Author: The Beauty Nation

Dyspareunia

Vaginismus occasionally develops in women with clinical symptoms of severe dyspareunia (painful intercourse). When dyspareunia has a firm basis in pelvic pathology, the existence of which escapes examining physicians, and over the months or years coition becomes increasingly painful, vaginismus may result. The patient is not reassured by the statement that “it’s all in your head” or equally unsupportive pronouncements when she knows that it is always severely painful for her when her husband thrusts deeply into the vagina during coital connection.

As an example of this situation, vaginismus has been demonstrated as a secondary complication in two cases, of severe laceration of the broad ligaments. Also recorded are two classic examples of onset of vaginismus, the first in a young woman with pelvic endometriosis, the second in a 62 years old postmenopausal widow who without sex-steroid replacement therapy went through remarriage sought a return to sexual functioning after seven years of abstinence.

The two women developing a syndrome of vaginismus subsequent to childbirth laceration of the broad ligaments supporting the uterus (universal-joint syndrome) have similar histories. A composite history will suffice to demonstrate the pathology involved.

Marital Couple D was seen with the complaint of increasing difficulty in accomplishing vaginal penetration developing after 6 years of marriage. There were two children in the marriage, with the onset of severe dyspareunia oriented specifically to the delivery of the second child. The second child, a postmature baby of 8 pounds 14 ounces, had a precipitous delivery.

There is a positive history of nurses’ holding, the patient’s legs together to postpone delivery while waiting for the obstetrician. As soon as sexual activity was reconstituted after the delivery the patient experienced severe pain with deep penile thrusting.

During the next year, the pain became so acute that the wife sought subterfuge to avoid sexual exposure. The coital frequency decreased from two to three times a week to the same level per month. On numerous occasions, the patient was assured, during medical consultation, that there was nothing anatomically disoriented in the pelvis and that pain with intercourse was “purely her imagination.”

Supported by these authoritative statements, the husband demanded an increased frequency of sexual function. When the wife refused, the couple separated for a few months. During this period, the woman assayed intercourse on two separate occasions with two different men, but with each experience, the pelvic pain with deep penile thrusting was so severe that her obvious physical distress terminated sexual experimentation.

The marital couple was reunited with the help of their religious adviser, but with attempted intercourse vaginal penetration was impossible. After 8 months of repeatedly unsuccessful attempts to reestablish coital function, the couple was referred for therapy.

Family Couple E had been married 8 years when seen in the Clinic. They mutually agreed that a coital connection had not been possible more than once or twice a month in the first two years of marriage. Each time, the wife had moaned or screamed in pain as her husband was thrusting deeply into her pelvis.

After the first two years of marriage, every attempt at vaginal penetration had been unsuccessful. Both Mr. and Mrs. E had been under intensive psychotherapy, the husband for three and the wife for four years, when referred to the Foundation.

During the routine physical examinations, advanced endometriosis was discovered, and severe vaginismus was demonstrated. In due course, the wife underwent surgery for correction of the pelvic pathology. After recovery from the surgery, she returned with her husband for therapeutic relief of the vaginismus which, as would be expected, still existed despite successful surgical correction of the endometriosis.

Marital Couple F, a 66 years old husband, and his 62 years old wife, were seen in consultation. When the wife was 54 years old, her first husband died after a three-year illness during which sexual activity was discontinued.

She remarried at 61 years of age, having had no overt sexual activity in the interim period. She had never been given hormone replacement therapy to counteract the natural involution of pelvic structures.

First attempts at the coital connection in the present marriage produced a great deal of pain and only partial vaginal penetration. With reluctance, the wife sought medical consultation. Her physician instituted hormone replacement techniques.

After a 6-week respite, further episodes of coital activity also resulted in pain and distress. Despite the fact that by this time the vaginal walls were well stimulated by effective steroid replacement, the new husband found it impossible to attain vaginal intromission.

