Female Orgasmic Disorder

The etiology of FOD is multifactorial, influenced by a combination of biologic, psychological, interpersonal, and sociocultural factors (see figure Biopsychosocial Model).

Biopsychosocial Model

Data from Parish SJ, Hahn SR, Goldstein SW, et al. The International Society for the Study of Women's Sexual Health Process of Care for the Identification of Sexual Concerns and Problems in Women. Mayo Clin Proc. 2019;94(5):842-856. doi:10.1016/j.mayocp.2019.01.009

Biological: Medical conditions like diabetes, multiple sclerosis, chronic pain, spinal cord injuries, and vulvar disease can contribute to orgasm issues (1). Menopausal women may experience changes in orgasm, possibly due to hormonal changes involving decreased levels of estrogen, progesterone, and testosterone (2). Antihypertensives or antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), are also known to impact orgasm (3).

Psychological: Emotional distress, such as depression with decreased interest, or pleasure or anxiety associated with cognitive distraction or spectatoring (eg, viewing oneself or sexual activity as if one is viewing it from the outside) can interfere with the ability to orgasm. Additionally, factors like negative body image and negative perception of one's genitals may also impact orgasmic functioning (4, 5).

Interpersonal: A number of relational factors may contribute to FOD, including a lack of emotional connection with a partner, relationship discord, unresolved resentment or anger, poor sexual communication, or sexual issues experienced by the partner (4, 6). Discomfort with masturbation can impact a woman’s ability to orgasm either alone or with a partner.

Sociocultural: Religious or cultural beliefs such as feelings of shame or guilt can suppress sexual expression. Limited sexual education, particularly about female anatomy and orgasm, may also contribute to orgasm-related issues (7). One common societal misconception is that women, like men, can achieve orgasm through penetration alone. The lack of awareness that most women need clitoral stimulation to achieve orgasm can hinder understanding and expectations of female orgasms (8).  

The symptoms of FOD include absent, delayed, or less intense orgasm accompanied by significant distress (1).

• History and pelvic examination

• Clinical criteria

A thorough evaluation of FOD often begins with a clinical interview that centers on a woman’s sexual history. (See table Components of the Sexual History for Assessment of Female Sexual Dysfunction.) The evaluation should align with Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) diagnostic criteria, and also utilize a biopsychosocial framework to identify precipitating, perpetuating, and maintaining factors.

DSM-5-TR criteria for female orgasmic disorder require an absence of or a significant decrease in ≥ 3 of the following (1):

• Delayed, infrequent, or absent orgasm or markedly decreased intensity of orgasm after a normal sexual arousal phase on all or almost all occasions of sexual activity

• Distress or interpersonal problems due to orgasmic dysfunction

Criteria require that these symptoms have been present for ≥ 6 months, cause significant distress in the individual, and not be better explained by another psychiatric or general medical condition, significant relationship stressors, or use of a medication or substance.

If it is determined that orgasm issues occur only during partnered sexual activity, but not during masturbation, it may be beneficial to include the partner in both the evaluation process and subsequent treatment (2).

Standardized measures of sexual function, such as the Female Sexual Function Index (FSFI) (3) may be incorporated to support diagnosis. If general medical factors are suspected to play a significant role in orgasm issues, referral to a gynecologist or other medical specialist may be warranted.

• Self-stimulation

• Sex therapy

• Psychological therapies

Treatment should be comprehensive and focused on the biopsychosocial contributing factors, and may include psychosexual education, referral to a sex therapist, and a pelvic floor physical therapist (PFPT).

Psychosexual Education: Psychosexual education about the female sexual response cycle, the importance of both physical and mental stimulation for orgasm, and prevalence rates of FOD (ie, that it is common, which may normalize the issue for patients) should be discussed. It is important to address common misconceptions, such as the belief that women should orgasm through vaginal-penile penetration alone. In reality, most women require clitoral stimulation to reach orgasm, and research shows that few (18.4%) orgasm through vaginal penetration alone (1). Clinicians can suggest educational resources related to enhancing sexual communication and techniques. Many women benefit from the use of a vibrator.

Sex Therapy: A referral to a sex therapist should be considered when orgasm issues persist despite general treatment strategies. Sex therapists are licensed mental health professionals with additional training in sexual health. They often use traditional psychotherapy like cognitive behavior therapy or mindfulness interventions to address thoughts and behaviors that influence sexual functioning and satisfaction. One common technique for FOD is directed masturbation, which involves a series of at-home masturbation exercises designed to promote body awareness and enhance sexual pleasure (2). Sensate focus, a widely used therapeutic technique for many sexual concerns, is comprised of a series of touching exercises focusing on present-moment awareness and sensations, to help decrease performance anxiety and cognitive distractions (3).

Pelvic Floor Physical Therapist (PFPT): A referral to a PFPT may be beneficial for improving pelvic floor muscle function, which may enhance arousal and orgasm (4).

• Female orgasmic disorder is delayed, infrequent, absent, or less intense orgasm in 75% to 100% of sexual encounters for at least 6 months, causing significant distress.

• Etiology is multifactorial and may be biologic, psychological, interpersonal, or sociocultural. Contributing factors include medical conditions, menopausal hormonal changes, medications, depression, anxiety, relationship issues, and poor sexual communication or self-concept.

• Diagnosis is based on medical and sexual history, physical examination, and clinical criteria; imaging or laboratory tests are sometimes performed to evaluate for causative or contributing factors.

• Treatment focuses on contributing factors and may include psychosexual education, sex therapy, self-stimulation, and pelvic floor physical therapy.