Category: Women’s Health

For many women, one of the most frequent causes for orgasmic dysfunction, either primary or situational, is a lack of complete identification with the marital partner.

The husband may not meet her expectations as a provider. He may have physical or behavioral patterns that antagonize.

Most Important

He may stand in the place of the man who had been much preferred as a marital partner but was not available or did not choose to marry the distressed woman. For myriad reasons, if the husband is considered inadequate according to his wife’s expectations, a negative dominance will be created in the psychosocial structure of many women.

Such a situation is exemplified by the following:

Mr. and Mrs. C

were 46 and 42 years of age, respectively, when referred to the Foundation. The wife complained of a lack of orgasmic return. The couple had been married 19 years when seen in treatment. The marriage was the only one for either partner. There were three children, the eldest of whom was 17, the youngest 12. There were barely adequate financial circumstances.

Mrs. C’s adolescent background had been somewhat restrictive. Her mother was a dominant woman with whom she developed little rapport. Her father died when she was 9 years old. There was one other sibling, a sister 8 years younger. Mrs. C went through the usual high school preparation, had two years of college, and then withdrew to take secretarial training and go to work in a large manufacturing company.

During her formative years, there were several friends, none of them particularly close except for one girl with whom she shared all her confidences. Mrs. C as a girl was fairly popular with boys, dated with regularity, and went through the usual petting experiences, but decided to avoid coital connection until marriage. She had no masturbatory history but described pleasure in the petting experiences, although she was not orgasmic.

Shortly after her twenty-second birthday, she fell in love with a young salesman for the company in which she worked. Theirs was a very happy relationship with every evidence of real mutuality of interest. She came to know and thoroughly enjoy his family, and they made plans to marry.

Three weeks before the marriage, her fiance, on a business trip, met and a week later married another woman, a divorced with two children. The jilted girl was crushed by the turn of events. This had been her only serious romantic attachment, and it had been a total commitment on her part.

Their Sexual Expression: petting and manipulated her fiance to ejaculation regularly.

Although she had been highly stimulated by his approaches she had not been orgasmic. The coital connection had not been attempted.

Six months later she married Mr. C, whom she thought kind and considerate. Their sexual experiences together were pleasant, but she achieved nothing comparable to the high levels of excitation provided by the first man in her life.

She described life with her husband as originally a good marriage. The children arrived as planned and the husband continued to progress satisfactorily in his business ventures, but husband and wife had very few mutual interests.

As the years passed Mrs. C became obsessed with the fact that she had never been orgasmic. She began to masturbate and reached high levels of excitation. Straining and willing orgasmic return without being able to fully accept the unrealistic nature of her imagery and fantasying, she failed, of course, in accomplishment.

Inexperience Husband

Her husband, with very little personal sexual experience other than in his marriage, had no real concept of an effective sexual approach. She repeatedly tried to tell him of her need, but his cooperative effort, maintained for only brief periods of time, was essentially unsuccessful.

After 12 years of marriage, Mrs. C sought sexual release outside the marriage with a man sexually much more experienced than her husband.

He did excite her to high plateau levels of sexual demand, but she always failed to achieve orgasmic release. This connection lasted off and on for a year and was only the first of several such extramarital commitments, always with the same disappointment in sexual return.

She was never able to avoid the fantasy of her former fiance whenever she approached orgasmic return, but her fantasy included a primarily negative impetus. Her frustration at “marrying the wrong man” was a constant factor in her coital encounters, as it was in most other aspects of her life.

As time passed she blamed her husband increasingly for her lack of orgasmic facility and became progressively more discontented with her lot in the marriage. She began to find fault with his financial return and social connections.

In short, Mrs. C felt that her husband was not providing satisfactorily for her needs and inevitably compared him with the man “she almost married.” This man had become a relatively well-known figure in the local area, had done extremely well financially, and apparently had a happy, functioning marriage.

Although Mrs. C never saw her former fiance, she constantly dwelt on what might have been, to the detriment of the ongoing relationship. Mrs. C sought psychiatric support for her non-orgasmic status but was unable to achieve the only real goal in her life, orgasmic release.