The wife had developed obvious psychosocial resistance to the concept of sexual activity in the 60 plus age group based on

1. the pain that had been experienced attempting to consummate her new marriage.
2. a real sense of embarrassment created by the need for medical consultation and the necessity of admitting that she had been indulging in coital activity at her age.

As a result of the trauma that developed with attempts to renew sexual function subsequent to almost ten years of continence, she developed involuntary spastic contraction of the vaginal outlet. Judicious use of Hegar dilators and a detailed, thorough, and authoritative refutation of the taboo of aging sexual function (based on the belief that sexual activity in the 60, 70, or even 80 year age groups represents some form of perversion) were quite sufficient to relax and relieve the vaginal spasm.

Sex with Female Homosexual

Two case histories illustrate the occasional effect of homosexual orientation upon the female partner.

Marital Couple G

was composed of a 26 years old woman married to a man 37 years old. The wife had been actively homosexual since seduction by an elder sister when she was 12 years old. There had been no history of heterosexual function before meeting her husband. He was a successful professional man and offered the woman much in the form of social status and financial security. He had been previously married and divorced.

Sexual exposure during the short engagement had been restricted, by female edict, to multiple manipulative approaches. There was a total inability to penetrate on the wedding night or to consummate the marriage thereafter. When the couple was seen after 18 months of marriage, the wife’s hymen was not intact but there was evidence of severe vaginismus.

Once all of her pertinent histories were obtained and shared with her marital partner, there was little further resistance to penile penetration. She was orgasmic with intercourse within two weeks after termination of the acute phase of therapy.

Marital Couple H

had been married for 7 years. There were two children. The husband became an alcoholic, lost his job, and left his family without warning. He was out of the home for 3 years before he could be persuaded to seek professional help. There was another year spent in treatment before he could return to family and social position.

Fortunately, there was sufficient financial resource, so no great financial hardship was suffered by his family. The wife, distraught at first, sought support from her best friend, also married and living in the neighborhood.

Within a year an overt homosexual relationship developed. Mrs. H had no prior history of homophile orientation. Two years after her husband left the home, Mrs. H attempted sexual intercourse on several different occasions with two different men, but neither man could penetrate.

There was no further heterosexual exposure after these failures until her husband was released from institutional control to return to normal activity. When attempting intercourse, Mr. H could not penetrate, nor was he able to during the subsequent two years before the marital couple was seen in therapy.

The vaginismus was obvious at physical examination. The probable cause of her involuntary rejection of coitus was explained and accepted by both partners. Dilators were used effectively and coital functioning was reestablished quickly.

One marriage had existed in a sexual successful state for almost 10 years when the husband was detected in an extramarital affair. There was a 4-month period of continence while marital fences were mended with help from clergy.

Although verbally forgiving his transgressions, the wife evidenced vaginal spasm during subsequent attempts at coital connection. The marital couple’s inability to reestablish a successful coital pattern continued for almost 18 months until, consumed with fears for performance, feelings of guilt, and finally of personal rejection, the husband became secondarily impotent. When seen in therapy, both vaginismus and impotence were presenting systems.

There have been 7 more instances of vaginismus treated by Foundation clinic personnel. Onset of symptoms has ranged from evidence of involuntary vaginal spasm with a first coital opportunity to dysfunction secondary to physiological or psychological trauma. There seems little need for further illustration of the onset of the syndrome.

Regardless of onset, an effective therapeutic approach is to establish the etiological influences by careful history-taking, and then to approach treatment confidently. With adequate dissemination of information so that full appreciation of onset of the sexual dysfunction is acquired by marital couple involved, and the sexual partners’ mutual cooperation in therapy, reversal of the syndrome of vaginismus is accomplished with relative ease.

The following history exemplifies the onset of vaginismus subsequent to episodes of psychosexual trauma. There have been three women referred to therapy so physically and emotionally traumatized by unwelcome sexual attacks that vaginismus developed subsequent to their traumatic experiences.

