Input: Could not generate response.

Response:
Major changes have taken place in the assessment and treatment of ED since approval of sildenafil (Viagra) and two other PDE5 inhibitors, tadalafil and vardenafil (Cialis, Levitra), since 1998 (Rosen & McKenna, 2002; Rosen, 2005). The approval and availability of these three landmark drugs has greatly increased the number of men seeking treatment for ED and has significantly altered the medical and psychological management of the disorder. Historically within the province of urologists and sex therapists, ED is now managed predominantly by primary care practitioners. Costly and potentially invasive diagnostic procedures such as penile cavernosography or cavernosometry, once the mainstay of urological assessment of ED, are seldom performed nowadays. New management guidelines emphasize the need for a brief sexual and medical history and a focal physical examination. In reality, many middle-aged men with ED receive prescriptions for Viagra, Cialis, or Levitra with little or no medical or psychological evaluation. Further diagnostic studies are usually reserved for those patients who fail to respond to an initial trial of a PDE5 inhibitor (Lue et al., 2004).

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Despite these important benefits, some disadvantages and risks associated with the widespread use of sildenafil have been identified. Although PDE5 inhibitors are generally safe and well tolerated, there may be specific medical risks for selected subpopulations. For example, concomitant nitrate use is a strong contraindication for all three current PDE5 inhibitors. Patients with high-risk cardiac conditions (e.g., unstable angina, recent myocardial infarction) may be at risk for sexual activity, although PDE5

use per se is not contraindicated in these patients (DeBusk et al., 2000; Kostis et al., 2005). Patients with sickle-cell disease or those using other erectogenic agents (e.g., intracorporal injections) may be at risk for priapism. Due to sildenafils effects on phosphodiesterase enzymes in the eye, patients with opthalmological disorders (e.g., retinitis pigmentosa or nonarteric anterior ischemic optic neuropathy [NAION]) should be carefully evaluated prior to treatment with PDE5 inhibitors.

Although all three PDE5 inhibitors are effective in restoring erections in about 75%

of men who use the drugs, differences have been observed in patient preferences or the pattern of side effects associated with the drugs. Some studies have suggested that sildenafil (Viagra) or vardenafil (Levitra) may be associated with a firmer or more satisfying erection, whereas other studies have suggested that tadalafil (Cialis) is preferred by many patients due to the longer lasting effects of the drug. One recent study, in particular, showed that the majority of patients preferred tadalafil due to the increased sense of spontaneity and reduced time pressure with this drug compared with sildenafil. Further studies are needed to confirm this finding.

**Psychological Factors**

Despite the efficacy and overall safety of PDE5 inhibitors (Padma-Nathan, 2003; Rosen

& McKenna, 2002), increasing evidence suggests that a substantial proportion of men with ED discontinue treatment or fail to seek help. A recent large-scale, multinational study of more than 25,000 men in eight countries found that 58% of men with erection problems had discussed their problems with health professionals, although less than half of these men received prescriptions for sildenafil or other medication, and only 16%

were continuing to use the drugs at the time of the study (Rosen et al., 2004). Multiple reasons were cited for the high rate of discontinuation, including lack of education or counseling from physicians, fear of side effects, partner concerns, and distrust of medications. Failed expectations may be another important reason for patient dropout from medical therapy, as many men or their partners are disappointed at the lack of change in the quality of the sexual relationship. For these reasons, the importance of combined medical and psychological treatment approaches has been emphasized.

Leiblum (2002), Perelman (2005), and others have noted additionally that success rates with PDE5 inhibitors may be significantly lower in couples who have experienced chronic sexual or marital conflict, lack of desire in one or both partners, or significant psychiatric illness in either partner. These individuals are generally excluded from clinical trials of sildenafil, and the efficacy of the drug in such cases is essentially unknown. PDE5s may also lose efficacy over time because of other factors, such as 75

progression of the underlying disease state or development of tolerance to the pharmacological effects of the drug (El-Galley, Rutland, Talic, Keane, & Clark, 2001).

Systematic trials of combination drug and sex therapy have not been performed to date.

Despite their overall effectiveness in restoring erectile function for many men, PDE5

inhibitors should not be regarded as a panacea or "magic bullet" for achieving sexual happiness.

Whereas current management guidelines recommend sex or marital therapy (Althof et al., 2005; Lue et al., 2004) or the use of vacuum constriction devices (VCDs) as alternative first-line therapies, these are far less widely used at present than medications.

The simplicity and ease of use of an oral medication are major advantages, particularly for primary care physicians with little training or interest in the management of sexual dysfunction. Referral to a sex therapist or mental health professional is only likely to occur when requested, when couples or psychological issues present a major obstacle to treatment, or when oral medications fail. Referrals for other urological treatments (e.g., intracorporal injection, penile implant surgery) are similarly reserved mostly for oral therapy failures nowadays.

**PSYCHOSOCIAL ASSESSMENT AND SEX THERAPY**

**APPROACHES**

The specific psychosocial therapy approach for ED is dependent on an understanding of all medical and nonmedical contributions to the problem. It is not a matter of which psychosocial therapy is most effective for treating ED, but rather it is a matter of which approach or approaches are most suitable for addressing the mosaic of contributions to a mans ED problem. The specific nonmedical approach, therefore, is dependent on a comprehensive assessment that identifies all factors contributing to the problem.

