Category: Women’s Health

When the marital partners extend their psychosensory interchange to coition in the female-superior position, the wife once mounted is instructed to hold herself quite still and simply to absorb the awareness of penile containment.

Interspersed with moments of sensate pleasure created by her proprioceptive awareness of vaginal dilatation should be the opportunity to feel and think sexually. The vaginal distention should be interpreted as the sensual desire for further increment in sexual pleasure.

This increasing demand for sexual stimulation can be further implemented by the female partner if she will institute a brief period of controlled, slowly exploring, pelvic thrusting. The husband’s specific responsibility at this moment is to provide the needed erect penis without any concept of a demanding thrusting pattern on his part.

In anticipation of her need, the co-therapists must encourage the wife to think of the encompassed penis as hers to play with, to feel, and to enjoy, until the urge for more severe pelvic thrusting involuntarily emerges into her levels of conscious demand. It may take several episodes of female-superior coital positioning, as the woman plays pelvically with the contained penis before full sensate focus develops vaginally.

Once vaginal sensation develops a pleasant or even a fully demanding vein, the next phase is to add to the sensate picture the male-initiated, non demanding, slow pelvic thrusting.

The non-demanding thrusting by the husband should be kept at a pace communicated by his wife. This constrained form of male pelvic thrusting is suggested to create an obvious opportunity for the extension of the female’s sensory potential and to provide sufficient stimulative activity to maintain an effective erection.

Ejaculatory Control

At this time the question frequently asked by the male member of marital units whose concept of sexual interaction has been based primarily on the stock formula of performing, produce, and achieve is, “What if I feel like ejaculating?” It requires continuous effort by the co-therapists to convey the concept not only that acquiring ejaculatory control is possible but also that such a facility usually is enhancing for the male as well as his female partner.

The couple must be educated to understand that ejaculatory control enlarges the range of sensual pleasure in the sexual relationship for both marital partners. However, it is appropriate for co-therapists to emphasize the fact that ejaculation or spontaneously occurring orgasm is not caused for alarm, nor is this involuntary breakthrough considered a breach of direction.

The husband and wife must be reassured that if such a breakthrough from the original direction occurs, the experience should be enjoyed for itself. Within a reasonable length of time, the unit is encouraged to provide another opportunity in which to follow the originally described interactive concepts.

When the husband has developed security of erective maintenance, the episodes of vaginal containment with exploratory pelvic thrusting should continue for as long as both partners demonstrate pleasurable reactions. At appropriate intervals during the total coital episode, the partners should separate two or three times and lie together in each other’s arms.

Once rested, they should return to whatever manner of manual sensate pleasuring they previously enjoyed and continue without any concept of time demand. They should remount, again using the female-superior position, repeating earlier opportunity for the wife’s stimulative proprioceptive awareness of vaginal containment of the penis to be emphasized by alternate periods of exploratory thrusting and lying quietly together in the coital connection.

The timing and duration of sexually stimulative activity should follow the directive formula as outlined in the Therapy topic. Generally interpreted, any period of time is acceptable that emerges from mutual interest and continues to be enjoyable for both marital partners without the incidence of either emotional or physical fatigue.

Once both partners have been successfully educated to employ experimental pelvic movement during their episodes of coital connection rather than following the usual prior pattern of demanding pelvic thrusting, a major step has been accomplished.

Women have little opportunity to feel and think sexually while pursuing or receiving a pattern of forceful pelvic thrusting before their own encompassing levels of excitation are established.

If a woman initiates the demanding thrusting, she usually is attempting to force or to will an orgasmic response. The wife repeatedly must be assured that this forceful approach will not contribute to the facility of response.

If the husband initiates the driving, thrusting coital pattern, the wife must devote conscious effort to accommodate to the rhythm of his thrusting, and her opportunity for quiet sensate pleasure in coital connection is lost.

Frequently, it is of help to assure the wife that once the marital unit is sexually joined, the penis belongs to her just as the vagina belongs to her husband. When vaginal penetration occurs, both partners have literally given of themselves as physical beings to derive pleasure, each from the other.

Woman Sexuality

A separate discussion of female sexuality is necessary primarily because the role assigned to the functional component of a woman’s sexual identity rarely has been accorded the socially enforced value afforded male sexuality.

While the parallel between sexes as to physiological function has gained general acceptance, the concept that the male and female also can share almost identical psychosocial requirements for effective sexual functioning brings expected to protest.

Only when a male requests treatment for symptoms of sexual dysfunction, and possible contributing factors are professionally scrutinized in the clinical interest of symptom reversal, are the psychosocial influences noted to be undeniably similar to those factors which affect female responsivity.

