TREATMENT**

**Psychological Treatments**

A number of psychological approaches have been used to treat FOD, including psychodynamic, cognitive-behavioral, and systems theory approaches (Heiman, 2007).

The focus in this chapter is on cognitive-behavioral treatments (CBT), as these have received the most empirical support.

**Cognitive-Behavioral Approaches**

Cognitive-behavioral approaches include directed masturbation (DM; sometimes called

"guided masturbation"), communication skills training, sensate focus (SF) exercises, sex education, Kegel exercises, and systematic desensitization. Of these, DM has received the most support, particularly for women with primary anorgasmia, although it is often combined with other methods, such as SF.

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Introduced in the 1970s, DM comprises a program of education, followed by exercises involving self-exploration and self-pleasuring (Heiman & LoPiccolo, 1988).

Early phases of the program focus on the woman carrying out "solo" homework exercises, first involving nongenital touching and then gradually progressing to genital stimulation (sometimes incorporating a vibrator). Later phases include guidance on how to transfer orgasmic experiences to partnered sexual activity. DM has been evaluated in individual, couple, group, and bibliotherapy formats, although few studies have compared the effectiveness of these different modalities. Heiman (2002) concluded that there was sufficient evidence that DM (either alone or in combination with SF) met American Psychological Association criteria for a "well established," empirically supported treatment for primary anorgasmia and as a "probably efficacious" treatment for secondary anorgasmia. More recently, Ter Kuile, Both, and van Lankveld (2012) reviewed nine randomized controlled trials and concluded that following DM (delivered in either an individual or couple format), 60–90% of women with primary anorgasmia were able to experience orgasm during masturbation and a slightly lower proportion (33–85%) became orgasmic during partnered sexual activity. The authors concluded that for women with primary FOD, DM is the treatment of choice; for women with secondary FOD, although DM may be helpful, additional techniques, such as communication training, may be more valuable.

SF exercises, consisting of a graded series of touching exercises, from nongenital to genital, can be used in either an individual or couple context. These can reduce the

"genital focus" and goal-directed nature of the sexual activity evident in many women presenting with orgasmic problems. In a number of controlled studies, DM in combination with SF was more effective than SF alone (Heiman, 2002). Very few studies have assessed the use of SF alone, and in general little research has evaluated the effectiveness of different components of multimodal treatment packages (Ter Kuile et al., 2012). Regarding other behavioral techniques, such as systematic desensitization, communication skills training, and Kegel exercises, there is no empirical evidence that they are effective treatments for primary or secondary anorgasmia when used on their own, although they can be useful adjuncts to DM.

A smaller number of treatment outcome studies have evaluated cognitive-behavioral approaches that incorporate a more explicit focus on changing maladaptive cognitions that may be affecting orgasmic functioning. In one such study, involving 10 sessions of sexual skills training, anxiety reduction techniques, and cognitive retraining, therapy was successful for 80% of the female participants with anorgasmia (McCabe, 2001).

The coital alignment technique (CAT) is a coital position designed to increase clitoral stimulation during vaginal intercourse. There is some evidence from controlled studies of women with primary anorgasmia that it might be effective (Pierce, 2000), although some of these studies included components of DM as well as CAT, and all had small sample sizes.

Recently, mindfulness techniques, based on Eastern techniques designed to increase nonjudgmental, "present moment" awareness, have been used in therapy for women with problems related to desire, arousal, and orgasm. Although to date there have been no controlled trials of mindfulness as a treatment for FOD, uncontrolled studies suggest 100

that this approach has promise as an adjunct to CBT (Laan, Rellini, & Barnes, 2013).

**Pharmacological and Medical Treatments**

There are currently no approved pharmacological treatments for women with FOD. In a recent review of treatments for FOD, the authors concluded, "data support several potential treatments such as bupropion, sildenafil, estrogen, and testosterone" (Ishak, Bokarius, Jeffrey, Davis, & Bakhta, 2010, p. 3254). However, because of the lack of clinical trials that have evaluated these treatments in women with FOD, all of the studies included in this review involved women with other sexual disorders (e.g., FSAD, hypoactive sexual desire disorder).