Although a single factor may loom as the most likely contributor, more often than not there are two or more factors that may be contributing to a mans erection problem. In assessing ED, it is also especially important to identify the time line of the problem and consider predisposing, precipitating, and maintaining factors. Treatment may need to address all of the time-line factors or only one. For example, a precipitating factor for ED may have been a drinking experience, but the maintaining factor to be addressed is the performance anxiety.

The following model offers a conceptual strategy for a comprehensive assessment of all potential psychosocial contributions to ED. The model emphasizes a detailed consideration of three psychosocial areas: (1) self, (2) relationship/partner, and (3) environment.

**The Assessment Model**

**Self**

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The self refers to all of the possible individual factors that a man experiencing ED is contributing to his sexual problem. Self-factors are considered separately from relationship/partner factors and environmental factors. In any of the three areas, there may be more than one factor contributing to the ED.

PERFORMANCE ANXIETY

Performance anxiety is the most common psychosocial factor and is inherent in most cases of ED. This term simply means a focus on performance rather than on the ongoing pleasure of sex. Because a mans penis (either flaccid or erect) is visible to both the man and his partner, the occurrence of an erection or lack of an erection is a known event.

This increases the focus on performance for, men in a unique way that female partners do not usually experience. The word anxiety in this context is somewhat misleading.

Early work that looked at anxiety and sexual arousal in women (Hoon, Wincze, & Hoon, 1977) and the subsequent work of Barlow and his associates with men (Barlow, Sakheim, & Beck, 1983; Cranston-Cuebas & Barlow, 1990) suggest that physiological concomitants of anxiety may be less important than the effects of performance demand or cognitive distraction.

Most men experiencing ED can readily identify the presence of performance anxiety.

The assessment of performance anxiety is confirmed clinically if men are able to obtain erections under nonperformance situations such as during private masturbation to erotic stimulation, during sleep (confirmed by RigiScan assessment if a man is unaware of nocturnal erections), or during nondemand situations, such as when a female partner is menstruating and states she does not want intercourse. Men experiencing performance anxiety will report a focus on erections and a worry about erections during sexual activity; also, there is often a frequent visual or tactile checking of the penis.

COMORBID DISORDERS

Major mental health disorders such as depression, generalized anxiety, obsessive–

compulsive disorder, posttraumatic stress disorder, and substance abuse may be so severe that the mere presence of these disorders may not only contribute to the ED but interfere with any therapeutic attempts to treat the ED. In most cases of ED, when a severe comorbid mental health disorder is present, therapy must first address the comorbid disorder before addressing the ED.

HISTORY OF NEGATIVE SEXUAL MESSAGES

In some men, ED is associated with a history of powerful negative sexual messages generated by family, culture, or religion. When this factor is present, men will experience a flood of guilt or negative thoughts associated with sexual activity that counteracts any positive sexual expression and leads to ED.

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SEXUAL ABUSE OR TRAUMA

Men with a history of sexual or nonsexual trauma and abuse frequently present with loss of desire and/or difficulties in sexual performance. The degree of impairment varies widely depending on the extent and duration of the abuse.

GENDER IDENTITY, SEXUAL ORIENTATION, AND PARAPHILIA PROBLEMS

It is not unusual for some men to enter into sexual partnerships because of family expectations or social pressures in spite of a history of gender dysphoria, sexual orientation questions, or paraphilic desires. The rationalization is often that, once partnered, everything will work out. In fact, initial sexual relations in such cases often do work out (perhaps because novelty often contributes positively to sexual arousal), but, in long-term partnerships, ED may be subsequently experienced. In some cases, partners may initially accommodate a paraphilic desire but grow tired of this over time. When sex is attempted without the presence of paraphilic stimulation, ED occurs.

MISINFORMATION AND LACK OF SEXUAL SKILLS

Although there are some men who are sexual athletes, there are also men who are sexually unskilled. Men harboring sexual myths or misinformation who approach sex with an awkward narrow repertoire of sexual behaviors may be prone to ED. Some men, for example, may view foreplay as unnecessary or even as a weakness during sexual activity. Such views may inhibit adequate degrees of erotic input and result in ED.

Comprehensive assessment must explore details about sexual behaviors and attitudes in men experiencing ED to identify any possible inhibitory factors.

**Relationship/Partner**

In many cases of ED, there are significant contributions associated with the dynamics of the relationship or specifically from the partner. In spite of partner-related contributions to ED, the focus of the problem may initially be presented as "the mans problem."

When working with couples, assessment should be approached in the spirit of identifying contributions to the problem rather than assigning blame.

COUPLE CONFLICT

Interpersonal and couples issues play a major role in many, if not most, cases of erectile dysfunction. As noted by Masters and Johnson (1970), "there is no such thing as an uninvolved partner in any marriage in which there is some form of sexual inadequacy"

(p. 2). Relationship conflicts may be a primary source of the sexual difficulty or may serve to exacerbate or maintain the males inability to achieve adequate erections.

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Although the role of relationship factors is widely acknowledged in the clinical literature on the topic (e.g., Masters & Johnson, 1970; Kaplan, 1974; Leiblum & Rosen, 1991), relatively few studies have assessed the relationship between interpersonal distress and treatment outcome for ED. In an early study, sensate focus and graduated sexual stimulation techniques were evaluated in 36 couples presenting for treatment of psychogenic ED (Hawton, Catalan, & Fagg, 1992). The major determinant of treatment outcome in this study was the couples ratings of marital communication prior to treatment. Couples with higher ratings of marital communication responded more rapidly and with better outcomes to the sex therapy interventions provided.