Then such factors as selectivity, regard, affection, identity, and pride (to name a few of the heterogeneous variables) are revealed as part of the missing positive or present negative influence or circumstances surrounding the sexual dysfunction.

Woman Sexual Dysfunction

Man has had society’s blessing to build his sexual value system in an appropriate, naturally occurring context and woman has not. Until unexpected and usually little understood situations influence the onset of male sexual dysfunction, his sexual value system remains essentially subliminal and its influence more presumed than real.

During her formative years, the female dissembles much of her developing functional sexuality in response to societal requirements for a “good girl” facade.

Instead of being taught or allowed to value her sexual feelings in anticipation of an appropriate and meaningful opportunity for expression, thereby developing a realistic sexual value system.

She must attempt to repress or remove them from their natural context of environmental stimulation under the implication that they are bad, dirty, etc.

She is allowed to retain the symbolic romanticism which usually accompanies these sexual feelings, but the concomitant sensory development with the symbolism that endows the sexual value system with meaning is arrested or labeled for the wrong reasons, objectionable.

The reality of female sexual function today aside from its vital role in reproduction, still implies shame, although such a dishonorable role has been rather difficult to sustain with objectivity.

The arbitrary:
The social assignment of the role of sin to female sexuality has not contributed a desirably consistent level of marital harmony. Nor has society always found it easy to eliminate recognition of female sexuality while still supporting and maintaining the male’s role of tacit permission to be sexual with honor, or even praise.

Especially is this true of a society that continues to celebrate events before and after the fact of sexual expression (marriage, birth, etc.), and mourns the female menopause because it is presumed to signify the demise of sexual interest.

Since, as far as is known, elevated levels of female sexual tension are not technically necessary to conception, the natural function of a woman’s sexuality has been repressed in the service of false propriety and restricted by other unnecessary psychosocial controls for equally unsupportable reasons.

In short
The negation of female sexuality, which discourages the development of an effectively useful sexual value system, has been an exercise of the so-called double standard and its socio-cultural precursors.

Residual societal patterns of female sexual repression continue to affect many young women today. They mature acutely aware of repercussions from sexual discord between their parents and among other valued adults, so they grope for new roles of sexual functioning.

Discomfort in the communication of sexual material still prevails between parents and their children.

The young frequently are condemned, by lack of information about what is sexually meaningful, to live with decisions equally as unrewarding sexually as those made by their parents.

In other words, because of cultural restraints, the members of younger generations must continue to make their own sexual mistakes, since they, like previous generations, rarely have been given the benefit of the results of their parents’ past sexual experience; good, bad, or indifferent as that experience may have been.

The necessary freedom of sexual communication between parents and sons and daughters cannot be achieved until the basic component of sexuality itself is given a socially comfortable role by all active generations simultaneously.

She responds physiologically to sex-tension elevation. The four phases of the female cycle of sexual response established in the 1960s will be employed to identify clinically important vasocongestive and myotonic reactions developing in the pelvic viscera of any woman responding to sexual stimulation.

Sex-tension increment, the first physical evidence of her response to sexual stimulation is vaginal lubrication.

Lubrication is produced:

By a deep vasocongestive reaction in the tissues surrounding the vaginal barrel. There also is evidence of increased muscle tension as the vaginal barrel expands and distends involuntarily in anticipation of penetration.

When sex tensions reach plateau phase levels of responsivity, a local concentration of venous blood develops in the outer third of the vaginal barrel, creating partial constriction of the central lumen.

This vaginal evidence of a deep vasocongestive reaction has been termed the orgasmic platform. The uterus increases in size as venous blood is retained within the organ tissues.

The clitoris evidence increasing smooth-muscle tension by elevating from its natural, pudendal-overhang positioning and flattening on the anterior border of the symphysis.

With orgasm, reached an increment peak of pelvic-tissue vasocongestion and myotonia, the orgasmic platform in the outer third of the vagina and the uterus contract within regularly recurring rhythmicity as evidence of high levels of muscle tension.

Finally, with the resolution phase, both vasocongestion and myotonia disappear from the body generally, and the pelvic structures specifically.

If the orgasmic release has been obtained, there is rapid detumescence from these naturally accumulative physiological processes. The loss of muscle tension and venous blood accumulation is much slower if orgasm has not been experienced and there is an obvious residual of sexual tension.

The presence of involuntary-muscle irritability and superficial and deep venous congestion that woman cannot deny, for these reactions develop as physiological evidence of both conscious and subconscious levels of sexual tension.

With the accumulation of myotonia and pelvic vasocongestion, the biophysical system signals the total structure with stimulative input of a positive nature.