Finally, the husband and wife were referred to the Foundation to overcome professionally the conditioning of an adult lifetime and to cope with the requirements of her sexual value system impaired by the trauma it sustained when she was jilted by a man with whom she identified totally.

It is necessary to adjust to both her social and her sexual value systems be made in the hope of reversing or at least neutralizing the negative input of her psychosocial structure. There is no possible means of restructuring the negative input from “I married the wrong man” unless the problem is attacked directly.

First, in private sessions, the immature deification of her former fiance must be underscored.

Second, Mr. C must be presented to his wife in a different light, not in a platitudinal manner, but as the female co-therapist objectively views him.

A man’s positive attributes as he appears in another woman’s eyes carry value to the dysfunctional woman. Then there must be stimulation of the biophysical structure to levels of positive input. This, of course, is initiated by sensate-focus procedures.

Finally, the contrived somatic stimulation must be interpreted to Mrs. C’s sexual value system both by the co-therapists and by her husband. If these treatment concepts are followed successfully there is every good chance to reach the goal of orgasmic attainment.

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.

Sexual Values

An interesting variation on this classification of repression should be mentioned. There were several primarily non-orgasmic women whose receptivity to the repressive conditioning was slightly different. Their own particular personality characteristics or their relationship to negatively directive authority was such that they fully accepted the concept of sexual rejection.

They developed pride in their ability to comply with sexual repression and did so with apparent social grace. Their selection of a mate in most cases represented a choice of similar background. The difficulty arose with marriage.

For example:

On the wedding night, a completely unrealistic, negative sexual value system usually was revealed during their attempt to establish an effective sexual interaction. These women reported either total pelvic anesthesia or isolation of sexual feelings from the context of psychosocial support.

Women entering therapy in a state of non-orgasmic return reflected the complete failure of any effective alignment of their biophysical and psychosocial systems of influence.

They had never been able to merge either their points of maximum biophysical demand or their occasions of maximum psychosocial need with optimum environmental circumstances of time, place, or partner response to fulfill the requirements of their sexual value systems.

Primary orgasmic dysfunction:

A condition whereby neither the biophysical nor the psychosocial systems of influence that are required for the effective sexual function is sufficiently dominant to respond to the psychosexually stimulative opportunities provided by self-manipulation, partner manipulation, or coital interchange.

If the concept of two interdigital systems influencing female sexual responsivity can be accepted, what can be considered the weaknesses and the strengths of each? Input required by either system for the development of peak response is, of course, subject to marked variation.

There may be some value in drawing upon the previously described psychophysiological findings returned from preclinical studies. As a human female response to subjectively identifiable sexual stimuli, reliable patterns of accommodation by one system to the other can be defined, and tend to follow basic requirements set by earlier imprinting.

Patterns of imprinting can be either reinforced or redirected by controlled experimental influence. They can also be diverted in their signaling potential by reorientation of a previously unrealistic sexual value system. The sexual value system, in turn, responds to reprogramming by a new, positive experience.

Variations in the human female’s bio-physical system are, of course, relative to basic body economy. Is the woman in good health? Is there a cyclic hormonal ebb and flow to which she is particularly susceptible? Are the reproductive viscera anatomically and physiologically within normal limits, or is there evidence of pelvic pathology? Is there evidence of broad-ligament laceration, endometriosis, or residual from pelvic infection?

Certainly, most forms of pelvic pathology would weigh against the effective functioning of the biophysical system. On the other hand, are there those biophysical patterns that tend to improve the basic facility of her sexual responsivity? Is there well-established metabolic balance, good nutrition, sufficient rest, the regularity of sexual outlet?

Each of these factors inevitably improves biophysical responsivity. There must be professional consideration of multiple variables when evaluating the influence of the biophysical system upon female sexual responsivity.

Overcome Sexual Difficulty

However, the system with the infinitely greater number of variables is that reflecting psychosocial influence. Most dysfunctional women’s fundamental difficulty is that the requirements of their sexual value systems have never been met. Consequently, the resultant limitations of the psychosocial system have never been overcome.

Many women specifically resist the experience of orgasmic response, as they reject their sexual identity and the facility for its active expression.

Often these women were exposed during their formative years to such timeworn concepts as sex is dirty, nice girls don’t involve themselves, sex is the man’s privilege or sex is for reproduction only.