In addition to the paucity of outcome data, there is a lack of consensus regarding the choice of conceptual framework or intervention strategies for overcoming relationship conflicts in couples with ED. Thus some sex therapists have formulated couples issues from a psychodynamic perspective (e.g., Kaplan, 1974; Scharff, 1988; Levine, 1992); others have provided a cognitive-behavioral perspective (Wincze & Carey, 2001); still others have argued for a family systems approach (Verhulst & Heiman, 1979; LoPiccolo, 1992). This lack of agreement concerning theory and practice of couple therapy has impeded efforts to develop more standardized approaches for dealing with couples issues in ED. Rather, this essential aspect of treatment is often based upon an eclectic array of techniques and interventions.

COUPLE STRESS UNRELATED TO CONFLICT

In some cases, ED may be related to an overwhelming preoccupation with stress in a couples life. A couple may get along well and love each other but be affected by serious problems, such as job loss, financial worry, a parents failing health, or childrens struggles. Although some couples are able to function sexually in spite of stress in their lives, many couples are not able to do so, and sexual relations end with ED.

LACK OF SEXUAL ATTRACTION TO A PARTNER

In some cases, the presence of ED is directly related to the lack of attraction that a man has toward his partner. The reason may be a history of conflict that has changed a mans perception of his partner, or it may be a partners physical changes over time. Obesity and lack of personal care on the part of a partner are sometimes present in the dynamics of a couples relationship as contributors to ED. Because of the sensitive nature of issues related to a partners appearance, this is often a topic that is not openly discussed. As we discuss later, this is a prime reason that assessment interviews should be conducted separately for the man presenting with ED and his partner.

PARTNER-RELATED SEXUAL AND NONSEXUAL PROBLEMS

Men presenting with ED often ignore or diminish the impact that their partners 79

problems have on their ED. It is not at all unusual for a man presenting with ED to mention that his partner has never enjoyed sex, has never initiated sex, or has never been comfortable with sex. Although a partners negative sexual attitude or limited sexual repertoire may not initially contribute to an ED problem, it may do so in the long run. In addition, a partner may have such severe mental health problems that there is an interference with sexual relations. A partners severe depression, obsessive–compulsive disorder, or substance abuse can definitely inhibit sexual desire and behavior.

**Environment**

Therapists often make the false assumption that couples are having sex under favorable conditions and rarely ask about the specific environment or conditions under which sex usually occurs. An inquiry about the conditions under which sex occurs may identify interfering factors. Favorable conditions for sex usually include comfort, privacy, and relaxed time.

LACK OF COMFORT

Comfort includes not only the physical comfort of the bed or surface on which sex occurs but the general surroundings as well. Attempted sexual relations in the backseat of a car or in a bed with parents pictures on the wall have been identified as contributors to ED in some of our patients.

LACK OF PRIVACY

Feelings of a lack of privacy have often been identified as factors contributing to ED in some of our patients. Worries about children or in-laws in the bedroom next door or in the house during sexual activity or worries about pets in the bedroom have all been mentioned as interfering factors. Architectural issues have also been identified in our patients, including lack of doors or glass doors on a bedroom.

LACK OF RELAXED TIME

Because of multiple responsibilities or commitments or because of demanding or incompatible work schedules, many couples are faced with conditions in which they have very little time with each other. One partner working a day shift and the other partner working a night shift or one partner traveling and coming home only on weekends severely limits favorable time for sexual relations. Couples in such situations often try to "take advantage of the time together" and engage in sexual activity whether they feel like it or not. It is not unusual that such conditions can contribute to ED.

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**Assessment Strategy**

Men seeking professional help with sexual dysfunction generally and ED in particular typically present under three conditions: as single men without partners, as men with partners who are unavailable or uncooperative, and as men with partners who are available and cooperative. Whenever there is an available and cooperative partner, separate interviews are conducted to ensure conditions for full disclosure of all important factors and to evaluate each partners perspective of the problem and each partners medical, psychological, and sexual profile. The availability of a cooperative and available partner usually offers a more complete assessment and facilitates the therapy process.

**Clinical Interview**

With the preceding model in mind, psychological assessment of ED is accomplished primarily through a comprehensive interview that examines each of the possible contributing factors in the model. Confidentiality is assured to each separate partner so that the therapist can obtain important information that otherwise might not have been disclosed in the presence of a partner. For example, information related to masturbation practices, sexual relations with prostitutes, or sexual relations with another partner might not have been shared. This information, however, is clinically very important when attempting to understand the etiology and scope of the ED problem and when developing a treatment strategy. Assessment that reveals ED only with a partner but not in other circumstances would take a very different course than ED that occurs under all circumstances. When sexual or relationship secrets are revealed during partner assessment, the therapist faces a difficult challenge in how best to proceed.

**Psychometrics**

The use of psychometric instruments may be used as part of a comprehensive assessment strategy for ED. Valid and reliable instruments such as the Minnesota Multiphasic Personality Inventory (MMPI) may be used to evaluate the presence of comorbid disorders that may be contributing to the ED. The most widely used self-report scales for assessing erectile function directly are the International Index of Erectile Function (IIEF) (Rosen et al., 1997) and the Sexual Health Inventory for Men (SHIM) (Rosen, Cappelleri, Smith, Lipsky, & Pena, 1999), which are commonly used in both research and clinical settings. More specialized measures focus on rigidity and reliability of erection, including the validated Erection Quality Scale (EQS; Wincze et al., 2003; Wincze et al., 2004).