When first seen, Couple C had been married for 18 months, with repeated attempts to consummate the marriage reported as unsuccessful. The husband, age 31, reported effective sexual function with several other women prior to marriage. The wife, age 28, described successful sexual connection with four men over a five-year period before the specific episode of sexual trauma.

One of these relationships included coitus two or three times a week over a 10-month time span. She had been readily orgasmic in this association. The traumatic episode in her history was a well-authenticated episode of gang rape with resultant physical trauma to the victim requiring two weeks’ hospitalization.

Extensive surgical reconstruction of the vaginal canal was necessary for basic physical rehabilitation. No psycho-therapeutic support was sought by or suggested for the girl following this experience.

Mr. and Mrs. C met one year after the rape episode and were married a year after their introduction. Prior to the marriage, the husband-to-be was in full possession of the factual history of the gang-raping and of the resultant physical distress.

During the latter stages of their engagement period, several attempts at intercourse proved unsuccessful in that despite full erection, penetration could not be accomplished. It was mutually agreed that in all probability the security of the marital state would release her presumed hysterical inhibitions. This did not happen.

After the marriage ceremony, attempts at consummation continued unsuccessful despite an unusually high degree of finesse, kindness, and discretion in the husband’s sexual approaches to his traumatized partner. Severe vaginismus was demonstrated during physical examination of the wife after referral to the Foundation.

The remaining two rape experiences were family-oriented and almost identical in history. In both instances, young girls were physically forced by male members of their immediate family to provide sexual release, on numerous occasions, for men they did not know.

In one instance, a father, and in another, an older brother, forced sexual partners upon teenage girls (15 and 17 years of age) and repeatedly stood by to ensure the girls’ physical cooperation. Sexually exploited, emotionally traumatized, and occasionally physically punished, these girls became conditioned to the concept that “all men were like that.”

When released from family sexual servitude each girl avoided any possibility of sexual contact during the late teens and well into the twenties, until married at 25 and 29 years of age. Even then, they could not make themselves physically available to consummate their marriages, regardless of how strongly they willed sexual cooperation. Severe vaginismus was present in both eases.

The husbands’ physical and psychosexual examinations were within expected limits of normal variability. Neither husband had been made aware of the family-oriented episodes of controlled rape that had occurred years before their association with their wives-to-be. Once apprised of the etiology of their wives’ psychosomatic illness, both men offered limitless cooperation in the therapeutic program. There are various etiological orientations to vaginismus.

As evidenced previously, trauma initiating involuntary vaginal spasm can be either physiological or psychological, or both, in origin. Of course, there are factors of psychosomatic influence that predispose to vaginismus other than those frequently noted categories of channelized religious orthodoxy, male sexual dysfunction, and episodes of sexual trauma.

Marital Couple A is illustrative of an etiological factor frequently encountered in vaginismus, that of the influence of channel visioned religious orthodoxy upon the immature and/or adolescent girl.

Sex and Religious Orthodoxy

When the couple was first seen in consultation, Mr. and Mrs. A’s marriage had existed unconsummated for 4 1/2 years. The wife, from a sibling group of four females and one male, was the only one not to take the vows of a religious order.

Her environmental and educational backgrounds were of strictest parental, physical, and mental control enforced in a stringent disciplinary format and founded in religious orthodoxy.

She was taught that almost any form of physical expression might be suspect of objectionable sexual connotation.

For example, she was prohibited when bathing from looking at her own breasts either directly or from reflection in the mirror for fear that unhealthy sexual thoughts might be stimulated by visual examination of her own body. Discussions with a sibling of such subjects as menstruation, conception, contraception, or sexual functioning were taboo.

Pronouncements on the subject were made by the father with the mother’s full agreement. Her engagement period was restricted to a few chaste, well-chaperoned kisses, for at any sign of sexual interest from her fiance, the girl withdrew in confusion.

