To consider situationally non-orgasmic, a woman must have experienced at least one instance of orgasmic expression, regardless of whether it was induced by self or by partner manipulation, developed during vaginal or rectal coital connection, or stimulated by the oral-genital exchange.

Orgasmic experience during homosexual encounters would rule out any possibility of a diagnosis of primary orgasmic dysfunction. Three arbitrary categories of situational sexual dysfunction have been defined as masturbatory, coital, and random orgasmic inadequacy.

A woman with masturbatory orgasmic inadequacy has not achieved orgasmic release by partner or self-manipulation in either homosexual or heterosexual experience. She can and does reach orgasmic expression during coital connection.

Coital orgasmic inadequacy applies to the great number of women who have never been able to achieve orgasmic return during coition. The category includes women able to masturbate or to be manipulated to orgasmic return and those who can respond to orgasmic release from oral-genital or other stimulative techniques.

The random orgasmic-inadequacy grouping includes those women with histories of orgasmic return at least once during both manipulative and coital opportunities. These women are rarely orgasmic and usually are aware of little or no physical need for sexual expression.

For Example:

They might achieve orgasmic return with coital activity on a vacation, but never while at home. Occasionally these women might masturbate to orgasm if separated from a sexual partner for long periods of time. Usually, when they obtain orgasmic release, the experience is as much of a surprise to them as it is to their established sexual partner.

The situational non-orgasmic state may best be described by again pointing out the varying levels of dominance created by the biophysical and the psychosocial structures of influence. If the woman’s sexual value system reflects sufficiently negative input from prior conditioning psychosocial influence, she may not be able to adapt sexual expression to the positive stimulus of the particular time, place, or circumstance of her choosing nor develop a responsive reaction to the partner of her choice.

If that part of any woman’s sexual value system susceptible to the influence of the biophysical structure is overwhelmed by a negative input from pain with any attempted coital connection, there rarely will be an effective sexual response.

Thus there is a multiplicity of influences thrown onto the balance wheel of female sexual responsivity. Fortunately, the two major systems of influence accommodate these variables through involuntary interdigitation. If there were not the probability of admixture of influence, there might be relatively few occasions of female orgasmic experience.

Sexual Partner

A major source of orgasmic influence for both primarily and situationally dysfunctional women is partner orientation. What value has the male partner in the woman’s eyes? Does the chosen male maintain his image of masculinity? Regardless of his acknowledged faults, does he meet the woman’s requirements of character, intelligence, ego strength, drive, physical characteristics, etc.?

Obviously, every woman’s, partner requirements vary with her age, personal experience and confidence, and the requisites of her sexual value system.

The two case stories below underscore the variables of a woman’s orientation to her male sexual partner. The histories of Mr. and Mrs. E and Mr. and Mrs. F are presented, to emphasize that a potential exists for radical change in attitudinal concepts during the course of any marriage.

Mr. and Mrs. E

were referred for treatment of orgasmic dysfunction after 23 years of marriage. They had two children, a girl 20 and a boy 29.

The history of sexual dysfunction dated back to the twelfth year of the marriage. Both had relatively unremarkable backgrounds to family, education, and religious influences.

Both had masturbated as teenagers and had intercourse with other partners and with each other before marriage. Mrs. E usually had been orgasmic during these coital opportunities with her husband-to-be and with two other partners.

During the first twelve years of the marriage, the couple prospered financially and socially and had many common interests. Their sexual expression is resolved into an established pattern of sexual release two or three times a week.

There was the regularity of orgasmic return and frequently multi-orgasmic return during intercourse. During the twelfth year of the marriage, the unit experienced a severe financial reversal. Mr. E was discharged from his position with the company that had employed him since the start of the marriage.

In the following 18 months, he was unsuccessful in obtaining any permanent type of employment. He became chronically depressed and drank too much. The established pattern of couple sexual encounter was either quite reduced or, on occasions, demandingly increased.

Husband Extramarital Relationship

Then Mrs. E found that her husband was involved in an extramarital relationship and confronted him in the matter. A bitter argument followed, and she refused him the privilege of the marital bed. This sexual isolation lasted for approximately six months, during which time.