**Sex Therapy and Integrated Treatment of ED**

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Treatment strategy is dependent on a comprehensive medical and psychosocial assessment. Depending on the exact nature of all of the factors in a particular case, treatment may focus entirely on medical factors, entirely on psychosocial factors, or on a combination of medical and psychosocial factors. Also, depending on the assessment findings, treatment may focus initially only on medical factors and subsequently on psychosocial factors, or simultaneously on both medical factors and psychosocial factors.

Because of all of the possible factors contributing to ED, there is no one prescription for treatment. Rather, there is a need to follow a pathway that addresses all factors contributing to the ED problem. Nonetheless, there are certain psychosocial approaches that present as part of most treatment protocols for men experiencing ED.

**Sensate Focus**

The sensate focus approach developed by Masters and Johnson (1970) is still a cornerstone of treatment for most cases of ED. The basic procedure asks a couple to have sexual relations without intercourse regardless of the mans erection. The procedure encourages couples to be orgasmic by any means other than intercourse. This procedure not only takes the focus off of the erection but introduces a novel approach and variety. Both of these elements are conducive to arousal. The goal of sensate focus is to focus on the moment and sensations rather than focusing on the outcome and performance. A therapists suggestion, for example, to focus on the fragrance of your partners hair, the feel of your partners body helps to keep a mans mind in the moment. Couples are generally asked to repeat this exercise a number of times until there is a comfort with approaching sex and an achievement of being able to focus on the moment rather than the outcome. Most couples following this procedure will report experiencing erections within one or two sessions. Once erections are being achieved and comfort is present, then a therapist might suggest to the couple to include intercourse as an "option."

**Cognitive-Behavioral Interventions**


Input: Write a detailed prompt about the chapter on orgasm disorders in women, focusing on the prevalence, diagnosis, and assessment of these disorders. The prompt should also discuss the importance of orgasm in women's sexual satisfaction, the role of distress in diagnosing these disorders, and the impact of cultural and religious beliefs on women's attitudes toward masturbation and orgasm. Additionally, the prompt should explore the comorbidity of sexual difficulties in partners and the potential for improvement in sexual functioning in one partner when the other receives individual therapy for a sexual problem.

Response:
Cognitive interventions are used increasingly in the psychological treatment of erectile dysfunction. In particular, bibliotherapy and cognitive restructuring techniques are used to overcome sexual ignorance and to challenge the unrealistic sexual expectations that typically accompany ED (Wincze & Carey, 2001). We often recommend self-help books that address dysfunctional beliefs or other cognitive issues in men with ED (Alterowitz

& Alterowitz, 2004; Wincze, 2009; Zilbergeld, 1992). Note that although the first book is oriented to prostate cancer survivors, the sections on cognitive issues are valuable and appropriate for all men with ED.

Men (and their partners) frequently harbor gross misconceptions regarding the basic mechanisms and processes of erectile function and causes of sexual dysfunction. The 82

effects of illness and drugs, aging, and male–female differences in sexual response are additional common areas of ignorance. As noted by Zilbergeld (1992), men frequently subscribe to a fantasy-based model of sex, in which male performance is viewed as the cornerstone of every sexual experience and a firm erection is seen as the sine qua non of a satisfying sexual encounter. Sexual performance difficulties are often interpreted, according to this view, as a loss of masculinity or declining sexual interest in the partner.

Dysfunctional sexual beliefs and expectations are a potentially important focus for treatment. In an early study, elderly couples with a history of ED were randomly assigned to either an educational workshop program or a waitlist control condition (Goldman & Carroll, 1990). Posttreatment evaluations revealed a significant improvement in sexual knowledge and attitudes in the workshop participants, which was associated with increased sexual frequency and satisfaction. Educational interventions have recently been combined with medical therapies (Perelman, 2005), although the specific benefits of this combined approach need to be further evaluated.

Other authors have recommended that positive imagery training, either with or without masturbation, can assist in the development of sexual confidence and control (Rosen, Leiblum, & Spector, 1994; Zilbergeld, 1992). Again, these fantasy and masturbation exercises can be combined with use of oral medications, and clinicians frequently recommend use of PDE5 inhibitors initially with masturbation or fantasy to develop familiarity and comfort with the use of the drugs. On the other hand, Apfelbaum (2000) has cautioned that although sexual fantasies may be used by dysfunctional males to temporarily "bypass" a lack of arousal or interest in their partners, this solution is unlikely to be effective and may lead to a loss of sexual desire when used on a long-term basis.

**Sexual Stimulation Techniques**

It has often been noted that ED is most psychologically distressing for individuals or couples with limited sexual scripts and few alternatives to intercourse (Zilbergeld, 1993; LoPiccolo, 1992; Gagnon, Rosen, & Leiblum, 1982; Leiblum & Rosen, 1991). In particular, performance demands and fear of failure are increased markedly for individuals or couples who lack alternative means of sexual satisfaction to penile–

vaginal intercourse. For these individuals, the males inability to achieve a firm and lasting erection typically results in a complete cessation of all sexual activity. This, in turn, may lead to diminished sexual desire in one or both partners and increased distance or conflict in the relationship (Leiblum & Rosen, 1991). A "vicious cycle"

phenomenon frequently ensues, as the loss of sexual or affectionate interaction is associated with increased performance demands and interpersonal distress. In one early study, sexual communication training was found to be superior to sensate focus alone in the treatment of secondary erectile dysfunction (Takefman & Brender, 1984).