Mrs. A entered marriage without a single word of advice, warning, or even good cheer from her family relative to marital sexual expression. The only direction offered by her religious adviser relative to sexual behavior was that coital connection was only to be endured if conception was desired.

Mrs. A’s only concept of woman’s role in sexual functioning was that it was dirty and depraved without marriage and that the sanctity of marriage really only provided the male partner with an opportunity for sexual expression.

For the woman, the only salvation to be gained from sexual congress was pregnancy. With the emotional trauma associated with wedding activities, and an injudicious, blundering, sexual approach from the uninformed but eager husband, the wedding night was a fiasco quite sufficient to develop or to enhance any preexisting involuntary obstruction of the vaginal outlet to a degree sufficient to deny penetration.

The husband, of the same orthodox background, had survived these traumatic years without developing secondary impotence. His premarital experience had been two occasions of prostitute exposure, and there was no reported extramarital experience. He masturbated occasionally and was relieved manually by his wife once or twice a week. His wife had no such outlet. Her only source of effective relief was well-controlled psychotherapy.

With an incredible number of thou-shalt-nots dominating Mrs. A’s environmental background, it is little wonder that she was never able to develop a healthy frame of reference for the human male in general and her husband in particular as a sexual entity. Her sexual value system reflected severe negative conditioning.

The presenting complaint for Marital Couple B upon referral to the Foundation was that of secondary impotence. The husband’s history was one of successful response to coital opportunities with three women over a period of 18 months before meeting his wife.

An eight-month courtship followed without attempted coital connection or, for that matter, any physical approach, as the man was overwhelmed by the multitude of restrictions placed upon courtship procedure by the girl’s religious control. The husband-to-be was of the same faith, but his background was not orthodox.

Following a chaste engagement period, failure to consummate the marriage occurred on the wedding night. Religious orthodoxy, although of major import, was not the only factor involved in this traumatized marriage. With both husband and wife tired and tense, he unfortunately hurried the procedure.

All too cognizant of prior coital success and totally frustrated by lack of sexual exposure to his wife, he attempted penetration as soon as erection developed. While attempting rapid consummation, his wife, unprepared for the physical onslaught, was hurt. She screamed; he lost his erection and could not regain function. By mutual agreement, further attempts at consummation were reserved for the seclusion of the wedding trip.

Attempts at coition were repeated during the honeymoon and thereafter almost daily for the first five to six months of the marriage and two to three times per week for the next year, but there was no success in vaginal penetration.

Eighteen months after the wedding the husband developed marked loss of erective security. He rarely could achieve or maintain an erection quality sufficient for intromission. When there was erective success, frantic attempts at vaginal penetration stimulated pain, fear, and physical withdrawal from his female partner.

During the remaining two years before consultation, attempts at coition gradually became less frequent. The husband’s history included a report of eight months of psychotherapeutic support without relief of the symptoms of secondary impotence. No consideration had been given to the possibility of coexistent female pathology.

The involuntary vaginal spasm certainly could have been present before marriage, invalidating the initial attempt at intromission. Also, it is possible that over a long period, the severe degrees of frustration resultant from multiple unsuccessful attempts to penetrate could initiate involuntary vaginal spasm.

If a moderate degree of spasm were present at marriage, the sexual ineptitude of the husband and the episodes of pain with attempted penetration would tend to magnify the severity of the syndrome well beyond any initially existent level. Secondary impotence resulting from long-denied intromission is not at all uncommon.

Vaginismus may be of such severity that a marriage cannot be consummated. Medical consultants frequently have mistaken unrecognized involuntary vaginal spasm for the presence of a pressure-resistant hymen.

As the result of this clinical confusion, surgical excision of the presumed resistant hymen has been recommended and conducted on many occasions without providing the patient and her husband with the expected relief from physical obstruction to effective coital connection. The possibility of coexistent vaginismus should be explored in depth by means of an accurate psychosexual-social history as well as a definitive, but not forced, pelvic examination before surgical excision of a presumed all-resistant hymen is conducted.