Clinical trials of the use of testosterone patches as a treatment for women with low sexual desire have reported significant increases in orgasm frequency compared with placebo (e.g., Davis et al., 2008), but again none of these studies included women with primary orgasm complaints. Similarly, although several studies have investigated the effects of tibolone, a synthetic steroid, on sexual functioning in postmenopausal women and have reported improvements in orgasmic functioning (Ziaei, Moghasemi, & Faghihzadeh, 2010), none of these have sampled women with FOD.

There has been one randomized, placebo-controlled trial of sildenafil for women with sexual side effects related to SSRI use. At baseline 98.7% of the women reported marked delay in orgasm; sildenafil was associated with significant improvement in orgasmic functioning compared with placebo (Nurnberg et al., 2008).

Nutritional supplements such as ArginMax, which contains L-arginine, ginseng, and ginkgo, have been heavily marketed as "natural" sexual enhancement products, but there have only been two controlled studies of their efficacy in improving orgasmic functioning. In one randomized, placebo-controlled trial in pre-, peri-, and postmenopausal women, ArginMax had no significant effect on orgasm frequency (Ito, Polan, Whipple, & Trant, 2006). Another study investigated the effect of administration of ginkgo biloba extract on women with arousal and/or sexual desire problems (Meston, Rellini, & Telch, 2008). Compared with placebo, there were no positive effects of the active treatment on orgasmic functioning (or on arousal, desire, or lubrication).

The Eros clitoral therapy device is an FDA-approved, prescription-only vacuum therapy device designed to enhance clitoral blood flow and improve sexual arousal in women with sexual problems. The only published evidence that the device improves ability to achieve orgasm comes from uncontrolled studies involving small samples of women (Billups et al., 2001).

**Summary**

To summarize, cognitive-behavioral approaches, in particular DM, either alone or in combination with other techniques such as SF, remain the treatment of choice for most cases of female orgasmic difficulty. This is in line with recent "standard operating 101

procedures" put forward by the International Society of Sexual Medicine, which recommended DM in conjunction with other interventions, such as sex education, anxiety reduction techniques, and CBT, as the main therapeutic tool in FOD (Laan et al., 2013). There has been very little research that has evaluated pharmacological or hormonal treatments in women diagnosed with FOD, and there are currently no empirically supported pharmacological or hormone treatments for female orgasmic problems. Figure 4.1 presents a treatment choice algorithm for FOD.

**FIGURE 4.1** **.** Treatment algorithm for FOD.

As discussed earlier, the etiology of FOD is often multifactorial. For example, SSRI-related side effects may be partially responsible for initiating an orgasm problem, but psychological and relationship factors may contribute to maintenance of the problem.

Even where a clinician does not have the opportunity to work as part of a multidisciplinary team, it is important in clinical assessment and management of women with sexual problems that there is an understanding by the clinician not only of physical mechanisms but also of psychological and sociocultural factors.

In the following section, two clinical examples are presented, both involving CBT

treatment with couples in which the female partner presented with orgasmic difficulties

—one a case of lifelong anorgasmia and the other of situational anorgasmia.

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**CASE DISCUSSIONS**

**Case 1**

Ellen was a 28-year-old woman who had married Brian, age 32, a year previously. She had had several sexual relationships before, but this was the first relationship that she had wanted to result in marriage. In general, the couple was very close and expressed a lot of affection.

Recently Brian had been asking Ellen why she didn't experience an orgasm when they had sex. She had found this difficult to discuss. In fact, she had had no problem reaching orgasm during masturbation on her own and first experienced orgasm in this way when she was 16. However, she had always used a particular technique that involved lying on top of something that would produce pressure on her clitoris and moving her body around. She had never described this to any of her sexual partners and had always been vague about her orgasms, though not denying that she had experienced them.