LoPiccolo (1992) has emphasized the critical role of the female partners attitude toward nonintercourse forms of sexual stimulation. According to this author, the partners willingness to be satisfied by manual or oral stimulation may be a critical 83

determinant of treatment outcome in most cases of erectile dysfunction: "Far more effective than sensate focus in reducing performance anxiety is the patients knowledge that his partners sexual gratification does not depend on his having an erection. If the patient can be reassured that his partner finds their lovemaking highly pleasurable, and that she is sexually fulfilled by the orgasms he gives her through manual and oral stimulation, his performance anxiety will be greatly reduced" (LoPiccolo, 1992, p. 190).

From this perspective, treatment is often focused on the sexual receptivity of the partner to nonintercourse forms of stimulation.

Elsewhere, a "sexual scripting" approach has been recommended for a variety of sexual performance difficulties, including ED (Gagnon, Rosen, & Leiblum, 1982; Rosen, Leiblum, & Spector, 1994). Essentially, this approach involves detailed assessment of both the performative, or overt, script between the partners and the ideal or imagined script of each individual partner. Performative scripts can be analyzed according to four major script dimensions: complexity, rigidity, conventionality, and satisfaction. In couples with chronic sexual dysfunctions, including ED, performative scripts typically become increasingly restricted, repetitive, and inflexible, with diminishing sexual satisfaction for either partner. Script restrictions may either precede the onset of a specific sexual problem or may develop as a consequence of the disorder (Leiblum & Rosen, 1991).

Case 3: Mr. and Mrs. E

John and Barbara were both 64 years old, had been married 40 years, and had two adult daughters. John was an employed professional white collar worker, and Barbara was employed part time in an office job. Both were college educated and were financially comfortable. John presented with a 10-year history of intermittent ED with his wife and a complaint of low desire. He also reported that he and Barbara had not had sex for 1 year. Recently, she was very angry because she discovered that John had been viewing pornography on the Internet. John reported that Barbara had considerable anger toward him and that they had a history of very poor communication. John also presented with a complicated medical history of untreated hypogonadism, hypertension, and dyslipidemia.

Barbara presented with a history of hypoactive sexual desire disorder, dyspareunia, and anger toward John. She was hurt by Johns use of pornography and described herself as extremely sensitive to criticism and avoidant of conflict.

Medically, Barbara presented with untreated type II diabetes, vaginal atrophy, and a past hysterectomy.

In a separate interview with John, he revealed that he was able to obtain an erection sufficient for penetration during masturbation to pornography, although the erection was not a completely full one. Both John and Barbara stated that they wanted to stay together, and both were willing to work together in therapy to improve their situation.

From the start of therapy both John and Barbara obtained medical treatment.

John worked on diet changes and exercise, and treatment for hypogonadism was 84

initiated. Barbara spent a week at a specialty clinic for diabetes and gained a great deal through the diabetic education and necessary diet changes. She also was seen by a gynecologist familiar with female sexual dysfunction and received treatment for vaginal atrophy.

Because the couple presented with a great deal of anger over pornography use, this issue was addressed initially and put into perspective in a way that was acceptable to both John and Barbara. They were each encouraged to see and appreciate the others needs. In addition, it was necessary to also initially address communication issues through role playing with the therapist, as the couples faulty communication was a continuing source of conflict. Focus on sexual issues in general and ED in particular was delayed until the medical issues, pornography issues, and communication issues were addressed and progress was made. The focus on sex began about 1 year after therapy was initiated and began with a more general focus on increasing intimacy. The couple were given assignments to arrange "date nights"

and other intimacy exercises. After about 6 months of additional therapy, the couple reported spontaneous initiation of successful intercourse and success in achieving greater relationship intimacy.

**Comment**

This case illustrates an example of the type of complex cases that we see today. This type of complex case is a far cry from the more simplistic cases treated by Masters and Johnson in the early 1970s. This case is complicated by both the medical and psychosocial problems presented by both partners. It is also a case that illustrates the need to treat problems in sequence. The ED problem that was initially presented was not directly treated by psychological approaches until after a year of medical intervention and couple therapy. A key element in the successful treatment of this case was the motivation on the part of both John and Barbara to improve their situation. Blame was removed early on in therapy so that the couple could approach their mutual problem as

"two adults working together." Sex was approached gradually, with an emphasis on building intimacy in terms of how the couple related to each other both verbally and physically. All intimacy was given value, and sexual intercourse was focused on as only one of many options to express intimacy.

**CONCLUSIONS**

Erectile dysfunction is a highly prevalent sexual disorder, with significant effects on mood, quality of life, and interpersonal relationships. Since the introduction of PDE5

inhibitors, approximately 100 million men worldwide have sought treatment for ED, and the drugs are now widely used as first-line therapy for ED, although many men fail to make adequate use of the medication. As described in this chapter, an integrated 85

approach of medical and psychosocial interventions is feasible and potentially superior as an overall treatment approach. Psychological and sex therapy approaches are strongly emphasized in this model, either in conjunction with or as an alternative to medical therapies. Despite the overall safety and effectiveness of PDE5 inhibitors, many couples discontinue treatment for psychological and interpersonal reasons. This combined approach is intended to address these issues and to improve overall satisfaction with treatment.

Future directions for this area include the potential integration of cardiovascular risk prevention and lifestyle modification approaches, including weight loss and exercise, as adjunctive treatments for ED in men with both erection difficulties and major cardiovascular risk factors. The relative benefits and potential challenges in integrating couple therapy or treatment approaches involving partners of men with ED remains to be addressed. Finally, the impact of the new DSM-5 definition of ED and the inclusion of the penile rigidity criterion in particular remains to be evaluated.