Regardless of whether women voluntarily deny their biological capacity for sexual function, they cannot deny the pelvic, irritative evidence of inherent sexual tension for any length of time.

Once a month with some degree of regularity women are reminded of their biological capacity. Interestingly, even the reminder develops in part as the result of local venous congestion and increased muscle tension in the reproductive organs.

On occasion, the menstrual condition, through the suggestive sensation created by pelvic congestion, stimulates elevated sexual tensions.

The presence or absence of patterns of sexual desire or facility for a sexual response within the continuum of the human female’s menstrual cycle also has defied reliable identification.

Possibly, confusion has resulted from the usual failure to consider the fact that two separate systems of influence may be competing for dominance in any sexual exposure.

The necessity for such individual consideration can best be explained by example:

It is possible for a sexually functional woman to feel the sexual need and to respond to high levels of sexual excitation even to orgasmic release in response to a predominantly biophysical influence in the absence of a specific psychosocial requirement.

This freedom to respond to direct biophysical-system demand requires only from its psychosocial counterpart that the female’s sexual value system not transmit signals that inhibit or defer how erotic arousal is generated. In any situation of biophysical dominance, the effective sexual response requires only a reasonable level of interdigital contribution by the psychosocial system.

Conversely, it also is possible for a human female to respond to erotic signals initiated by the predominant psychosocial factors of the sexual value system, regardless of conditions of biophysical imbalance such as hormonal deficiency or obvious pathology of the pelvic organs.

A woman may respond sexually to the psychosocial system of influence to orgasmic response in the face of surgical castration and spite of a general state of chronic fatigue or physical disability. In any situation of psychosocial dominance, the effective sexual response requires only a reasonable level of interdigital contribution by the biophysical system.

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 the therapy he at first refused to join her in treatment on the basis that it was her problem. When faced with 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.

Increasing complaints of the inadequacy of human sexual function, it would seem that the potpourri of cultures that influence the behavior of so many might designate some area less vital to the quality of living than the sexual expression to receive and to bear the burden of the social ills of human existence.

As recently as the turn of the century, after marriage rites and the advent of offspring were celebrated as evidence of perpetuation of family and race, the woman was considered to have done her duty, fulfilled herself, or both, depending of course upon the individual frame of reference.

In reality:

The society honored her contribution as a sexual entity only about her breeding capacity, never relative to the enhancement of the marital relationship by her sexual expression.

In contradistinction to the recognition accorded her as a breeding animal, the psychological importance of her physical presence during the act of conception was considered nonexistent. It must be acknowledged.

However, there always have been men and women in every culture who identified their need for one another as complete human entities, each denying nothing to the other including the vital component of sexual exchange.

Unfortunately, whether from sexual fear or deprivation (both usually the result of too little knowledge), those who socially could not make peace with their sexuality were the ones to dictate and record concepts of female sexual identity.

The code of the Puritan and similar ethics permitted only communication in the negative vein of rejection. There was no acceptable discussion of what was sexually supportive of marital relationships.

So far the discussion has focused on an account of past influences from which female sexual function has inherited its baseline for functional inadequacy.

Because this influence still permeates the current “cultural” assignment of the female sexual role, its existence must be recognized before the psychophysiological components of dysfunction can be dealt with comprehensively.

Socio-Cultural Influence

More often than not places a woman in a position in which she must adapt, sublimate, inhibit, or even distort her natural capacity to function sexually to fulfill her genetically assigned role. Herein lies a major source of a woman’s sexual dysfunction.

The adaptation of sexual function to meet socially desirable conditions represents a system operant in most successfully interactive behavior, which in turn is the essence of a mutually enhancing sexual relationship.

However, to adapt the sexual function to a philosophy of rejection is to risk impairment of the capacity for effective social interaction. To sublimate sexual function can enhance both selves and that state to which the repression is committed if the practice of sublimation lies within the coping capacity of the particular individual who adopts it.

To inhibit sexual function beyond that realistic degree which equally serves social and sexual value systems positively, or to distort or maladapt sexual function until the capacity.

And to function is extinguished, which is to diminish the quality of the individual and of any marital relationship to which he or she is committed.

When it is realized that this psychosocial backdrop is prevalent in histories developed from husband and wives with complaints of female sexual inadequacy, the psychophysiological and situational aspects of female orgasmic dysfunction can be contemplated realistically.

The human female’s facility of physiological response to sexual tensions and her capacity for orgasmic release never have been fully appreciated.

Lack of comprehension may have resulted from the fact that functional evaluation was filtered through the encompassing influence of socio-cultural formulations previously described in this topic.

There also has been a failure to conceptualize the whole of sexual experience for both the human male and female as constituted in two totally separate systems of influence that coexist naturally.