Ellen referred herself to a female sex therapist without telling Brian. She wanted to find out what sort of help might be available. The therapist asked her in detail about how she stimulated herself sexually and what various methods she had tried. She had not tried using a vibrator. She was then asked how she would feel telling Brian about these experiences. She would find it difficult, she explained, because she thought she was in some way abnormal, and she was worried about how he would react. The therapist then asked Ellen to describe what happened when they were having sex. Ellen typically found the physical contact pleasurable and enjoyed stimulating Brian sexually and giving him pleasure. She would get sexually aroused when Brian caressed her around her genitalia, and his natural tendency was to proceed to vaginal intercourse as the next step in giving her, as well as himself, more pleasure and eventually orgasm. Although Ellen enjoyed the sensation of having him inside her, in particular the closeness and intimacy involved, she did not get as much sexual pleasure as when Brian was directly stimulating her genitalia, particularly her clitoris. Also, the "vaginal insertion" phase was typically short, because Brian would soon ejaculate.

The therapist came to the conclusion that the next appropriate step would be to start couple therapy. First, she wanted to reassure Ellen that there was nothing abnormal about her own method of achieving orgasm. Women varied substantially in what type of stimulation suited them best. There was no reason why Ellen should not incorporate her method of stimulation into her lovemaking with Brian, though they might need to experiment a bit. The idea of incorporating a vibrator into the process might be worth considering. However, the first step would be to explain to Brian what worked for her, and the therapist could help this process by assuring Brian that there was nothing abnormal about Ellen's pattern of stimulation. It was, however, made clear to Ellen that this would be a gradual process. The therapist would need to meet Brian and check with him as to how he would feel about engaging in sex therapy. She would check as to whether Brian had any particular concerns, including any about his own sexual responsiveness.

Both Brian and Ellen were motivated to engage in therapy together. The therapist 103

first made clear that this would be a gradual process, in which the therapist would set clear limits to what the couple could do in the period between each therapy session, and that for the first few sessions, this would not involve genital stimulation of either partner (SF, stages 1 and 2). It was explained that this phase was often helpful in uncovering important issues about the relationship that may need to be dealt with first.

The couple agreed to accept this approach, and the first therapy appointment was arranged. This involved the usual assignments of avoiding any genital contact, but each partner in turn would focus on touching the other's body, initially to find ways of enjoying the touch, and subsequently to give pleasure to the person being touched. Ellen and Brian reported reasonable success with these assignments, with each being able to indicate what they liked and avoiding what they didn't like. They also recognized, somewhat to their surprise, the extent to which each enjoyed being the "toucher."

The next crucial step was to gradually include genital touching in these sessions, with each taking her or his turn. By this time it had become easier for Ellen to talk about her particular needs, and these were discussed and their "normality" emphasized at the treatment session before starting the genital touching (SF stage 3). This stage started off reasonably well, with pleasure being experienced and expressed. At the next treatment session, the therapist talked further about Ellen's particular needs and encouraged her to try using a part of Brian's body, perhaps his thigh, to rub her clitoris against. Much to Ellen's relief, Brian expressed interest in her doing this. The couple was also encouraged to obtain a vibrator and to both try using this as a form of stimulation (SF Stage 4). They were reminded that they had not yet reached SF Stage 5, when vaginal intercourse was added to the agenda.

There was good progress; the vibrator enabled both of them to experience orgasm in the presence of the other, and on another session, Ellen achieved orgasm rubbing on Brian's thigh. They were now allowed to incorporate vaginal intercourse, with the understanding that the thigh rubbing or vibrator could be used after a period of vaginal intercourse if either partner wanted to.

This successful outcome reflected the basically satisfactory relationship that existed between Ellen and Brian; that there were no major relationship hurdles to be overcome.

The main issue was for Ellen to be open about her needs, and the gradual approach involved in this type of sex therapy paved the way for her.

**Case 2**

Anne was a 26-year-old woman who had recently started her first "steady" sexual relationship with Colin, a 29-year-old man. She had had three previous sexual partners, though the relationships were short-lived, and the sexual activity involved was not particularly enjoyable for her. With Colin she had found sexual contact to be pleasurable, and she had enjoyed giving him sexual pleasure. But Anne had never experienced an orgasm. Colin asked her about this and expressed concern that she seemed unable to have this experience. Anne decided to seek professional advice and made an appointment with a female sex therapist.