There are also those whose resistance is established and sustained by a stored experience of mental or physical trauma, rape, dyspareunia which is signaled by every sexual encounter.

Again from a negative point of view, there may be extreme fear or apprehension of sexual functioning instilled in any woman by inadequate sex education. Any situation leading to sexual trauma, real or imagined.

During her adolescent or teenage years or her sexual partner’s, crude demonstration of his own sexual desires without knowledge of how to protect her sexually would be quite sufficient to create a negative psychosocial concept of a woman’s role in sexual functioning.

The woman living with residual of specific sexual trauma (mental or physical) frequently is encountered in this category.

Finally, there is the woman whose background forces her into automatic sublimation of psychosexual response. This individual simply has no expectations for sexual expression that are built upon a basis of reality. She has presumed that sexual response in some form simply would happen but has a little, idea of its source of expression.

In these instances, sexual sublimation is allowed to become a way of life for many reasons. Particularly is this reaction encountered in the woman who has failed to enjoy the privilege of working at being a woman.

The positive side:

The psychosocial value system can overcome physical disability with dominant identification that may be personal and/or situational in nature. In states of advanced physical disability, the strength of loved-partner identification can provide orgasmic impetus to a woman physically consigned to be sexually unresponsive.

When there has been a pattern of little bio-physical sexual demand, as in a postpartum period, sexual tension may be rapidly restored by the psychosocial stimulation of a vacation, anniversary, or other experience of special significance.

Again the biophysical and psychosocial systems of influence are interdigital in orientation, but there is no biological demand for their mutual complementary responsivity. It is in the areas of involuntary sublimation that the psychosocial system is gravely handicapped and would tend to exert a negatively dominant influence in contradistinction to any possible biophysical stimulative function.

For many women, a basic homophile orientation is a major etiological factor in heterosexual orgasmic dysfunction. For those women committed to homosexual expression, lack of orgasmic return from heterosexual opportunity is of no consequence.

But there are a large number of women with significant homosexual experience during their early teenage years that, in time, have withdrawn from active homophile orientation to living socially heterosexual lives.

When they marry, many are committed to orgasmic dysfunction by the prior imprinting of homosexual influence upon their sexual responsivity.

Prior homosexual conditioning acts to create a negatively dominant psychosocial influence. Their biophysical capacity, freely evidenced in homosexual opportunity, continues operant in their electively chosen heterosexual environment, but it may not be of sufficient quality to overcome the negative input from their psychosocial system.

It is difficult to evaluate homosexual influence upon heterosexual function. There can be no question that both means of sexual expression will always be an integral part of every culture. So it has been for recorded time.

The problems of sexual adjustment do not rest with those committed unreservedly to a specific pattern of response. Rather, it is the gray area dweller that creates for him or herself a sexually dysfunctional status.

When moving from one means of sexual expression to the other for the first time, the sexual value system must be reoriented if the desired transfer of sexual identification is to be completed. Such was the problem of Mrs. G who had not been able to adapt her sexual value system to her elected heterosexual world when seen in therapy.

Mr. and Mrs. G

were referred for treatment after seven years of marriage, she was 33, her husband 38 years old. The current marriage was his second, the first ending in divorce.

The presenting complaint was that Mrs. G had never been orgasmic in the marriage. Her childhood and adolescence were spent in-a small Midwestern town as an only child of elderly parents. Her mother was 41 when she was born.

Introverted as a teenager, the girl did well in school but had few friends and was not popular with male classmates. When she was 15 years old she formed a major psychosexual attachment to a high-school teacher, who seduced the girl into a homosexual relationship.

The courtship continued for six months before physical seduction was accomplished. Once fully committed to the homosexual relationship, the girl matured rapidly in personality and took a great deal more care with her dress and person. She vested total psychosexual commitment in her “teacher” throughout her high-school years.

Full responsivity in the sexual component of the relationship developed slowly for the teenager, although she was occasionally orgasmic with manipulation within a few months ‘of her first physical experience.

Initially, hers was primarily a receptive role, but as she matured in the relationship psychologically, mutual manipulation and oral-genital stimulation in natural sequence became part of the unit’s pattern of sexual expression.