Vaginismus has been encountered frequently in marriages with rarely occurring coitus as well as in non consummated marriages. Interestingly, the syndrome has a high percentage of association with primary impotence in the male partner, providing still further clinical evidence to support procedural demand for simultaneous evaluation and treatment of both marital partners when sexual dysfunction within a marital couple is the presenting complaint.

In retrospect, when primary impotence and vaginismus exist in a marriage, it is difficult to be sure whether there was involuntary spasm of the vaginal outlet prior to the unsuccessful attempts at coital connection or whether the vaginismus emerged from the wife’s high levels of sexual frustration developing secondary to the male partner’s lack of erective security.

Vaginismus and Primary Impotence

Probably antedate one another with equal frequency, but when either exists a marriage cannot be consummated, and sexual dysfunction is likely to appear in the other partner. If severe vaginismus exists prior to attempted consummation of a marriage, primary or secondary impotence can result from repetitive failures at intromission. Of course, within many marital couples involuntary vaginal spasm has existed for years without resulting in any symptoms of male sexual dysfunction.

In such cases either the husband is satisfied with ejaculatory release with minimal or partial penetration or the degree of involuntary spasm is sufficient only to delay and not to deny vaginal penetration.

Twenty-nine cases of vaginismus have been diagnosed and treated in the past years. While etiological factors are multiple, the syndrome is frequently identified in association with male sexual dysfunction.

Equaling male dysfunction as an etiological agent is the psychosexually inhibiting influence of excessively severe control of social conduct inherent in religious orthodoxy. Third in etiological frequency are the symptoms of involuntary vaginal spasm which have been identified as related to specific episodes of prior sexual trauma. Fourth in order of occurrence is the stimulus toward vaginismus derived from attempted heterosexual function by a woman with prior homosexual identification.

There are in the clinical files 12 examples of religious orthodoxy as a major etiological factor in the onset of vaginismus. The presence of this syndrome contributed to 9 non consummated marriages and 3 in which coitus was infrequent. Of the female partners with vaginismus 4 were oriented to a restrictive orthodox Jewish background, 6 were products of a psychosexually repressive Catholic background, and 2 had the religious orientation of stringent Protestant fundamentalism.

In these 12 cases in which religious orthodoxy was a factor in vaginismus, 5 male partners were primarily impotent and also had similar orthodox religious backgrounds ; 2 husbands who had been successful in coital connection with other women before meeting their wives-to-be became secondarily impotent after repetitively unsuccessful attempts at vaginal penetration.

There were 2 husbands who continued potent despite marriages of fourteen and two years without successful vaginal penetration. Neither described sexual activity outside of the marriage. Male partner tension relief usually was obtained from manipulation by the wife. The wives were not responsive to similar approaches.

Severe Premature Ejaculator

In one marriage, the male partner was a severe premature ejaculator. Intromission rarely occurred during the first four years because the husband could not control his ejaculatory process sufficiently to accomplish vaginal penetration. It must be pointed out, however, that a heavy burden had been placed upon this premature ejaculator by the extremely difficult vaginal penetration.

The excessive stimulation returned to the male by difficult penetrative efforts contributed to the husband’s acknowledged rapid ejaculatory tendencies. When seen in therapy, the wife, denying coital experience before marriage, had involuntary vaginal spasm. Whether spasm was present at marriage is debatable, but the marital combination of premature ejaculation and vaginismus was insuperable sexually for both husband and wife.

Of specific interest is the fact that 6 primarily impotent males with religious orthodoxy as the major etiological factor influencing their sexual dysfunction have been treated at the Foundation. Five of these men married women who have been categorized as evidencing vaginismus. For the wives as well as the husbands, the indisputable etiological factor in both partners’ sexual inadequacy was the overwhelming influence of religious orthodoxy.