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Anne reported no real history of masturbation. She had made some attempts at genital stimulation, but these didn't go very far. She described a long-standing anxiety about "letting herself go" sexually, most obviously in a relationship context. What would happen if she lost control? A key factor in Anne's history was her being sexually abused at the age of 12 by her 16-year-old brother. He had started to caress her, and she found this pleasurable and exciting, then he proceeded to rape her, which she found painful and extremely traumatic emotionally. No one else found out about this, and her account to the therapist was the first time she had spoken to anyone about it. After she recovered from the initial shock and came to realize, even though she was not to blame, how

"sinful" this event was, she started to worry about the fact that initially she had found the encounter enjoyable. Thus the fear of "letting herself go" sexually was established.

As she progressed through adolescence, Anne emerged as a sexually attractive young woman. Men often showed interest in her, and, on the face of it, the idea of having a sexual relationship with a man, being married, and having a child all appealed to her.

But underlying this was a fear of losing control of herself sexually.

The therapist reached the conclusion that Anne should first be treated on an individual basis, before looking at how she was faring in her relationship with Colin. It was explained to Anne that "fear of losing control" or "letting herself go" is commonly experienced by women. The key process is to establish a relationship with someone whom you trust and with whom it is safe to "let yourself go." In fact this is a particular aspect of human sexuality: The ability to "lose control" in front of another person and to remain safe and secure is a powerful factor in establishing intimacy (Bancroft, 2009).

The most important and striking form of "loss of control," for both women and men, is experiencing orgasm. For a moment you are out of control (what Kinsey et al., 1953, likened to an epileptic fit), though overall it is a pleasurable experience.

The primary objective of the individual therapy was to enable Anne to experience orgasm on her own. It was, of course, possible that she might fall into the 9% of women that Kinsey et al. (1953) concluded were never able to experience orgasm. On the other hand, her history suggested a marked inhibitory factor, with the possibility that if the inhibitory component could be lessened in therapy, orgasm would occur.

There were two components to this therapy: working out suitable behavioral goals for her to work toward on her own and exploring, as she worked toward these goals, her feelings about her sexuality and the impact of her childhood abuse experience.

Behaviorally, Anne was asked to go through an SF program, similar to that used for couples, in which within defined limits she explored how to touch herself. Initially, this involved only nongenital parts of her body. If she started to feel any pleasant sensation, what was her emotional reaction to it? Gradually, she reported positive responses, first to nongenital touching and later to genital touching. The latter, in particular, tended to make her feel anxious. This anxiety was discussed. Why should she feel anxious doing this to herself? To some extent the therapist needed to counter her traditional attitudes about masturbation being sinful, making the important point that masturbation is a crucial way for a woman to learn about her own sexuality and to enable her to effectively be involved in a sexual relationship.

With genital self-stimulation Anne made some progress, though not to the point of 105

orgasm. She was starting to feel more comfortable about these sexual sensations and to feel that she was not in danger of losing control because of them. Anne was then asked to try a vibrator. She was apprehensive but willing. Initially she was asked to use the vibrator on nongenital parts of the body. Her experience with this was that the effects could vary from the pleasurable to the uncomfortable, depending on how the vibrator was applied. Then she tried the vibrator on her clitoris. This initially made her anxious, because the resulting sensations were intense. But the therapist reassured her and reminded her that inducing an orgasm in the privacy of her home would be completely safe.

Eventually, the vibrator induced an orgasm. Anne was somewhat shocked; this was an intense, unusual experience, but quite enjoyable. The therapist then encouraged her to continue using both self-touch and the vibrator two or three times a week for the next month. So far all of this was outside her relationship with Colin. She continued to elicit pleasurable orgasms using the vibrator, though not every time, and was feeling less anxious and less worried about "losing control." The therapist then suggested that Anne talk to Colin about what the therapy had involved. If he reacted in a positive way (which he did), then she could discuss bringing self-touch and vibrator stimulation into her lovemaking sessions with him, guiding him to follow some of the ways that she had learned to stimulate herself. She should not expect to experience an orgasm during vaginal intercourse but might do so either before or after. Anne did well over the next few weeks, gradually finding herself free from fear of losing control in the presence of Colin and able to enjoy orgasms in his presence.