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Azadzoi, K. M., & Goldstein, I. (1992). Erectile dysfunction due to atherosclerotic vascular disease: The development of an animal model. Journal of Urology, 147, 1675–1681.

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Goldman, A. S., & Carroll, J. L. (1990). Educational intervention as an adjunct to treatment of erectile dysfunction in older couples. Journal of Sex and Marital Therapy, 16, 127–141.

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**Orgasm**

89

**CHAPTER 4**

Orgasm Disorders in Women

Cynthia A. Graham

**"W** omen clearly differ in how important orgasm is to their sexual satisfaction," Graham writes. She notes, however, that this difference may stem from how widely women vary in the ease and manner in which they experience orgasm. In general, most women find it easier to have an orgasm from self- as opposed to partner stimulation. Of those experiencing orgasmic difficulties, younger and older women are more frequently represented. Poor overall health and relationship difficulties are also associated with difficulty experiencing orgasm.

These findings raise important questions: To what extent is a womans difficulty experiencing orgasm during partnered sex due to an individual issue rather than a skills deficit on the part of her partner? Is orgasm a marker for relationship satisfaction? To what extent is experiencing orgasm a learned phenomenon? In response to these and other questions, Graham critically reviews the literature and neatly summarizes the requisite elements of a sensitive assessment of orgasmic difficulties. Although she acknowledges that directed masturbation remains a highly successful treatment approach, she advises that there is room for improvement. Medication and mindfulness are two of the options that are discussed as Graham makes the case for a more comprehensive treatment approach.

**Cynthia A. Graham, PhD,** is currently a Senior Lecturer in the Department of Psychology at the University of Southampton in the United Kingdom, a Research Fellow at The Kinsey Institute for Research in Sex, Gender, and Reproduction, and a Research Fellow at the Rural Center for AIDS/STD Prevention, Indiana University. She is Editor-in-Chief of the Journal of Sex Research and is an editorial board member for the Journal of Sex and Marital Therapy and the International Journal of Sexual Health. She is a Chartered Psychologist, an Associate Fellow of the British Psychological Society, a Fellow of the Society for the Scientific Study of Sexuality, and was a member of the Sexual and Gender Identity Disorders Workgroup for DSM-5. She was elected President of the International Academy of Sex Research in 2009.

Although there is no universally accepted definition of orgasm (Mah & Binik, 2001), most proposed definitions incorporate both subjective experience and physiological changes. Unlike orgasm in the male, which is usually accompanied by ejaculation, there is no objective "marker" of orgasm in women, and there is no clear evidence that orgasm has a role to play in female reproductive fitness (Levin, 2011). Both the subjective experience of and the physiological changes associated with female orgasm are extremely varied (King, Belsky, Mah, & Binik, 2011; Meston, Levin, Sipski, Hull, & Heiman, 2004). Women also vary considerably in the age at which they first experience orgasm, the consistency with which they are able to reach orgasm, and the importance they attach to orgasm (Graham, 2010).

Medical and societal perspectives on female orgasm and about what constitutes a problem have shifted dramatically; the fact that we now recognize and treat lack of orgasm in women has been described as a "cultural accident" (Heiman, 2007). With very few exceptions (Brody, 2010), researchers and clinicians no longer make distinctions 90

between "clitoral" and "vaginal" orgasms or consider orgasms achieved through one type of stimulation more or less "mature" or healthy than another (Laan & Rellini, 2011). Indeed, there is no clear evidence that orgasms can be reliably distinguished by the type or pattern of stimulation that is associated with them (Prause, 2011).

Women show wide variability in the type and intensity of stimulation that induces orgasm (American Psychiatric Association, 2013). Although orgasms are most commonly induced by genital stimulation, other types of nongenital stimulation, including imagery, can produce orgasms in some women (Komisaruk & Whipple, 2011). There is consistent evidence that women reach orgasm more easily by themselves than during partnered sexual activity (Laumann, Paik, & Rosen, 1999; Zietsch, Miller, Bailey, & Martin, 2011). Women who experience orgasm through clitoral stimulation but not during sexual intercourse do not meet Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria for female orgasmic disorder (FOD; American Psychiatric Association, 2013).

Orgasm problems most commonly present as delay or absence of orgasm, although a minority of women (6–15% in epidemiological surveys) report reaching orgasm too quickly (Laumann et al., 1999; Richters, Grulich, de Visser, Smith, & Rissel, 2003). The DSM classification of FOD (American Psychiatric Association, 2013) distinguishes between lifelong versus acquired subtypes (if the orgasm difficulties develop only after a period of normal functioning) and generalized versus situational subtypes (if the orgasm difficulties are limited to certain types of stimulation, situations, or partners) and includes a specification for a woman never having experienced an orgasm under any situation. Somewhat different terminology has been used in the clinical literature, in which "primary" anorgasmia (to refer to lifelong) and "secondary" (to denote situational or acquired orgasmic problems) have been used. Secondary FOD thus includes women who experience orgasm only during masturbation or only with specific sexual partners, as well as those who no longer experience orgasm at all but who have done so in the past. Secondary FOD is believed to be more common and more difficult to treat than primary FOD (Heiman, 2007).