During the girl’s last year in high school, mutual sexual tensions were maintained at a high level, and physical release was sought by either or both women at a minimum frequency level of three to four times a week. Both women were multi-orgasmic. Mrs. G has no history of heterosexual dating in high school.

There was physical separation when Mrs. G went to college, but since the separation represented a distance of only fifty miles, she and the teacher spent many weekends together. However, toward the end of Mrs. G’s sophomore year in college, the high-school teacher was apprehended approaching other girls, was discharged, and left the geographical area.

This was a major blow to the girl. She had lost her love and at the same time was made aware that the teacher had sought other outlets. Her grades suffered and she became severely depressed and totally antisocial.

She dropped out of school for a semester, during which time she did very little but write long forgiving letters to her mentor, and even visited her for a ten-day period under the pretext of going to see friends.

It was not until Mrs. G graduated from college that the homosexual relationship was finally terminated. During the four college years, she had only two dates, both involving attendance at school events and of no sexual portent.

After graduation, Mrs. G took secretarial training and began working in a larger city in the Midwest. She still suffered from recurrent bouts of depression and finally sought psychiatric support. Helped by this counseling, she gradually enlarged her social circle, began heterosexual dating, and once more showed an interest in her dress and person.

While in college she had developed masturbatory patterns for tension release. The frequency throughout college and during her early years working as a secretary was several times per week. She usually was multi-orgasmic, as she had been during her continuing homosexual relationship.

At age 25 Mrs. G deliberately took advantage of an available partner to attempt intercourse. This experience was sought purely from curiosity demand.

There were several coital exposures with this eager but relatively inexperienced young man.

She found herself repulsed by the man’s untutored, harsh approaches as opposed to those of her high school teacher. She was not physically responsive and found the seminal fluid objectionable.

Added to this general rejection of heterosexual interest was the fact that shortly after establishing the sexual relationship there was a 10-day delay in the onset of a menstrual period. Her fear of pregnancy only contributed to her rejection of any psychosocial concept of heterosexual functioning.

Shortly thereafter Mrs. G met her husband. He had been divorced six months previously for the stated reason that his wife had wanted to marry another man. There were two children of the marriage, both living with their mother.

They were both lonely people and gravitated to each other. There was warmth and affection between them and several mutual interests, so they married.

Mr. G was sexually well versed, kind, considerate, and gentle with his wife. She felt warmly toward him and enjoyed providing him with sexual release. In doing so she lost her incipient phobia for the seminal fluid.

However, she was unstimulated by his sexual approaches beyond that degree necessary to produce adequate vaginal lubrication. Both partners agreed they did not want children, so contraceptive medication was taken by the wife.

The marriage, though warm and comfortable, for several years was essentially one of convenience. However, as time passed, the two partners grew closer together, learned to communicate, and to exchange vulnerabilities.

Yet there was no improvement in the wife’s sexual responsivity, and this became an increasingly important factor in their lives. Mrs. G had never told her husband of her homosexual experience and was guilt-ridden by the concept that her past sexual orientation might have precluded any possibility of effective response in her now desired heterosexual state. The husband and wife were referred for treatment at her insistence.

During the rapid treatment program, the daily report and ensuing discussions between the co-therapists and marital partners describing the non-orgasmic wife’s reactions and as well as those of her interacting husband, provide an incisive measure of the degree to which the requirements of her functioning sexual value system are being met or negated, or the extent to which she progressively can adapt her requirements.

These discussions provide a simultaneous opportunity for a more finite evaluation of the levels of interactive contribution to sexual function by her biophysical and psychosocial systems.

The treatment of both primary and situational orgasmic dysfunction requires a basic understanding by patients and co-therapists that the peak of sex-tension increment resulting in the orgasmic release cannot be willed or forced.

Orgasmic experience evolves as a direct result of individually valued erotic stimuli accrued by the woman to the level necessary for psychophysiological release. Just as the trigger mechanism which stimulates the regularity of expulsive uterine contractions sending a woman into labor is still unknown, so is the mechanism that triggers orgasmic release from sex-tension increment.

Probably they are inseparably entwined to identify one may be to know the other.

It seems more accurate to consider female orgasmic response as an acceptance of naturally occurring stimuli that have been given erotic significance by an individual sexual value system than to depict it as a learned response.