**CONCLUSIONS**

The approaches taken in both of the preceding cases involved the use of a cognitive-behavioral approach with two couples presenting with fairly straightforward sexual difficulties. The same type of approach, suitably adapted, can be adopted with clients presenting with more complex, or comorbid, sexual problems. The successful outcomes highlight the importance of a careful assessment and of tailoring the approach used to the needs of the particular couple. For example, in the case involving Anne and Colin, individual sessions were first arranged with Anne, and only later were conjoint sessions held. For women presenting with primary anorgasmia, therapy may often (but not always) proceed in this way, with the initial goal being for a woman to reach orgasm on her own.

This chapter highlights how female orgasm in many ways remains an enigma.

However, although basic research into the central mechanisms underlying orgasm in women is required, there is a pressing need for further treatment outcome studies, particularly of psychological therapies, but also of pharmacological treatments. Only with additional research on both types of treatment will we be able to develop effective integrated treatments.

It is now 20 years since Hawton (1992) questioned whether sex therapy research had 106

"withered on the vine." Since then there has been a paucity of psychological treatment outcome studies, particularly on treatments for arousal, desire, and orgasm disorders in women, whereas there is now an abundant literature on trials of potential pharmacological treatments for these disorders (Ishak et al., 2010). As Heiman (2002) commented, the tendency to neglect the importance of evidence for psychological treatments is "troubling and a poor reflection on the field overall at a time when female (and male) sexual functioning could benefit from (a) more research on both psychologic and physiologic treatments and (b) a pursuit of comparison and combination studies of each treatment category." (p. 449)

**ACKNOWLEDGMENT**

I thank John Bancroft for his help in providing the clinical examples and for his feedback on drafts of the chapter.

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**CHAPTER 5**

Treatment of Premature Ejaculation

Psychotherapy, Pharmacotherapy, and Combined

Therapy

Stanley E. Althof

**A** lthof remarks: "These days, delaying men's ejaculatory latency is relatively straightforward; however, restoring men's sexual confidence and reversing the impact on the relationship is more complicated." Althof observes that treatment options for men suffering from premature ejaculation (PE) have expanded from the early days of sex therapy in which behavioral interventions such as stop–start or the squeeze technique predominated.

Psychopharmacological interventions are now quite often used, alone or in conjunction with behavioral techniques.

This change reflects an understanding that rapid ejaculation may not simply be the result of faulty learning or unfortunate early life experiences but may stem from a biological vulnerability. Despite our increasing knowledge concerning the biological underpinnings of PE, Althof asserts that sex therapy is more relevant now than ever. He notes that the psychological impact of PE on a man, his partner, and their relationship may be very damaging. PE

can make sexual intimacy a frustrating experience for the woman and a humiliating one for the man. Anxiety, which maintains the pattern of rapid ejaculation, may lead to the development of other sexual problems, including erectile dysfunction, and may not abate with medication alone. Choosing the right combination of medication and individual and couple therapy is key to treatment success. And yet despite all the reasons for optimism Althof still cautions "that we cannot help everyone."

**Stanley E. Althof, PhD,** is the Executive Director of the Center for Marital and Sexual Health of South Florida and Professor Emeritus at Case Western Reserve University. Dr. Althof is a clinical psychologist who specializes in both male and female sexual problems, as well as relationship issues. Dr. Althof has served as the President of both the Society for Sex Therapy and Research (SSTAR) and the International Society for Women's Sexual Health (ISSWSH). He is currently a Board Member of the Sexual Medicine Society of North America. Dr. Althof is an accomplished speaker on sexual problems of men and women and has over 100 peer-reviewed publications.

The landscape has dramatically changed for patients seeking treatment for premature ejaculation (PE). Prior to the mid-1990s, psychotherapy or behavioral treatment was considered to be the treatment of choice for this distressing sexual dysfunction. By 1995, clinicians began successfully experimenting with the off-label administration of selective serotonin reuptake inhibitors (SSRIs) to delay ejaculatory latency (Waldinger, Zwinderman, Schweitzer, & Olivier, 2004). Over the past 7 years, dapoxetine, a novel, short-acting SSRI, received medical approval in several countries, but not the United States. Other compounds are in various stages of development, but as of this writing, none have received approval.

