Sexual Dysfunction: Libidinal And Orgasmic Dysfunction (Anorgasmia)

Introduction

• Description: Sexual dysfunction/anorgasmia is the lack of interest in sexual expression or sexual contact or the inability to achieve orgasm. Most studies indicate that only 30%–40% of women are able to experience orgasm during intercourse, and up to 15% of sexually active women have never experienced sexual release. Some limit the appellation of “dysfunction” to only those cases involving personal distress. (Dyspareunia is discussed separately in Chapter 37 , Chapter 94 .)

• Genetics: No genetic pattern.

• Prevalence: 40% of women, 10%–12% of women associated with or causing personal or interpersonal distress. Most experience libidinal dysfunction episodically. Of sexually active women, 10%–15% experience orgasmic failure; most experience it episodically. In “happy” or “very happy” marriages, sexual dysfunction occurs in almost two-thirds of women, with three-fourths reporting sexual difficulties that fall short of true dysfunction (such as lack of interest or inability to relax). In one survey, almost half of the women reported trouble becoming sexually excited, one-third had trouble maintaining excitement, and one-third were completely disinterested in sex. Almost half of the women reported difficulties in achieving orgasm.

• Predominant age: Reproductive and beyond.

• Genetics: No genetic pattern.

Signs and Symptoms

• Libidinal dysfunction —disinterest in or avoidance of sexual expression and lack of pleasure from sexual encounters. Dysfunction can occur in any or all of the phases of the sexual response cycle. Low sexual desire is the most common symptom (23%–46%).

• Orgasmic dysfunction —failure to obtain sexual release through any means (18%–41% of patients).

• Causes: The most common causes of sexual dysfunction are relationship problems, intrapsychic factors, and medical factors. Relationship problems are an obvious source for sexual problems, but both the patient and her provider often overlook them. Marital or relationship stresses may be acted out by sexual distancing, orgasmic failure, or exploitation. Anger, hidden agendas, lack of trust, or infidelity may be expressed through the withdrawal of intimacy. Libidinal mismatches are common, but when combined with poor communication, they lead to dysfunction. Dual-income families may not realize the impact fatigue and a fast-paced lifestyle may be having on their ability to express warmth and be sexually expressive. Medical factors that influence sexual performance include drug and alcohol use, depression, anxiety, chronic illness, pregnancy, untreated menopause, and the effects of surgical therapies. Once proximation (the process of courting, flirting, and desire that begins progress toward physical sexual expression) and arousal have occurred, orgasmic success requires effective stimulation, of a sufficient quality over a sufficient time, provided in a supportive environment. Failures in any of these areas may present as orgasmic problems.

• Risk factors: Abuse, restrictive rearing, depression, distorted body image, fatigue, sleep disorders, medical conditions (obesity, thyroid dysfunction, hyperprolactinemia, diabetes, hypertension, genitourinary syndrome of menopause, multiple sclerosis, and Parkinson disease). Nicotine may inhibit sexual arousal.

Diagnostic Approach