Female orgasmic disorder has been treated from psychoanalytic, cognitivebehavioral, pharmacological, and systems theory perspectives. Because substantial empirical outcome research is available only for cognitive-behavioral and, to a lesser degree, pharmacological approaches, only these two methods of treatment will be reviewed here.

Cognitive-Behavioral Approaches

Cognitive-behavioral therapy for female orgasmic disorder aims at promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. Traditionally, the behavioral exercises used to induce these changes include directed masturbation, sensate focus, and systematic desensitization. Sex education, communication skills training, and Kegel exercises are also often included in cognitive-behavioral treatment programs for anorgasmia.

Directed Masturbation

Masturbation exercises are believed to benefit women with orgasm difficulties for a number of reasons. To the extent that focusing on nonsexual cues can impede sexual performance, masturbation exercises can help the woman to direct her attention to sexually pleasurable physical sensations. Because masturbation can be performed alone, any anxiety that may be associated with partner evaluation is necessarily eliminated. Relatedly, the amount and intensity of sexual stimulation is directly under the woman’s control and therefore the woman is not reliant upon her partner’s knowledge or her ability to communicate her needs to her partner. Research that shows a relation between masturbation and orgasmic ability provides empirical support for this treatment approach. Kinsey reported that the average woman reached orgasm 95% of the time she engaged in masturbation compared with 73% during intercourse. More recently, in a random probability sample of 682 women, Laumann reported a strong relation between frequency of masturbation and orgasmic ability during masturbation. Sixty-seven percent of women who masturbated one to six times a year reported orgasm during masturbation compared with 81% of women who masturbated once a week or more.

LoPiccolo and Lobitz were the first to outline a program of directed masturbation (DM). Since then, several other researchers have provided variations. The first step of DM involves having the woman visually examine her nude body with the help of a mirror and diagrams of female genital anatomy. During the next stage she is instructed to explore her genitals tactually as well as visually with an emphasis on locating sensitive areas that produce feelings of pleasure. Once pleasure-producing areas are located, the woman is instructed to concentrate on manual stimulation of these areas and to increase the intensity and duration until "something happens" or until discomfort arises. The use of topical lubricants, vibrators, and erotic videotapes are often incorporated into the exercises. Once the woman is able to attain orgasm alone, her partner is usually included in the sessions in order to desensitize her to displaying arousal and orgasm in his presence, and to educate the partner on how to provide her with effective stimulation.

DM has been used to effectively treat female orgasmic disorder in a variety of treatment modalities including group, individual, couples therapy, and bibliotherapy. A number of outcome studies and case series report DM is highly successful for treating primary anorgasmia. Heinrich reported a 100% success rate for treating primary anorgasmia using therapist DM training at 2 month follow-up. The study was a controlled comparison of therapistdirected group masturbation training, self-directed masturbation training (bibliotherapy), and wait-list control. Forty-seven percent of the bibliotherapy subjects reported becoming orgasmic during masturbation compared with 21% of wait-list controls. In a randomized trial comparing written vs. videotaped masturbation assignments, the effects of self-directed masturbation training were further investigated. Sixty-five percent of women who used a text and 55% of women who used videotapes had experienced orgasm during masturba ion and 50% and 30%, respectively, were orgasmic during intercourse after 6 weeks. None of the control women had attained orgasm. Few controlled studies have examined the exclusive effects of DM for treating secondary anorgasmia. Fichen compared minimal therapist contact bibliotherapy with a variety of techniques including DM and found no change in orgasmic ability. Hurlbert and Apt recently compared the effectiveness of DM with coital alignment technique in 36 women with secondary anorgasmia. Coital alignment is a technique in which the woman assumes the supine position and the man positions himself up forward on the woman. After only four 30-min sessions, 37% of women receiving instructions on coital alignment technique vs. 18% of those receiving DM reported substantial improvements (.50% increase) in orgasmic ability during intercourse. The benefits of this technique are due to the fact that clitoral contact, and possibly paraurethral, stimulation are maximized.

In summary, DM has been shown to be an empirically valid, efficacious treatment for women diagnosed with primary anorgasmia. For women with secondary anorgasmia, who are averse to touching their genitals, DM may be beneficial. If, however, the woman is able to attain orgasm alone through masturbation but not with her partner, issues relating to communication, anxiety reduction, trust, and ensuring the woman is receiving adequate stimulation either via direct manual stimulation or engaging in intercourse using positions designed to maximize clitoral stimulation (i.e., coital alignment technique) may prove more beneficial.