Given the efficacy and relative safety of the off-label treatments, some clinicians may perceive psychotherapy/behavior therapy for rapid ejaculation as an obsolete and 111

antiquated intervention. On the contrary, psychotherapy and a combination of medical treatment and psychotherapy remain more relevant than ever. These days delaying men's ejaculatory latency is relatively straightforward, however, restoring men's sexual confidence and reversing the impact on the relationship is more complicated (Althof, 2005).

Psychotherapy remains useful either in its traditional form as the sole intervention for men or couples with rapid ejaculation or, in an updated rendering, as an integral aspect of a combined medical and psychological intervention (Althof, 2003, 2005; Althof et al., 2010)

**WHAT'S IN A NAME?: DEFINING PE**

Several definitions of PE exist, having been crafted by various professional organizations and/or individuals (American Psychiatric Association, 2000; Masters & Johnson, 1970; Metz & McCarthy, 2003; Waldinger, Hengeveld, & Zwinderman, 1998; World Health Organization, 1994). The major criticisms of the existing definitions include their failure to be evidence based, lack of specific operational criteria, excessive vagueness, and reliance on the subjective judgment of the diagnostician. Nonetheless, three common constructs underlie most definitions of PE: (1) a short ejaculatory latency; (2) a lack of perceived self-efficacy or control about the timing of ejaculation; and (3) distress and interpersonal difficulty (related to the ejaculatory dysfunction).

Because of the discontent with the existing definitions, as well as pressure from the regulatory agencies concerning the inadequacy of the PE definitions, the International Society for Sexual Medicine (ISSM) convened a meeting of experts to review the evidence-based literature and to develop a definition grounded in clearly definable scientific criteria (McMahon et al., 2008). After carefully reviewing the literature, the committee proposed that lifelong PE is

A male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about one minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy. (McMahon et al., 2008)

The definition applies only to intravaginal sexual activity. It does not define PE in the context of other sexual behaviors or men having sex with men. Additionally, the Committee concluded that there are insufficient published objective data to propose a new evidence-based definition of acquired PE, although it believed that the proposed criterion for lifelong PE might be applied to acquired PE as well.

DSM-5 (American Psychiatric Association, 2013) has accepted the ISSM definition, adding that the dysfunction needs to be present for at least 6 months and occur in 75%

of sexual intercourse events. Overall, I am pleased to see DSM-5 moving away from its previous definition to a more evidence-based criterion set. The subtypes of lifelong and acquired PE have also been retained and may prove useful in selecting appropriate 112

treatment interventions.

"Lifelong" PE characterizes a man who has always struggled with the dysfunction, whereas "acquired" refers to an individual who previously had the ability to control ejaculation but who later developed the dysfunction. Approximately two-thirds of men with PE have the lifelong form, and one-third have the acquired type. It may turn out that a subgroup of lifelong rapid ejaculators have a biological vulnerability, but not those with acquired symptoms (Cooper, Cernoskey, & Colussi, 1993; Gospodinoff, 1989).

Case Vignette

Larry, a 58-year-old attorney in his second marriage, typified men with lifelong rapid ejaculation. He described never being able to last more than 15 seconds with any sexual partner. He had tried masturbating prior to lovemaking, excessively drinking alcohol, and distracting himself with nonsexual thoughts. He had read books about premature ejaculation and diligently practiced the stop–start exercises to no avail.

This "disability" was a great source of shame for him, and he felt it had greatly interfered in his relationships prior to marriage and in both of his marriages. His wife, Dana, was supportive and praised Larry for going "all out to please her after his orgasm." They appeared to have a good relationship, and neither partner had significant psychological problems. They had come for consultation after reading that SSRIs were helpful to men with rapid ejaculation. He seemed like an ideal candidate for pharmacotherapy and did well with it.

Acquired PE calls upon the clinician to explore the forces that generated the new symptom, which may reflect recent psychosocial stressors or be a consequence of an illness (prostatitis, hyperthyroidism), medication, or surgery. For instance, acquired rapid ejaculation may be a consequence of erectile failure. Men with ED develop performance anxiety regarding their erectile reliability, hurry intercourse, and are at risk to develop PE.