Mr. E began working again, regained control of his alcohol intake, and terminated his extramarital interest. For the duration of this isolation period, Mrs. E had no coital opportunity and did not masturbate. When the privilege of the bedroom was restored, to her surprise she was distracted rather than stimulated by her husband’s sexual approaches and was not orgasmic.

She had lost confidence in her husband not only as an individual but also as a masculine figure. Mrs. E found herself going through the motions sexually. From the time the bedroom door was reopened until the unit was seen in therapy, she was non-orgasmic regardless of the mode of sexual approach. The coital connection had dwindled to a ten-day to the two-week frequency of “wifely duty.”

When a major element in any woman’s sexual value system (partner identification in this instance) is negated or neutralized by a combination of circumstances, many women find no immediate replacement factor. Until they do, their facility for sexual responsivity frequently remains jeopardized.

When Mr. E combined loss of his masculine image as the provider with excessive alcohol intake and, also, acquired another sexual partner, he destroyed his wife’s concept of his sexual image, and, in doing so, removed from availability a vital stimulative component of her sexual value system. The negative input of psychosocial influence created by Mr. E’s loss of masculinity and impairment of her sense of sexual desirability was sufficient to inhibit her natural sexual responsivity.

Mr. and Mrs. F

were referred for treatment six years after they married when he was 29 and she was 24 years old. They had one child, a girl, during their third year together. Mrs. F Was from a family of seven children and remembers a warm community experience in growing up with harried but happy parents.

Mr. F had exactly the opposite background. He was an only child in a family where both father and mother devoted themselves to his every interest, in short, the typical overindulged single child.

He had masturbated from early teens, had some sexual experiences, and one brief engagement with coital connection maintained regularly for six months before he terminated the commitment. Mrs. F, although she dated regularly as a girl, was fundamentally oriented to group-type social commitments. She rarely had experienced single dating.

The school years were uneventful for both individuals. They met and married almost by accident. When they first began dating, each was interested in someone else. However, their mutual interest increased rapidly and developed into a courtship that included regularity of coital connection for three months before marriage.

Every social decision was made by Mr. F during the courtship. The same pattern of total control continued into marriage. He insisted on making all decisions and was consistently concerned with his own demands, paying little or no attention to his wife% interests. Constant friction developed, as is so frequently the case with marital partners whose backgrounds are opposed.

Mrs. F had not been orgasmic before marriage. In marriage, she was orgasmic on several occasions with manipulation but not during coition. As the personal friction between the marital partners increased, she found herself less and less responsive during active coital connection.

Pregnancy intervened sex

There was an occasional orgasmic success with manipulation. Pregnancy intervened at this time, distracting her for a year, but thereafter her lack of coital return was distressing to her and most embarrassing to her husband.

He worried as much about his image as a sexually effective male as he did about his wife’s levels of sexual frustration. Mrs. F’s lack of effective sexual response was considered a personal affront by her uninformed husband.

They consulted several authorities on the matter of her sexual inadequacy. The husband always sent his wife to authority to have something done to or for her. The thought that the situation might have been in any measure his responsibility was utterly foreign to him.

When the unit was referred for therapy he at first refused to join her in treatment on the basis that it was her problem. When faced with the Foundation demand that both partners cooperate or the problem would not be accepted for treatment, Mr. F grudgingly consented to participate.

Little comment is needed. This intentionally brief history is typical of the woman who cannot identify with her partner because he will not allow such communication. There is no world as dosed to the vital ingredient of marital expression as that of the world of the indulged only child.

Particularly is this attitudinal background incomprehensible to a woman with a typical large family orientation. When Mr. F failed to accord his wife the representation of her own requirements, she had no opportunity to think or feel sexually. The catalytic ingredient of mutual partner involvement was missing.

Although emphasis has been placed upon the role of premature ejaculation in the etiology of primary orgasmic dysfunction, primary or secondary impotence also contributes. Again the basic theme of man and woman coital interaction must be emphasized.

If there is not a sexually effective male partner, the female partner has the dual handicap of fear for her husband’s sexual performance as well as for her own.

If there is no penile erection there will be no effective coital connection.

Frequently women married to impotent men cannot accept the idea of developing a masturbatory facility or being manipulated to orgasm as a substitute for tension release.