Clinical histories illustrative of the potential sexual difficulties inherent in marriages between orthodox partners have been presented in the discussion on primary impotence and primary orgasmic dysfunction and will not be repeated.

Histories describing direct association of vaginismus with male sexual inadequacy are made available to underscore the fact that sexual dysfunction, regardless of whether originally invested in the male or the female partner, is a marital-couple rather than an individual problem.

Vaginismus is a psychophysiological syndrome affecting women’s freedom of sexual response by severely, if not totally, impeding coital function. Anatomically this clinical entity involves all components of the pelvic musculature investing the perineum and outer third of the vagina.

Physiologically, these muscle groups contract spastically as opposed to their rhythmic contractual response to orgasmic experience. This spastic contraction of the vaginal outlet is a completely involuntary reflex stimulated by imagined, anticipated, or real attempts at vaginal penetration. Thus, vaginismus is a classic example of a psychosomatic illness.

Vaginismus and Female Sexual Dysfunction

Vaginismus is one of the few elements in the wide pattern of female sexual dysfunctions that cannot be unreservedly diagnosed by any established interrogative technique. Regardless of the psychotherapist’s high level of clinical suspicion, a secure diagnosis of vaginismus cannot be established without the specific clinical support that only a direct pelvic examination can provide.
Without confirmatory pelvic examination, women have been treated for vaginismus when the syndrome has not been present.

Conversely, there have been cases of vaginismus diagnosed by pelvic examination when the clinical existence of the syndrome had not been anticipated by therapists. The clinical existence of vaginismus is delineated when vaginal examination constitutes a routine part of the required complete physical examination. The presence of involuntary muscular spasm in the outer third of the vaginal barrel, with the resultant severe constriction of the vaginal orifice, is obvious.

The literature has remarked on an unusual physical response pattern of a woman afflicted with vaginismus. She reacts in an established pattern to psychological stress during a routine pelvic examination that includes observation of the external genitalia and manual vaginal exploration.

The patient usually attempts to escape the examiner’s approach by withdrawing toward the head of the table, even raising her legs from the stirrups, and/or constricting her thighs in the midline to avoid the implied threat of the impending vaginal examination. Frequently this reaction pattern can be elicited by the woman’s mere anticipation of the examiner’s physical approach to pelvic examination rather than the actual act of manual pelvic investigation.

When vaginismus is a fully developed clinical entity, constriction of the vaginal outlet is so severe that penile penetration is impossible. Frequently, manual examination can be accomplished only by employing severe force, an approach to be decried, for little is accomplished from such a forced pelvic investigation, and the resultant psychosexual trauma can make the therapeutic reversal of the syndrome more difficult.

The diagnosis of vaginismus can easily be established by a one-finger pelvic examination. If a nontraumatic pelvic exploration is conducted, and a markedly apprehensive woman is somewhat reassured in the process, the first step has been taken in a therapeutic reversal of the involuntary spasm of the vaginal outlet.

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

But there are a large number of women with significant homosexual experience during their early teenage years that, in time, have withdrawn from active homophile orientation to live socially heterosexual lives. When they marry, many are committed to orgasmic dysfunction by the prior imprinting of homosexual influence upon their sexual responsivity.

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

It is difficult to evaluate homosexual influence upon heterosexual function. There can be no question that both means of sexual expression will always be an integral part of every culture. So it has been for recorded time. The problems of sexual adjustment do not rest with those committed unreservedly to a specific pattern of response.

Rather, it is the gray-area dweller that creates for him or herself a sexually dysfunctional status. When moving from one means of sexual expression to the other for the first time, the sexual value system must be reoriented if the desired transfer of sexual identification is to be completed. Such was the problem of Mrs. G who had not been able to adapt her sexual value system to her elected heterosexual world when seen in therapy.