DSM-IV-TR (American Psychiatric Association, 2000) also instructs clinicians to designate whether the PE is generalized or specific. "Generalized" refers to a man who manifests the conditions with all partners, whereas in the specific type the man has a variable pattern of normal ejaculation with some partners and rapid ejaculation with others. A specific pattern would strongly suggest that psychological factors are responsible for the rapid ejaculation. It is not uncommon for men to report a greater ejaculatory latency during masturbation than during partner sexual behaviors. However, the longer latency with masturbation does not by itself constitute a specific form of PE, especially if the man reports rapid ejaculation with all sexual partners.

Case Vignette

Jay, a 6′2″ well-muscled, 30-year-old, never-married Marine sought consultation because he had developed rapid ejaculation with his new partner of 6 weeks. Jay prided himself on his masculinity and said he could not understand why this was happening to him now.

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There was a bragging quality to Jay as he detailed his sexual history. He had slept with many women and had never suffered from rapid ejaculation. Most of his prior relationships were of relatively brief duration. Jay enjoyed being single and sleeping around.

The essential question in my mind was what was different now. With some embarrassment Jay revealed that he was intimidated by his new partner. She was a beautiful, successful woman, the CEO of a small corporation, and he felt

"dominated" by her. I asked if he had ever been in a relationship with any other woman in which he felt dominated. At first he said no, then he laughed and recalled that many years ago there was such a woman, and, yes, he also suffered from rapid ejaculation with her. We immediately knew which issue to focus on.

Anteportal ejaculation is the term for men who ejaculate prior to vaginal penetration and is considered the most severe form of PE. Such men or couples typically present when they are having difficulty conceiving children. It is estimated that 5% of men with lifelong PE suffer from anteportal PE (Pagani, Rodrigues, Torselli, & Genari, 1996; Waldinger, Rietschel, Nothen, Hengeveld, & Olivier, 1998)

Although they are not evidence based, Waldinger proposed two additional

"subtypes" for men who are distressed about their ejaculatory function but do not meet the ISSM criterion for PE (Waldinger, 2008). These subtypes should be considered provisional; however, they accurately characterize many men who do not qualify for the diagnosis of PE and are asking for help. These two subtypes are termed "natural variable PE" and "premature-like ejaculatory dysfunction." Natural variable PE is characterized by early ejaculations that occur irregularly and inconsistently with a subjective sense of diminished control. This subtype is not considered a sexual dysfunction or psychopathology but rather a normal variation in sexual performance.

Premature-like ejaculatory dysfunction is characterized by (1) subjective perception of consistent or inconsistent rapid ejaculation during intercourse; (2) preoccupation with an imagined early ejaculation or lack of control of ejaculation; (3) actual intravaginal ejaculation latency time (IELT) in the normal range or even of longer duration (i.e., an ejaculation that occurs after 5 minutes); (4) ability to control ejaculation (i.e., to withhold ejaculation at the moment of imminent ejaculation) may be diminished or lacking; and (5) the preoccupation is not better accounted for by another mental disorder (Waldinger, 2008).

Case Vignette

George, a 35-year-old single auto worker, came in asking for a drug to prolong his ejaculatory latency. His girlfriend was complaining that he ejaculated too quickly and that she was unable to reach orgasm. Upon inquiry George stated that his IELT was 20 minutes. I was astounded that he believed he had rapid ejaculation. He was obviously distressed and hurt by his girlfriend's comments and very much wanted to please her.

I asked how long he thought the average man lasted during intercourse. Forty 114

minutes, he responded. He said the guys at work talked about intercourse that lasted between 30 and 60 minutes. He had difficulty believing me when I told him that the average man lasted between 5 and 10 minutes. He was not relieved to hear me say that he did not have rapid ejaculation. He still wanted to know how he could prolong his ejaculation and was upset that we were not willing to give him medication. I urged him to consider coming to see me with his girlfriend but was not surprised that he did not follow through.

This vignette highlights the not infrequently seen dynamic of women who blame men for their struggles with orgasm or sexual pain. On the other hand, George's girlfriend may have held false beliefs about how easily and regularly women achieve orgasm with intercourse.

