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Anorgasmia (often related to delayed ejaculation in males) is a form of sexual dysfunction sometimes classified as a psychiatric disorder in which the patient cannot achieve orgasm, even with "adequate" stimulation. However, it can also be caused by medical problems such as diabetic neuropathy, multiple sclerosis, pelvic trauma, hormonal imbalances, total hysterectomy, spinal cord injury and cardiovascular disease. Anorgasmia is far more common in females than in males and is especially rare in younger men.
A common cause of anorgasmia, in both males and females, is the use of selective serotonin reuptake inhibitors (SSRIs), in post-SSRI sexual dysfunction. Though reporting of anorgasmia as a side-effect of SSRIs is not precise, it is estimated that 15-50% of users of such pharmaceuticals are affected by this condition. Some popular SSRIs are venlafaxine, escitalopram, paroxetine, fluoxetine and sertraline. The chemical amantadine has been shown to cure SSRI-induced anorgasmia in some, but not all, people.
The rest of this article primarily discusses anorgasmia in women, since male anorgasmia has had very little study compared to female anorgasmia. Four types of anorgasmia have been defined: primary, secondary, situational and random.[How to reference and link to summary or text]
Primary anorgasmia is a condition where one cannot physically orgasm. This is significantly more common in women, although it can occur in men who lack the gladipudendal reflexes.
Women with this condition can sometimes achieve a relatively low level of sexual excitement and may think of intercourse or other sexual activities as pleasant despite their inability to orgasm. They may get most of their reward from touching, holding, kissing, caressing, attention, and approval. However, women who regularly achieve high levels of sexual response without orgasmic release of tension may find the experience frustrating. Emotional irritability, restlessness, and pelvic pain or a heavy pelvic sensation may occur because of vascular engorgement.
Women who have not yet had an orgasm usually have some combination of the following:[How to reference and link to summary or text]
- Sociocultural inhibitions that interfere with normal sexual response.
- Unresolved feelings towards a traumatic sexual experience as in sexual abuse or rape.
- A lack of knowledge about sex and sexuality, which interferes with normal sexual development.
- A lack of opportunity to practice in a safe, secure, socially acceptable, and private atmosphere (alone or in a relationship) in a situation that offers approval and support.
- A partner who has primary or secondary difficulty in achieving an erection.
- Dyspareunia, or painful intercourse.
- Genital mutilation ("female circumcision") that removes part or all of the clitoris, scars the genital area, or constricts the opening to the vagina. Often, vaginal intercourse is painful not only because of scarring from this procedure but also because of associated infection.
Often, though, there is no obvious reason why orgasm is unobtainable. Regardless of having a caring, skilled partner, having adequate time and privacy, and having no medical issues which would affect sexual satisfaction, some women are unable to orgasm. This situation is extremely frustrating because with no discernible cause, a plausible solution is difficult to discover.
In many contexts, many people have been able to find effective relief from anorgasmia despite a physical factor through a mental process of conditioning, as such hypnosis can have a positive impact.
Primary male anorgasmia is very uncommon, and thus has been studied very little. Given the social climate where males are just expected to be able to orgasm, it is possible that they feel ashamed, and refuse to discuss it, or distance themselves sexually. Either way, primary anorgasmia is largely considered a "female only" condition, which can be extremely frustrating to males who are left feeling alone by an affliction that few people acknowledge.
Secondary anorgasmia is the loss of the ability to have orgasms. The cause may be alcoholism, depression, grief, pelvic surgery or injuries, certain medications, illness, estrogen deprivation associated with menopause or an event that has violated the patient's sexual value system.
Secondary anorgasmia is close to 50% among males undergoing prostatectomy; 80% among radical prostatectomies. This is very alarming considering that radical prostatectomies are usually given to younger males who are expected to more easily recover from the entire removal of their prostate. This is generally caused by damage to the primary nerves serving the penile area, which typically pass through the prostate gland. Removal of the prostate frequently damages or even completely severs the nerves, making sexual response unreasonably difficult.
Due to the existence of these nerves in the protstate, surgeons performing sex reassignment surgery on transsexual male to female patients avoid removing the prostate, leaving it there so that its presence near the newly formed wall of the vagina will result in stimulation of the nerves, providing a source of pleasure for the transsexual after the operation. Thus post-operative transsexuals do not typically suffer from anorgasmia due to surgical reasons.
Women who are orgasmic in some situations may not be in others. A woman may have an orgasm from one type of stimulation but not from another. Or a woman may achieve orgasm with one partner but not another, or have an orgasm only under certain conditions or only with a certain type or amount of foreplay. These common variations are within the range of normal sexual expression.
Doctors believe that a woman with situational anorgasmia should be encouraged to explore alone and with her partner those factors that may affect whether or not she is orgasmic, such as fatigue, emotional concerns, feeling pressured to have sex when she is not interested, or her partner's sexual dysfunction.
The same doctors believe that family plannings should consider recommending the female-above position for penile-vaginal intercourse, as it may allow for greater stimulation of the clitoris by the penis or symphysis pubis or both, and it allows the woman better control of movement. Bridging is the combining of a successful method for sexual stimulation with a desired technique so that the body learns to associate orgasm with that technique. If, for example, the woman is readily orgasmic with manual stimulation but not with penile-vaginal thrusting, she is encouraged to combine those two regularly until her body has learned to associate high levels of excitement and orgasm with penile-vaginal thrusting.