Homosexual or Lesbian Relationship

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

The presenting complaint was that Mrs. G had never been orgasmic in the marriage. Her childhood and adolescence were spent in a small Midwestern town as an only child of elderly parents. Her mother was 41 when she was born. Introverted as a teenager, the girl did well in school but had few friends and was not popular with male classmates. When she was 15 years old she formed a major psychosexual attachment to a high school teacher, who seduced the girl into a homosexual relationship.

The courtship continued for six months before physical seduction was accomplished. Once fully committed to the homosexual relationship, the girl matured rapidly in personality and took a great deal more care with her dress and person.

She vested total psychosexual commitment in her “teacher” throughout her high-school years. Full responsivity in the sexual component of the relationship developed slowly for the teenager, although she was occasionally orgasmic with manipulation within a few months of her first physical experience.

Initially, hers was primarily a receptive role, but as she matured in the relationship psychologically, mutual manipulation and oral-genital stimulation in natural sequence became part of the couple’s pattern of sexual expression. During the girl’s last year in high school, mutual sexual tensions were maintained at a high level, and physical release was sought by either or both women at a minimum frequency level of three to four times a week.

Both women were multi-orgasmic. Mrs. G has no history of heterosexual dating in high school.

There was physical separation when Mrs. G went to college, but since the separation represented a distance of only fifty miles, she and the teacher spent many weekends together.

However, toward the end of Mrs. G’s sophomore year in college, the high-school teacher was apprehended approaching other girls, was discharged, and left the geographical area.

Emotional Loss and Sex Drive

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

She dropped out of school for a semester, during which time she did very little but write long forgiving letters to her mentor, and even visited her for a ten-day period under the pretext of going to see friends. It was not until Mrs. G graduated from college that the homosexual relationship was finally terminated. During the four college years she had only two dates, both involving attendance at school events and of no sexual portent.

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

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

At age 25 Mrs. G deliberately took advantage of an available partner to attempt intercourse. This experience was sought purely from curiosity demand. There were several coital exposures with this eager but relatively inexperienced young man. She found herself repulsed by the man’s untutored, harsh approaches as opposed to those of her high-school teacher.

She was not physically responsive and found the seminal fluid objectionable. Added to this general rejection of heterosexual interest was the fact that shortly after establishing the sexual relationship there was a 10 day delay in the onset of a menstrual period.

Fear of Pregnancy

only contributed to her rejection of any psychosocial concept of heterosexual functioning. Shortly thereafter Mrs. G met her husband. He had been divorced six months previously for the stated reason that his wife had wanted to marry another man. There were two children of the marriage, both living with their mother. They were both lonely people and gravitated to each other. There was warmth and affection between them and a number of mutual interests, so they married.

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

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

The marriage, though warm and comfortable, for several years was essentially one of convenience. However, as time passed, the two partners grew closer together, learned to communicate and to exchange vulnerabilities. Yet there was no improvement in the wife’s sexual responsivity, and this became an increasingly important factor in their lives. Mrs. G had never told her husband of her homosexual experience and was guilt-ridden by the concept that her past sexual orientation might have precluded any possibility of effective response in her now desired heterosexual state. The marital couple was referred for treatment at her insistence.

Inadequate Orgasm In Women

In order to be considered 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.

For instance, orgasmic experiences 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, 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 the 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. It is fortunate that 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.

Primarily dysfunction women

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 and 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 histories 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 with relation 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 resolved into an established pattern of sexual release two or three times a week. There was the regularity of orgasmic return (frequently multi-orgasmic return) during intercourse.

In the twelfth year of the marriage, the couple 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 marital couple sexual encounter was either quite reduced or, on occasions, demandingly increased.

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 couple 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 two-week frequency of “wifely duty.”

Wife’s concept of sexual image

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 a provider with excessive alcohol intake and, in addition, 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. Her husband 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 a number of sexual experiences, and one brief engagement with coital connection was 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.

Male sexual dominance

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 diametrically 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 connections.

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 couple 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 (vulnerability exchange) 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.

For many women, one of the most frequent causes of 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 case history.