There are many case histories recorded in this and related studies reporting orgasmic incidence in the developing human female at ages that correspond with ages reported in histories of onset of male masturbation and nocturnal emission.

These clearly described objective accounts are considered accurate because they correlated with subjective recall provided by several hundred women interrogated during previously reported laboratory studies. The initial authoritative direction in therapy includes suggestions to the marital unit for developing a non-demanding, erotically stimulating climate in the privacy of their own quarters.

At no time during the two-week therapy program is either of the marital partners under any form of observation, laboratory, or otherwise. Only the phenomenon of vaginismus is directly demonstrated to the husband of the distressed wife, under conditions routinely employed by appropriate practitioners of clinical medicine.

The co-therapists’ initial directions suggest ways of putting aside tension-provoking behavioral interaction for the duration of the rapid-treatment program and allow the woman to discover and share knowledge of those things which she personally finds to be sexually stimulating.

The further professional contribution must suggest to the marital unit ways and means to create an opportunity for the woman to think and feel sexually with spontaneity. She must be made fully aware that she has permission to express her sexual feelings during this phase of the therapy program without focusing on her partner’s sexual function except by enjoying a personal awareness of the direct stimulus to her sexual tensions that his obvious physical response provides.

Every non-orgasmic woman, whether distressed by primary or situational dysfunction, must develop adaptations within areas of perceptual, behavioral, and philosophic experience.

She must learn or relearn to feel sexual (respond to sexual stimuli) within the context of and related directly to shared sexual activities with her partner as they correlate with the expression of her own sexual identity, mood, preferences, and expectations.

The bridge between her sexual feeling (perception) and sexual thinking (philosophy) essentially is established through comfortable use of verbal and nonverbal (specifically physical) communication of shared experience with her marital partner.

Her philosophic adaptation to the acceptance and appreciation of sexual stimuli is further dependent upon the establishment of “permission” to express herself sexually. Any alteration in the sexual value system must, of course, be consistent with her own personality and social value system if the adaptation is to be internalized.

Keeping in mind the similarities between male and female sexual response, the crucial factors most often missing in the sexual value system of the non-orgasmic woman are the pleasure in, the honoring of, and the privilege to express the need for the sexual experience.

Restoration of sexual feeling to its appropriate psychosocial context (the primary focus of the therapy for the non-orgasmic woman) is the reversal of sexual dissembling. This, in turn, encourages a more supportive role for her sexuality. In the larger context of a sexual relationship, the freedom to express need is part of the “give-to-get” concept of inherent incapacity and facility for effective sexual responsivity.

Professional direction must allow for a woman’s justifiable, socially enhancing need for personal commitment because her capacity to respond sexually is influenced by psychosocial demand.

The commitment functions as her “permission” to involve herself sexually, when prior opportunities available to the formation of a sexual value system have not included an honorable concept of her sexuality as a basis upon which to accept and express her sexual identity.

Commitment apparently means many things to as many different women; most frequently encountered are the commitments of marriage or the promise of marriage, the commitment of love (real or anticipated) according to the interpretation of “love” for the particular individual.

Regardless of the form, the commitment takes after it is established the goal to be attained is the enjoyment of sexual expression for its own positive return and its enhancement of those involved.

During daily therapy sessions, interrogation of the sexually dysfunctional woman is designed to elicit material that expresses the emotions and thoughts that accompany the feelings (sexual or otherwise) developed by the sensate-focus exercise.

Also continually explored are the feelings, thoughts, and emotions that are related to the behavior of her marital partner. Her reactions when discussing material of sexual connotation are evaluated carefully to determine those things which may be contributing to ongoing inhibition or distortion being revealed by the regular episodes of psychophysiological interaction with her husband.

When a non-orgasmic female involves herself with her partner in situations providing opportunities for effective sexual function, her ever-present need is to establish and maintain communication.

Communication, both physical and verbal in nature, makes vital contributions, but it loses effectiveness in the rapid-treatment method is allowed to be colored by anger, frustration, or misunderstanding. While verbal communication is encouraged throughout the two-week period, physical communication is introduced in progressive steps following the initial authoritative suggestion to provide a non demanding, warmly encompassing, shared experience for the woman, with optimal opportunity for feeling.