However, if there has been a masturbatory pattern established before coital inadequacy assumes dominance, most women can return to this sexual outlet. In this situation, there is sufficient dominance of the previously conditioned biophysical structure to overcome negative input from a psychosocial system distressed by sexual performance fears.

But if there have been no previous substitute measures established, many women cannot turn to this mode of relief once impotence halts effective coital connection. In this situation, the psychosocial structure, unopposed by prior biophysical conditioning, assumes the dominant influence in the woman’s sexual response pattern.

Mr. and Mrs. D

were referred to the treatment of orgasmic inadequacy after four years of marriage. When seen in therapy she was 27 and her husband 43 years old. He had been married twice previously. There were children of both marriages and none in the current marriage.

The husband also was sexually dysfunctional in that he was secondarily impotent.

His second marriage had been terminated due to his inability to continue the effective coital connection. Although, when the unit was seen in consultation the marriage had been consummated, coitus occurred only once or twice a year.

Mrs. D’s background reflected somewhat limited financial means. Her father had died when the three siblings were young, and the family had been raised by their mother, who worked while the grandmother took care of the children.

Clothes were hand-me-downs, food the bare essentials. Her education had of necessity terminated with high school, and she worked as a receptionist in several different offices befo3e her marriage. She continued to live at home while working and contributed to what salary she made to help with the family’s limited income.

Mrs. D met her future husband when he visited the office where she worked. He invited the young woman to lunch. She accepted and married him four months later without knowledge of his sexual inadequacy, although she had been somewhat puzzled by his lack of forceful sexual approach during the brief courtship.

Mrs. D’s own sexual history had been one of a few unsuccessful attempts at masturbation, numerous petting episodes with boys in and out of high school, but no attempted coital connection. She had never been orgasmic.

Her husband had inherited a large estate and his financial situation certainly was the determining factor in his wife’s marital commitment. Since the girl had been distressed by a family background of genteel poverty, she felt the offer of marriage to be her real opportunity both to escape her environment and to help her two younger siblings.

The wedding trip was an unfortunate experience for Mrs. D when she realized for the first time that her husband had major functional difficulties. She knew little of male sexual response beyond the petting experiences but did try to help him achieve an erection by a multiplicity of stimulative approaches in his direction. There was no success in erective attainment.

The marriage was not consummated until six months after the ceremony. In the middle of the night, Mr. D awoke with an erection, moved to his wife, and inserted the penis. She experienced mild pain but reacted with pleasure, feeling that progress had been made.

However, following the usual pattern of .a secondarily impotent male, progress was fleeting. As stated, there were only a few other coital episodes in the course of the four-year marriage. In these instances, she always was awakened from sleep by her husband when he awoke to find himself with an erection.

Quick Ejaculation

Then there was rapid intromission and quick ejaculation. There was no history of a successful sexual approach by her husband under her conscious direction, insistence, or stimulation. Mr. D tried repetitively during long-continued manipulative and oral-genital sessions to bring his wife to orgasm, without result.

When they were referred for treatment, neither husband nor wife described sexual activity outside the marriage.

There have been 193 women treated for primary orgasmic dysfunction during the past 11years. Basically, in this method of therapy, the sexually dysfunctional woman is approached through her sexual value system.

If its requirements are non-serving limited, unrealistic, or inadequate to the marital relationship-by suggestion she is given an opportunity, with her husband’s help, to manipulate her biophysical and psychosocial structures of influence until an effective sexual value system is formed.

Sexual Lubrication

Probably the most frequent cause for dyspareunia originating with symptoms of burning, itching, or aching is a lack of adequate production of vaginal lubrication with sexual functioning.

During attempted penile intromission or with long-maintained coital connection, there must be adequate lubrication or there will be irritative distress for either or both coital partners.

Adequate production of vaginal lubrication is for women the physiological equivalent of erective attainment for men and her representation to her male partner of psychological readiness for vaginal penetration.

A consistent lack of functional levels of vaginal lubrication is as near as any woman can come to paralleling a man’s lack of effective erection.

Inadequate development of vaginal lubrication has many causes, but by far the most common is lack of interest in the particular opportunity or identification with the involved sexual partner. Women must experience positive input from their sexual value systems if they are to respond repetitively and effectively to their mate’s sexual approaches.