Lack of Orgasm

Mr. and Mrs. C was 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 a number of friends, none of them particularly close with the exception of 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 had been one of mutual petting and she had 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.

Female Masturbate

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. 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 marital couple was referred to the Foundation.

How does one overcome professionally the conditioning of an adult lifetime?

How many men could have met or continued 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?

Can necessary adjustments 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 and what possibility is there for positive stimulation of the biophysical structure?

These are the questions co-therapists should ask themselves when facing a problem such as that exemplified by the marital couple reported above.

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.

Professionals many times look for a specific influence or conditioning that predetermines sexual failure, and in most instances, it can be identified if the delving goes deep enough. There are, however, instances of neither positive nor negative dominance by either biophysical or psychosocial influence structures.

If a woman has never established a close juxtaposition between the biophysical and psychosocial systems of influence because she has lived in a protective vacuum, she will not have been stimulated to develop her own sexual value system and therefore will tend to neutralize most input material of sexual implication.

The case history below is presented to emphasize the fact that there need be no dominant influence (either positive or negative) in the development of primary orgasmic dysfunction.

Non-sexual Dominance

Mrs. B was an only child of parents in their thirties when she was born. Both parents, teachers in a small, church-oriented college, were more restrained by the habit of lifestyle and their own relationship than by religious influence. The child did not develop as an extension of their presumed intellectual interests but became the “doll” whom they dressed exquisitely, handled little, and disregarded emotionally (as she perceived her upbringing).

There was no real source of female identification, no opportunity to establish a sexual value system.

All decisions on her behalf included the theoretically objective presentation of two alternatives, but parental, primarily mother’s preference was emphasized. Mrs. B had no recollection of making a definitive decision of her own until her sophomore year at college when she chose for a husband a relatively older man (he was in graduate school and seven years her senior). With this one decision, she again relinquished all opportunity for self-determination.

They married upon his graduation at the end of her junior year in college. His assumption of total authority in marriage appeared more by default than demand and continued through 11 years of marriage, during which two children were born.

During the first years of the marriage, Mrs. B maintained a complacent attitude toward her sexual role within the marriage. However, in the last six years of the marriage, she developed an intense desire to realize full sexual expression for herself and greater sexual pleasure for her husband.

During this latter period her husband’s behavior, though warm and protective, was highly restrained in sexual as well as other facets of the marital relationship. He participated in the Foundation’s program with complete willingness, although with little concept of what or how anything in the marriage could be changed.

Reared by an older aunt and uncle he had learned little, by direction or observation, of the potential for human interaction on a personal level. However, he fortunately had not been given any primarily negative indoctrination.

Mrs. B’s enthusiasm for an effective sexual relationship within the marriage was and still is defined as real, but she has been unable to overcome anesthesia to any sensory perception that she can relate to erotic arousal.

She has been unable to establish sensory reference within which to develop and relate her well-defined affection and regard for her husband. The two contributing systems of influence on sexual function have remained in displaced positioning one from the other.

To date, she has demonstrated insufficient emotional and/or intellectual capacity to establish a symbiotic state between her two systems of influence.

It is with mixed clinical reaction that the cotherapists regard the positive reaction of Mr. B to therapy. His response was one of delighted enthusiasm to the concept of interaction marked by both physical and verbal communication. His feeling for his wife was intensified and he has become completely comfortable in a demonstrative marital role.

While both partners feel that the alteration in the quality of the marital relationship is of significant proportion, the therapy has in fact failed to achieve the aim of reversal of the presenting distress. This case represents a strikingly intense degree of negative conditioning, yet there was little of content in the history that could be termed specifically negative in its rejection of sexual expression.

This case also represents an example of the possible clinical warning system revealed by a negative reaction to the use of a moisturizing lotion as a medium of physical exchange. Mrs. B found its use “distracting” and of little meaning to the exchange with her partner, while Mr. B found it to be the crucial contribution to establishing his initial ability to touch and feel with comfort and receptivity.