After the early return from sensate-focus opportunity as directed at the roundtable discussion has been judged fully effective by marital partners and co-therapists the marital unit is encouraged to move to the next phase in sensate pleasure genital manipulation.

The co-therapists should issue specific instructions to the marital partners as “permission” is granted to the female to enjoy genital play.

Sexual instructions should include details of positioning, approach, time span, and above all, a listing of ways and means to avoid the usual pitfalls of male failure to stimulate his partner in the manner she prefers rather than as she permits him the privilege to function.

Treat Orgasm

Neither the biophysical nor the psychosocial systems which influence the expression of the human sexual component have a biologically controlled demand to make specifically positive or negative contributions to sexual function.

This fact does not alter the potential of the systems’ interdigitation contribution to the formation of effective patterns of sexual response. When this potential is not realized by the natural development of psychophysiological sexual complements, the result is sexual dysfunction.

The initial psychosocial contributions toward the realization of this potential may come through a positive experience of early imprinting. Imprinting is a process whereby a perceptual signal is matched to an innate releasing mechanism that elicits a behavioral pattern. Established at critical periods in development, imprints thereafter are considered more or less permanent.

Infantile imprinting of sexually undifferentiated sensory receptivity to the warmth and sensation of close body contact is considered a source of formative contribution to an individual’s baseline of erotic inclinations and choices.

This material essentially is unobtainable in specific form during history-taking. It becomes important to the rapid-treatment program only as it is reflected by statements of preference in physical communication or other recall pertinent to ongoing patterns of sexual responsivity.

Treatment Of Orgasmic Dysfunction

Foundation personnel makes use of two primary sources of material. These sources reliably reflect the female’s prevailing sexual attitudes, receptivity, and levels of responsivity. The first source, derived from history, is the identification by the non-orgasmic woman of erotically significant expectations or experiences (positive or negative) currently evoked during a sexual interchange with her marital partner.

The co-therapists must identify those things which the husband does or does not do that may not meet the requirements of his wife’s sexual value system previously shaped by real or imagined experience or expectation.

Past experiences of positive content involving other partners, or unrealizable expectations perceived as ideal, maybe over idealistically compared by her to the current opportunity; or negative experiences or negative expectation-related attitudes may intrude upon receptivity to her partner’s sexual approach.

Thus, a rejection or blocking of sexual input may be the result.

A discussion of memories of perceptual and interpretive reactions associated with the specific sexual activity may add a further dimension to the knowledge of the wife’s currently constituted sexual value system since these memories often have been noted to function as signals for the subconscious introduction of stored experience, either positive or negative in nature.

The second source of reliable, directly applicable material upon which the rapid-treatment therapy relies for direction indeed, it characterizes this particular mode of psychotherapy is developed from the daily discussions that follow each sensate-focus exercise.

As repeatedly stressed, defining the etiology of the presenting sexual inadequacy does not necessarily provide the basis for treatment. A reasonably reliable history is indispensable, but it is used primarily to provide interpretive direction and to amplify the definition of that which is of individual significance. (It even is used from time to time to demonstrate negative patterns of sexual behaviors)

The husband has directed to place himself in a sitting (slightly reclining, if desired) position, with his back against a comfortable placement of pillows at the headboard of the bed. With the husband’s legs adequately separated to allow his wife to sit between them, she should recline with her back against his chest, pillowing her head on his shoulder.

The length of torsos should determine the reclining angle that permits her head to rest comfortably. Her legs are then separated and extended across those of her husband.

This position provides a degree of warm security for the woman (“back-protected” phenomenon) and allows freedom of access for the man to encourage creative exploration of his wife’s entire body in the sensate-focus concept.

The level of physical communication in the manipulative sessions is encouraged further by direction for the female partner to place her hand in a lightly riding position on that of her husband.

By using a slight increase in pressure or gentle directional movement, the “where and how” of her need of the moment may be immediately communicated to her receptive husband. This and other forms of nonverbal communication allow sharing of her particular desires as they occur as manifestations of her sexual value system, and constitute a secure way by which her marital partner can identify and fulfill these desires by meaningful interaction.

This means of direct physical communication also provides the woman with the freedom to request specifics of genital play without the distraction of forced verbal requests or a detailed explanation.