**EPIDEMIOLOGY**

Determining the prevalence of female orgasmic problems is difficult, in part because the methods of evaluation and the time periods assessed have varied widely in epidemiological surveys (Graham, 2010). Moreover, although many researchers claim to have used standardized diagnostic criteria (e.g., DSM or International Classification of Diseases and Related Health Problems [ICD-10; World Health Organization, 1992]) to identify women with orgasmic disorders, few surveys have assessed the presence of clinically significant distress or the absence of other nonsexual mental disorders (both essential criteria for a DSM diagnosis of FOD). Although more recent surveys have included questions on distress regarding sexual difficulties (Bancroft, Loftus, & Long, 2003; Oberg, Fugl-Meyer, & Fugl-Meyer, 2004; Shifren, Monz, Russo, Segreti, & 91

Johannes, 2008; Witting et al., 2008), these have still rarely assessed distress regarding specific sexual difficulties—for example, orgasmic problems.

It has been argued that the detailed clinical assessment needed to diagnose a sexual dysfunction cannot be undertaken by large-scale surveys (Graham & Bancroft, 2006).

For example, in DSM-5 a diagnosis of FOD is not made if the orgasmic difficulties are considered the result of inadequate sexual stimulation, yet epidemiological surveys have rarely included assessment of the adequacy of sexual stimulation a woman receives.

Although what constitutes "adequate" stimulation will vary across women (Brotto, Bitzer, Laan, Leiblum, & Luria, 2010) and is necessarily dependent to some extent on clinician judgment, establishing whether orgasmic problems are due to inadequate sexual stimulation remains a fundamental (albeit very difficult) task for the clinician (Laan & Rellini, 2011). The estimates from epidemiological surveys should therefore be seen as providing evidence on the prevalence of orgasmic difficulties or problems rather than on FOD or dysfunction (Richters et al., 2003).

In a review of the prevalence of female orgasmic problems reported in 11 surveys, all of which used nationally representative samples, Graham (2010) observed rates of between 3 and 34%. Considering the evidence on orgasmic disorder from European surveys, Fugl-Meyer and Fugl-Meyer (2006) concluded, "the prevalence . . . appears to vary so widely that at the moment there is no conclusive evidence" (p. 35). The few cross-cultural data available suggest even wider prevalence estimates; in the Global Survey of Sexual Attitudes and Behaviors (Laumann et al., 2005), the prevalence of

"inability to reach orgasm" reported by women ranged from 17.7% (in northern Europe) to 41.2% (in Southeast Asia).

The duration of the symptoms, the length of the recall period, and whether distress concerning the orgasmic problem is assessed all affect prevalence rates of orgasmic difficulties (Graham, 2010; Hayes, Dennerstein, Bennett, & Fairley, 2008). A consistent finding has been that only about half of women who are unable to reach orgasm report associated distress (King, Holt, & Nazareth, 2007; Oberg et al., 2004; Shifren et al., 2008).

In the United Kingdom National Survey of Sexual Attitudes and Lifestyles (NATSAL), although 14.4% of women reported orgasm problems that lasted at least 1 month, only 3.7% had persistent problems (defined as lasting at least 6 months in the previous year; Mercer et al., 2003). In a U.S. survey involving 31,581 women, although the age-adjusted prevalence of "low orgasm" was 21.8%, the prevalence of orgasm problems with associated distress was only 3.4% (Shifren et al., 2008). In another U.S. study, physical aspects of sexual response (including orgasm) were relatively weak predictors of distress, and only 30–50% of women (depending on age, with older women less distressed than younger women) who did not experience an orgasm reported marked distress about their sexual relationships (Bancroft et al., 2003).

Women clearly differ in how important orgasm is to their sexual satisfaction. In a U.S. national sample of heterosexual women ages 20–65 years, 29.1% rated having an orgasm as very or extremely important to their "sexual happiness" (in contrast, 83.2%

rated feeling "emotionally close to my partner" as very or extremely important; Bancroft, Long, & McCabe, 2011). Laan and Rellini (2011) made the interesting suggestion that some women may report orgasms during partnered sex as being 92

relatively unimportant because they do not consistently experience orgasms in this way and that women who reach orgasm more easily might also rate orgasm as more important.

Few surveys have assessed the prevalence of orgasm difficulties in older women, but these have suggested higher prevalence rates than in younger women (Heiman et al., 2011; Levine, Williams, & Hartmann, 2008; Lindau et al., 2007). In a nationally representative sample of 1,550 U.S. women ages 57–85 years, 34% of those who were sexually active reported anorgasmia for "several months or more" during the previous 12 months (Lindau et al., 2007). Even less is known about the frequency of orgasm problems experienced by younger women (i.e., those in late adolescence or early adulthood), but the limited data suggest that inability to orgasm is the most common persistent difficulty in this age group (OSullivan & Majerovich, 2008). Although the proportion of women who report having experienced orgasm does increase with age (Kinsey, Pomeroy, Martin, & Gebhard, 1953), there have been conflicting findings on the association between age and orgasm problems. Some studies have reported that younger women had a greater likelihood of orgasmic difficulties than older women (Laumann et al., 1999), others have found no relationship between age and orgasm problems (Oberg et al., 2004), and some have reported that older women were more likely to report inability to reach orgasm than younger women (Richters et al., 2003).

Kinsey et al. (1953) estimated that approximately 9% of women did not experience orgasm through their lifetimes. Although the prevalence of orgasm difficulties is difficult to ascertain, clinic-based studies most often cite orgasm problems as the second most common presenting complaint in women (with low sexual interest as the most frequent; Robinson, Munns, Weber-Main, Lowe, & Raymond, 2011). It has been suggested that women with orgasm problems present less frequently now than when sex therapy was first introduced in the 1970s (Heiman, 2007; Robinson et al., 2011).

