Category: Women’s Health

One of the most obscure of pelvic 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.

Both contributing positively or negatively to any state of sexual responsivity but having no biological demand to function in a complementary manner.

With the reminder that finite analysis of male sexual capacity and physiological response also has attracted little scientific interest in the past.

Compare Male And Female

It should be reemphasized that similarities rather than differences are frequently more significant in comparing male and female sexual response. By intent, the focus of this topic is directed toward the human female, but much of what is to be said can and does apply to the human male.

The bio-physically and psychosocially based systems of influence that naturally coexist in any woman have the capacity if not the biological demand to function in mutual support.

Obviously, there is an interdigitation of systems that reinforce the natural facility of each to function effectively. However, there is no factor of human survival or internal biological need defined for the female that is totally dependent upon a complementary interaction of these two systems.

Unfortunately, they frequently compete for dominance in problems of sexual dysfunction.

Woman’s Response

When the human female is exposed to negative influences under circumstances of individual susceptibility, she is vulnerable to any form of psychosocial or biophysical conditioning, i.e., the formation of man’s individually unique sexual value systems.

Based on how an individual woman internalizes the prevailing psychosocial influence, her sexual value system may or may not reinforce her natural capacity to function sexually.

One need only remembers that sexual function can be displaced from its natural context temporarily or even for a lifetime to realize the concept’s import.

Women cannot erase their psychosocial sexuality and sexual identity, being female, but they can deny their biophysical capacity for natural sexual functioning by conditioned or deliberately controlled physical or psychological withdrawal from sexual exposure.

Yet woman’s conscious denial of biophysical capacity rarely is a completely successful venture, for her physiological capacity for sexual response infinitely surpasses that of man.

Indeed, her significantly greater susceptibility to negatively based psychosocial influences may imply the existence of a natural state of psycho sexual-social balance between the sexes that has been culturally established to neutralize woman’s biophysical superiority.

The specifics of the human female’s physiological reactions to effective levels of sexual tension have been described in detail, but brief clinical consideration of these reactive principles is in order.

For woman, as for man, the 3 specific total-body responses to elevated levels of sexual tension are:

1. Increased myotonia or muscle tension
2. Generalized vasocongestion, pooling of blood in tissues
3. Sex flush and breast enlargement.

When clinical attention is directed toward female orgasmic dysfunction, one particular biological area, the pelvic structures is of the moment.

Specific evidence has been accumulated from the incidence of both myotonia and vasocongestion in the female’s pelvis.

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 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’s 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 encounters 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.

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.

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

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.

When the marital partners extend their psycho sensory 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, producing, and achieving 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.

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 to 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.

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 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 a 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 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.