Any spontaneous form of expression of a man’s own sexual tensions is one of the most interactive contributions that he can make to his wife. It is a viable component of sexual “give to get” in any circumstance of physical sharing.

This principle applies equally to the marital unit carrying out the simplest sensate-focus exercise in the therapy program as it does to a marital unit that has never known sexual dysfunction.

The man must not presume his wife’s desire for a particular stimulative approach, nor must he introduce his own choice of stimuli. The husband’s assumption of expertise has no place in the initial learning phase of a marital unit seeking to reverse the life’s nonorgasmic condition.

The trial-and-error hazard this poses is not worth the small possibility of accidental pleasure that might be achieved. In truth, error in some facet of this controlled manipulative form of physical communication has already been established, or the marital-unit members probably would not consider themselves in need of professional support.

Only after both marital partners have established the fact of the wife’s sexual effectiveness with controlled genital play and have developed dependable physical signal systems should trial-and-error stimulative techniques be crone a naturally occurring dimension of pleasure.

It is well to mention that even those partners with an established, effective sexual relationship may find it both appropriate and advisable to check out their physical signal systems by verbal communication from time to time.

An additional value derived from the non-demand position and its accompanying sensate exercises is its contribution to the removal of the potential spectator’s role.

This role can become as much a pitfall for the nonorgasmic woman as it is for the impotent male. Already considered in descriptions of female-oriented patterns of sexual dissimulation, the spectator role is dissipated when the sexual involvement of husband and wife becomes mutually encompassing for both partners.

Educational Direction

For the husband is an integral part of the genital-play episodes. The co-therapists must be certain that the basics of effective pelvic play are clearly enunciated if the male partner is to provide an effective measure of stimulative return for the woman involved.

The husband is instructed both to allow and to encourage his wife to indicate specific preferences in the stimulative approach either by the light touch of her hand on his or by moving slightly toward the desired approach or away from excessive pressure.

Probably the greatest error that any man makes approaching a woman sexually is that of a direct attack upon the clitoral glans unless this is the stated wish of his particular partner. The glans of the clitoris has the same embryonic developmental background as that of the penis but usually is much more sensitive to touch.

As female sex tensions elevate, sensations of irritation, or even pain, may result from direct clitoral manipulation.

Rarely do women, when masturbating, manipulate the clitoral glans directly. Therefore, the male approach to clitoral stimulation would do well to correspond to that employed by women when providing self-release. There is a further, perhaps more subtle, reason for relative care in the intensity of stimulative concentration directed to the clitoris.

This originates from the fact that the clitoris, as a receptor and a transmitter of sexual stimuli, can rapidly react to create an overwhelming degree of sensation. When such a high level of biophysical tension is reached before the psychosocial concomitant has been subjectively appreciated, the woman experiences too much sensation too soon and finds it difficult to accept.

In the interest of a pleasurable, evolving sexual responsivity, the clitoris should not be approached directly. Specifically, manipulation should be conducted in the general mons area, particularly along either side of the clitoral shaft.

It must be remembered that the inner aspects of the thighs and the labia also are erotically identified areas for most women. Pressure and direction of manual stimulation should be controlled initially by the female partner for two educative reasons.

1. full freedom of manipulative control provides her with the opportunity to feel and think sexually without having to adjust to a partner’s assumption of what pleases her.
2. female control of manipulative activity also educates the male partner into the particular woman’s basic preferences in the stimulative approach to the clitoral area.

It must also be borne in mind by the male partner that there is no lubricating material available to the clitoris. As female sex tension increases there will be a sufficient amount of lubrication at the vaginal outlet.

This should be maneuvered manually from the vagina to include the general area of the clitoris. Vaginal lubrication used in this manner will prevent the irritation of the clitoral area that always accompanies any significant degree of manipulation of a dry surface.

A further dimension of sexual excitation is derived from manipulation of the vaginal outlet when lubricating material is acquired for clitoral spread by superficial finger insertion. There is usually little value returned from the deep vaginal insertion of the fingers, particularly early in the stimulative process.

While some women have reported a mental translation of the ensuing intravaginal sensation to that of penile containment, few had any preference for the opportunity.