Some women are orgasmic but not in enough instances to satisfy their sense of what is appropriate or desirable. Often such women have trouble momentarily giving up control and allowing themselves to respond fully. Therapy can be aimed at helping them give up the need to keep their sexual feelings under control at all times.
Effective treatment for anorgasmia depends on the cause. In the case of a women suffering from psychological sexual trauma or inhibition, pyschosexual counselling might be advisable and could be obtained through GP referral.
Women suffering from anorgasmia with no obvious psychological cause would need to be examined by their GP to check for absence of disease. Blood tests would also need to be done (full blood count, liver function, oestradiol/estradiol, total testosterone, SHBG, FSH/LH, prolactin, thyroid function, lipids and fasting blood sugar) to check for other conditions such as diabetes, lack of ovulation, low thyroid function or hormone imbalances. (Normal thresholds can be found in Berman et al, 2005). They would then need to be referred to a consultant specialising in female sexual dysfunction. There are very few such consultants in the UK (their details can be obtained from the Sexual Dysfunction Association).
A consultant in female sexual dysfunction would test for pudendal nerve damage using Genito-Sensory Analyzer (TSA; Medoc Ltd., Israel). The GenitoSensory Analyzer (GSA) is a quantitative sensory testing tool designed to quantify vibratory and thermal sensation in the vagina and clitoris in a reproducible manner, and may therefore contribute to the diagnosis and management of female sexual dysfunction. Normal thresholds for warm, cold, and vibratory sensation at predetermined points in the vaginal wall and clitoris have been established (Helpman L.,Greenstein A.,Hartoov J.,Abramov L. 2009) and a patients scores can be established against such thresholds. Testing equipment (the doppler test) is also available to test for genetal blood flow and genetal engorgement in the same way as it is for men. Such equipment is available in the US and may also be available in the UK.
Just as with erectile dysfunction in men lack of sexual function in women may be treated with hormonal patches, tablets or creams to correct imbalances, clitoral vacuum pump devices and medication to improve blood flow and sexual sensation.
Studies have been undertaken to test whether viagra is helpful for women with anorgasmia. A recent study (2009) in the Journal of Sexual Medicine found that Viagra is helpful in increasing genetal blood flow in postmenopausal women and therefore aiding them to move up the arousal spectrum. Viagra is not currently licensed for women, the reason being that its effect on the unborn child is not known. As with all such medictions that have not been tested on women there is a risk that taking such medication whilst pregnant coud lead to harm such as deformities in the unborn child. Viagra cannot normally be prescribed therefore by a GP, however it may be prescribed 'off label' by a consultant in female sexual dysfunction, where the womans sexual dysfunction is caused by physical causes e.g. nerve damage. Such a woman would need to have either been sterilised, post menopausal or be using the hormone releasing or non-hormone releasing IUD (which is a long term and highly reliable from of contraception) to prevent risk of pregnancy. Just as with men, Viagra and Cialis will improve blood flow (and thus lubrication) when combined with sexual stimulation in women with female sexual dysfunction due to physical causes. However all medications effect individuals in different ways, as we all have different genotypes. Therefore the extent to which such medications help (and the degree to which the side effects are tolerable) will vary from woman to woman. Therefore a woman wishing to be prescribed such medication by a specialist would be advised to try Viagra and if that doesn't work Cialis, and experiment with different doses (including the higher doses) to see what works for her.
Unfortunately, most GPs will have received little if any education in relation to female sexual dysfunction due to physical causes in women. Their 'outdated' training will most have taught them that female sexual dysfunction is always 'all in the mind.' Most GPs upon hearing that a woman has sexual dysfunction is most likely (and well meaninging) prescribe a course of psychosexual counselling. Thus a woman may suffer for many years with no adequate diagnosis or treatment. A GP may later refer the patient to a gynaecologist who would check for ovulation and conduct a manual physical examination (to check for benign polyps, poor ovulation or physical deformity), but as most gynaecologists recieve no training in female sexual dysfunction this visit may prove inconclusive.
A woman with female sexual dyfunction from physical causes may therefore wait years, whole decades or even most of her lifetime for proper medical treatment and diagnosis. In the meantime, this may cause unnecessary psychological suffering, low self esteem and relationship breakdown. It is therefore advisable that a woman suffering from anorgasmia from suspected physical causes (which for whatever reason cannot be diagnosed and remedial by her GP) is persistant in requesting to be refered to a consultant in female sexual dysfunction (who has access to GSA and possibly also doppler testing equipment).
- Dunsmuir WD, Emberton M, Neal DE, on behalf of the steering group of the National Prostatectomy Audit. There is significant sexual dissatisfaction following TURP. British Journal of Urology (77): 161A.
- Koeman M, Van Driel MF, Weijmar Schultz WCM, Mensink HJA. Orgasm after radical prostatectomy. British Jounal of Urology (77): 861–864.
Berman, J. E Bumiller, L. Berman (2005). For Women Only, Revised edition : A Revolutionary Guide to Reclaiming Your Sex Life, Owl Books: New York.
- The original text for this article is taken from the public domain CDC text at http://www.cdc.gov/nccdphp/drh/Africa_pdf/Chap_10.pdf
- A brief review that explores issues of the medicalization of the female orgasm
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