Factors that have been consistently associated with the likelihood of a woman experiencing orgasm difficulties include poor physical and mental health (Bancroft et al., 2003; Laumann et al., 1999; Richters et al., 2003) and relationship difficulties/partner variables (Goldhammer & McCabe, 2011; Kelly, Strassberg, & Turner, 2004). Witting et al. (2008) investigated sexual function, compatibility with partner, and sexual distress in a population-based Finnish sample of 5,463 women. Orgasm dysfunction decreased with age and with relationship length. All of the partner-compatibility items (too little foreplay; poor communication; partner more interested in sex than you are; you and/or your partner cannot do things "the right way" during sexual activity; you and/or your partner have sexual needs that you/he do not want to satisfy; partner is unattractive; partner has erection problems; partner has problems with early ejaculation) were associated with orgasm dysfunction. All partner-compatibility items (in particular, poor communication) were significantly associated with distress about sex.

There is evidence of a high degree of comorbidity between FOD and other sexual difficulties, particularly problems with arousal, vaginal dryness, and sexual desire (Basson, 2002; Fugl-Meyer & Fugl-Meyer, 2002; Nobre, Pinto-Gouveia, & Gomes, 2006). On the basis of this comorbidity, as well as the overlap between womens experiences of sexual arousal and sexual desire (Brotto, 2010; Graham, 2010), some have 93

argued that we should consider reconceptualizing orgasmic problems not as a separate discrete category but as more of a "global" or arousal-related problem (Basson, 2002; Hartmann, Heiser, Ruffer-Hesse, & Kloth, 2002). These suggestions are highly relevant to the merging of the categories of desire and arousal disorders in DSM-5 (Brotto, 2010; Graham, 2010).

**ASSESSMENT AND DIAGNOSTIC ISSUES**

**Assessment Issues**

In identifying whether a problem is primarily orgasmic, it is important to first establish that sexual arousal has occurred. Details about sexual repertoire during partnered sex, in particular the adequacy of stimulation received from a partner, and information about a partners sexual functioning should be obtained. It is also important to keep in mind that some women are unsure whether or not they have experienced an orgasm. Heiman (2007) suggested that an agreed-upon subjective definition of orgasm was an important starting point in assessment.

Comorbidity of sexual difficulties in partners is common. There is some evidence, for example, that women are more likely to experience orgasm difficulties when their male partners have premature ejaculation (Hobbs, Symonds, Abraham, May, & Morris, 2008). When one partner receives individual therapy for a sexual problem, there is often also improvement in sexual functioning in the other partner (Heiman et al., 2007).

Although there are now a number of validated psychometric instruments designed to assess womens sexual functioning and although almost all of these include questions on orgasm, most clinicians would not use these in place of a detailed, broad-based clinical interview (Brotto et al., 2010). For women in a relationship, interviews should ideally be conducted with both partners, separately and together, and the aim should be to try to establish predisposing, precipitating, and maintaining factors for the orgasm difficulties.

Possible contributing biological, psychosocial, and contextual factors (including cultural and religious beliefs/values) should all be explored. History of physical illness, surgery, and medical use should be carefully assessed (see Brotto et al., 2010, for a comprehensive list of factors typically included in an assessment).

Questions about attitudes toward masturbation and masturbation history should be included, including the type of stimulation used during masturbation. As is discussed later, masturbation is an important component in most treatment approaches for FOD.

Clinicians should, however, be sensitive to the fact that sometimes for cultural and religious reasons some women will not be open to engaging in masturbation. Although gender differences in sexual attitudes and behavior are narrowing, women are still less likely to masturbate than men and report engaging in masturbation less frequently (Petersen & Hyde, 2011). Kinsey and colleagues interview data suggested that women who masturbated to orgasm before marriage were more likely to reach orgasm during intercourse with their husbands than women who had never masturbated (Kinsey et al., 94

1953).

Also relevant to assess are expectations that a woman (and her partner) hold about female orgasm. In a qualitative study of women ages 19–60 years, the participants expressed a strong desire to experience orgasm through heterosexual intercourse in order to please their partners (Nicolson & Burr, 2003). Many individuals adhere to rigid sexual scripts dictating that women should orgasm before their male partner and that men are responsible for "bringing" their female partners to orgasm (Muehlenhard & Shippee, 2010). The strong media messages about the importance of orgasm for women may also engender unrealistic expectations and pressure on women to have orgasms.

As discussed earlier, the presence of a womans distress about experiencing infrequent or absent orgasm should be carefully assessed. In a U.K. study of women attending general practice clinics, although 18% of the women met ICD-10 criteria for orgasmic dysfunction, only 8% met criteria and also perceived that they had a sexual problem. An even smaller proportion (5%) met diagnostic criteria and reported that their anorgasmia was a "somewhat" or "very" distressing problem (King et al., 2007).

One study that focused on predictors of womens distress about their "own sexuality" or about their sexual relationship found that orgasmic frequency was not a significant predictor of distress; the best predictors were measures of general emotional well-being and the womans emotional relationship with the partner during sexual activity (Bancroft et al., 2003).

For a clinician seeing women presenting with acquired orgasmic difficulties, one crucial task of assessment is to consider to what extent a change in the womans experience of orgasm is an understandable, and perhaps even adaptive, response to adverse conditions in her life or in her relationship (Graham & Bancroft, 2009). The

"three windows approach" (Bancroft, 2009) provides a useful framework to assess this.