Women who cannot think or feel sexually, those reflecting fears of sexual performance, and even those acting out a spectator’s role in sexual functioning, either do not develop sufficient vaginal lubrication to support a painless coital episode or, if penetrated successfully, they cease production of the necessary lubricative material shortly after intravaginal penile thrusting is initiated.

Deep Penetration

Additionally, women fearful of pain with deep vaginal penetration, fearful of pregnancy with any coital connection, fearful of exposure to social compromise, and fearful of sexual inadequacy are frequently poor producers of vaginal lubrication. Any Component of fear present in sexual experiences reduces the receptivity to sensate input, thereby blunting biophysical responsivity.

If there is insufficient vaginal lubrication, there may or may not be acute pain with full penile intromission, depending primarily upon the parity of the woman, but they’re usually will be vaginal burning, irritation, or aching both during and after coital connection.

There are tens of thousands of women who become markedly apprehensive at the onset of any definitive sexual approach, simply because they know severe vaginal irritation will be experienced not only during but frequently for hours after any significantly maintained coital connection.

Not to be forgotten as a specific segment among the legions of women afflicted by inadequate production of vaginal lubrication are those in their postmenopausal years. If they are not supported by adequate sex-steroid-replacement techniques, the production of vaginal lubrication usually drops off markedly as the vaginal mucosa routinely turns atrophic.

There well may be aching and irritation in the vagina for a day or two after a coital connection for women contending with this evidence of sex-steroid starvation.

A major category of women tending to be poor lubrication producers during coital connection is that a significant segment of the female population with overt lesbian orientation. Many women psychosexually committed to a homophile orientation attempt regularity of coital connection for socioeconomic reasons. Frequently, they may not lubricate well during heterosexual activity, although there usually is ample lubrication when they are directly involved in the homosexual expression.

In most instances:

Inadequate production of vaginal lubrication can be reversed with a definite therapeutic approach. Certainly, women burdened by a multiplicity of sex-oriented fears can be provided psychotherapeutic relief of their phobias and subsequently reversed with relative ease from their particular pattern of sexual inadequacy.

Those women with chronic vaginal itching and irritation can be protected from continuing dyspareunia because both infectious and chemical vaginitis are reversible under proper clinical control. Senile vaginitis responds in short order to adequate sex-steroid-replacement techniques.

There are only two major categories of women for whom the co-therapists have little to offer to constitute effective production of vaginal lubrication: first, women mated to men for whom they have little or no personal identification, understanding, affection, or even sexual respect; and second, homosexually oriented women practicing coition for socioeconomic reasons with no interest in their male companions as sexual partners.

Undesired Sex

As opposed to the symptoms of aching, irritation, or burning in the vagina, complaints of severe pain developed during penile thrusting provide the most difficulty in delineating between subjective and objective etiology.

Although many women register this type of complaint when seeking to avoid undesired sexual approaches, there are some basic pathological conditions in the female pelvis that can and do engender severe pain in response to active coital connection.

One of the difficulties in delineating the severity of the complaint of dyspareunia is to identify pelvic pathology of a quality sufficient to support the female partner’s significant complaints of painful coition. The pelvic residual from severe infection or pelvic implants of endometriosis usually is easily identified by adequate pelvic and rectal examinations.

These clinical entities will be discussed briefly in context later in the topic. Current attention is drawn to probably the most frequently overlooked of the major physiological syndromes creating intense pelvic pain during coital connection.

One of the most obscure of pelvic pathological syndromes, yet one of the most psychosexually crippling, is traumatic laceration of the ligaments supporting the uterus. This syndrome was described clinically. Five women have been referred to the Foundation for relief of subjective symptoms of dyspareunia after referral sources had assured the husbands that there was no plausible physical reason for the constant complaint of severe pain with deep penile thrust.

These 5 postpartum women had severe broad ligament lacerations and were relieved of their distress by definitive surgical approaches, not by psychotherapy. Therefore, they do not represent a component of the statistical analysis of treatment for sexual dysfunction.

Three women reflecting the onset of dyspareunia after criminal abortion techniques also have been seen in consultation and are not reflected in the statistics of the sexual inadequacy study. Three more women have been seen in gynecological consultation for acquired dyspareunia after gang-rape experiences.