**PREVALENCE**

Most articles on rapid ejaculation begin by asserting that it is the most common male sexual dysfunction, affecting approximately one in three men. Several recent cross-sectional, international, epidemiological studies support the 20–30% prevalence figure for this disorder (Jannini & Lenzi, 2005; Laumann et al., 2005; Rosen, Porst, & Montorsi, 2004).

All these studies, however, have employed patient self-report or patient dissatisfaction with rapidity of ejaculation during intercourse rather than a diagnosis by a trained clinician. Reporting dissatisfaction with ejaculatory latency or labeling oneself as premature is not the same as meeting any of the published criterion sets, even the much-criticized DSM-IV-TR (American Psychiatric Association, 2000) definition. It may indeed be a problem for the individual; he may, however, not have a sexual dysfunction (recall the description of premature-like ejaculatory syndrome). In my opinion, these figures are likely to be an overestimate of the true prevalence of rapid ejaculation.

The prevalence of any disorder can be significantly changed by modifying its definition. With the adoption of the DSM-5 (American Psychiatric Association, 2013) definition of PE, with its approximately 1-minute IELT criterion, the prevalence of PE

will be greatly reduced.

**Is PE a Disorder of the Young?**

It has always been assumed that rapid ejaculation is a dysfunction of the young, with diminishing prevalence with age. This notion presumes that with age men habituate to the exciting sexual sensations or that there is a slowing of the ejaculatory reflex. This long-held belief was recently challenged by publication of two datasets demonstrating that the prevalence of premature/rapid ejaculation was constant across age groups 115

ranging from 18 to 70 (Laumann, Paik, & Rosen, 1999; Rosen et al., 2004). These studies are limited because they did not follow men longitudinally to assess changes in IELT

with age. Nonetheless, it appears that the belief that the prevalence of PE diminishes with age is not supported by current data. From a cross-sectional perspective, PE

appears to affect a broader age range of individuals than ED, and the prevalence of PE

appears to be higher than that of ED in any given age bracket studied.

**ETIOLOGY**

For years the prevailing opinion was that rapid ejaculation was a psychological or learned condition. However, a series of biological investigations has begun to unravel the physiological underpinnings of the ejaculatory process, leading theorists to speculate about organic contributions to this disorder (Gospodinoff, 1989; Grenier & Byers, 1997; Metz & McCarthy, 2003).

At this juncture, unlike in erectile dysfunction, in which a coherent story of smooth muscle relaxation/contraction mediated by nitric oxide has been elucidated, the pathophysiology of PE remains incomplete and yet to be determined.

Even if we were able to unequivocally state that a man's PE was due to exclusively biological factors, he would still manifest a psychological response that would worsen the condition. Additionally, his partner is also likely to be psychologically affected by the dysfunction, even if the condition might be due exclusively to organic factors.

The most promising biological etiologies include the role of serotonin receptors, an individual's genetic predisposition, hyperthyroidism, prostatitis, and increased penile sensitivity or nerve conduction abnormalities. However, none of these mechanisms account for more than a small percentage of men with PE.

In support of the serotonin receptor hypothesis, based on studies of rodents, Waldinger, Berendsen, Blok, Olivier, and Holstege (1998) report that activation of the 5-HT2C receptor delays ejaculation whereas activation of the 5-HT1A receptor speeds up ejaculation. Assuming congruency between rodent and human neuroreceptors, Waldinger, Berendsen, et al. (1998) speculate that rapid ejaculation may be understood as a hypofunction of the 5-HT2C receptor or a hyperfunction of the 5-HT1A receptor.

Because of safety concerns, this work cannot at present be performed on humans, so it remains only a highly intriguing theory.

The genetic hypothesis of PE was first formed by Bernhard Schapiro in 1942, who described how some family members of men with PE also have PE (Schapiro, 1943).

Many years later Waldinger, Berendsen, et al. (1998) hypothesized that both the IELT

and lifelong PE for some men are genetically determined. Like Schapiro, Waldinger (Waldinger, Rietschel, Nothen, Hengeveld, & Olivier, 1998) also found a high prevalence of PE among first-degree male relatives of Dutch men with lifelong PE.