Orgasmic Dysfunction Lifelong orgasmic disorder is more common than acquired loss of orgasm. Some women acquire orgasmic dysfunction in association with relationship problems, depression, substance abuse, medication (especially use of SSRIs), or chronic illness (e.g., multiple sclerosis). Aside from those using SSRIs, most women who experience lack of orgasm are found on careful questioning to have only modest degrees of subjective excitement. Sometimes women respond to reassurance that most couples do not experience orgasm simultaneously, that most women experience orgasm far more easily from direct clitoral stimulation, and that this does not constitute dysfunction.
Common causes of lack of orgasm include obsessive self-observation and monitoring during the arousal phase, sometimes accompanied by anxiety and distracting negative and self-defeating thoughts. The woman may be so intent on monitoring her own and her partner’s response and concerned about “failing” that she is unable to allow her natural reﬂexes to take over and trigger an orgasm. Lack of orgasm may be related to negative feelings toward sexuality, low self-esteem, poor body image, a history of sexual abuse, and fear of losing control, and ineffective sexual technique. The only evidenced-based therapy is encouragement of self-stimulation, accompanied by erotic fantasy, so-called directed masturbation. Several excellent self-help books are available to help women become orgasmic through self-stimulation (105). A vibrator may be helpful if the plateau of high arousal is reached but there is still no orgasmic release. When the woman has experienced orgasm with self-stimulation with or without the use of a vibrator, she may or may not be able to teach the technique to her partner. Issues of trust may surface, and more intense psychological help may be needed. To counter the orgasmic delay or absence induced by SSRIs, highly selected women benefited from the prophylactic use of sildenafil (61).
Vaginismus Vaginismus is an involuntary reﬂexive contraction of pelvic muscle precipitated by real or imagined attempts at vaginal entry. Often other muscles tighten including thighs, abdomen, buttocks, and even jaw, fists, and other muscle groups. It may be generalized—the woman is unable to place anything in her vagina, even her own finger or a tampon—or it may be situational, in which case she can use a tampon and can tolerate a pelvic examination but cannot have intercourse. Couples frequently cope with this difficulty for many years before they seek help and then do so in order to begin a family. Often there are no obvious circumstances predisposing to vaginismus, such as an unpleasant past sexual experience or trauma, sexual abuse, or a painful first pelvic examination. Higher rates of psychopathology were found with regards to agoraphobia without panic disorder and obsessive-compulsive disorder. Some studies showed that women with vaginismus have higher scores on neuroticism, depression, state anxiety, phobic anxiety, social phobia, somatization, and hostility. They were shown to have increased catastrophic thinking compared to those women without dyspareunia and those with other forms of pain (e.g., PVD). Women with vaginismus had higher propensity for disgust (55). Despite the theories, there is no scientific evidence that vaginismus is secondary to religious orthodoxy, negative sexual upbringing, or concerns about sexual orientation. Women with vaginismus typically have an extreme fear of vaginal entry and misconceptions about their anatomy and the size of their vagina. They fear that harm will come from something the size of a penis entering the vagina, and similarly they fear that they would be damaged by vaginal delivery.