They also have not been an integral part of the sexual-dysfunction study. These clinical problems will be mentioned in context. When first seen clinically, women with traumatic lacerations of the uterine supports, acquired with delivery or by specific criminal abortion techniques, present complaints that commonly accrue from pelvic vasocongestion, dyspareunia, dysmenorrhea, and a feeling of being excessively tired.

These complaints are secondary or acquired in nature. The traumatized women consistently can relate the onset of their acquired dyspareunia to one particular obstetrical experience even from among three or four such episodes.

The basic intercourse distress arises with deep penetration of the penis. Women describe the pain associated with intercourse to be as if their husbands had “hit something” with the penis during deep vaginal penetration.

These involved women may note other physical irritations frequently seen with chronic pelvic vasocongestion, a constantly nagging backache, throbbing or generalized pelvic aching, and occasionally, a sense that “everything is falling out.”

These symptoms are made worse in any situation requiring a woman to be on her feet for an exceptional length of time, as a full day spent doing heavy housecleaning or working as a saleswoman in a department store.

Most women lose interest in any regularity of sexual expression when distressed by acquired dyspareunia. Handicapped by constant anticipation of painful pelvic stimuli created by penile thrusting, they also may lose any previously established facility for orgasmic return.

The basic pathology of the syndrome of broad ligament laceration is confined to the soft tissues of the female pelvis. The striking features of the pelvic examination are the position of the uterus and almost always in severe third-degree retroversion and the particularly unique feeling that develops for the examiner with manipulation of the cervix.

This portion of the uterus feels just as if it were being rotated as a universal joint. It may be moved in any direction, up, down, laterally, or on an anterior-posterior plane with minimal, if any, correspondingly responsive movement of the corpus and body of the uterus.

Even the juncture of the cervix to the lower uterine segment is ill-defined. The feeling is one of an exaggerated Hegar’s sign of early pregnancy, in which the cervix appears to move in a manner completely independent of the attached corpus.

In addition to the “universal joint” feeling returned to the examiner when moving the cervix, a severe pain response usually is elicited by any type of cervical movement. However, pain is primarily occasioned by pushing the cervix in an upward plane.

In the more severe cases, either in advanced bilateral broad ligament laceration or in a presenting complaint of five years or more in duration even mild lateral motion of the cervix will occasion a painful response. During the examination, the retroverted uterus appears to be perhaps twice increased in size.

Pressing against the corpus in the cul-de-sac to reduce the third-degree retroversion also will produce a marked pain response. When the examiner applies upward pressure on the cervix or pressure in the cul-de-sac against the corpus, the patient frequently responds to the painful stimulus by stating, “It’s just like the pain I have with intercourse.”

A detailed obstetrical history is a salient feature in establishing the diagnosis of the broad ligament laceration syndrome. The untoward obstetrical event creating the lacerations may be classified as surgical obstetrics, as an obstetrical accident, or even as a poor obstetrical technique.

Occasionally, women with both the positive pelvic findings and the subjective symptoms of this syndrome cannot provide a positive history of obstetrical trauma, but this situation does not rule out the existence of the syndrome.

Many women are unaware of an unusual obstetrical event because they were under advanced degrees of sedation or even full anesthesia at the time.

Precipitate deliveries, difficult forceps deliveries, complicated breech deliveries, and postmature-infant deliveries are all suspect as obstetrical events that occasionally contribute to tears in the maternal soft parts.

If these tears are established in the supports of the uterus (broad ligaments) the immediate postpartum onset of severe dyspareunia can be explained anatomically and physiologically. It is important to emphasize clinically that although a woman may not be able to describe a specific obstetrical misfortune in her history, she well may be able to date the onset of her acquired dyspareunia to one particular obstetrical event.

Three cases have been seen in which a criminal abortion was performed by extensively packing the vaginal barrel, leading ultimately to dilation of the cervix and expulsion of uterine content.

These extensive vaginal-packing episodes created tears of the broad ligaments, completely parallel to those occasioned by actual obstetrical trauma. Each woman, although unaware of the etiological significance, dated the onset of the symptoms of acquired dyspareunia to the specific experience with the vaginal-packing type of abortive technique.