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Iran J Reprod Med Vol.13. No. 7. pp: 403-412, July 2015 Original article

The existing therapeutic interventions for orgasmic disorders: recommendations for culturally competent services, narrative review

Zahra Salmani1 Ph.D. Student, Ali Zargham-Boroujeni2 Ph.D., Mehrdad Salehi3 M.D., Therese K.Killeen4 Ph.D., Effat Merghati-Khoei5 Ph.D.

1. Student Research Center, School Abstract Mursing and , Isfahan University of Medical Science, Background: In recent years, a growing number of interventions for treatment of Isfahan Iran. female orgasmic problems (FODs) have emerged. Whereas is a extra 2. and Midwifery Care biologically and learnable experience, there is a need for practitioners that to be able Research Center, Faculty of to select which is the most appropriate to their context. Nursing and Midwifery, Isfahan University of Medical Sciences, Objective: In this critical literature review, we aimed to assess areas of controversy Isfahan Iran. in the existing therapeutic interventions in FOD with taking into accounted the 3. Psychosomatic research center, Iranian cultural models. Isfahan University of Medical Materials and Methods: For the present study, we conducted an extensive search Sciences, Isfahan Iran. 4. Addiction Science Division, of electronic databases using a comprehensive search strategy from 1970 till 2014. Medical University of South This strategy was using Google Scholar search, “pearl-growing” techniques and by Carolina, Charleston, South hand-searching key guidelines, to identify distinct interventions to women's Carolina, USA. orgasmic problem therapy. We utilized various key combinations of words such as:" 5. Sexual and Family Health Division in Brain and Spinal orgasm" OR "orgasmic "," female orgasmic dysfunction" OR Female anorgasmia Injury Research Center (BASIR), OR Female Orgasmic Disorder ", orgasmic dysfunction AND treatment, “orgasm Tehran University of Medical AND intervention”. Selection criteria in order to be included in this review, studies Sciences, Tehran, Iran. were required to: 1 employ clinical-based interventions, 2 focus on FOD.

Results: The majority of interventions (90%) related to non-pharmacological and other were about pharmacological interventions. Self-direct is suggested as the most privilege treatment in FOD. Reviewing all indicates couple therapy, sexual skill training and seem to be more appropriate to

be applied in Iranian clinical settings. Conclusion: Since many therapeutic interventions are introduced to inform sexually-related practices, it is important to select an intervention that will be Corresponding Author: culturally appropriate and sensitive to norms and values. Professionals working in Effat Merghati-Khoei, Keshavarz Blv; Imam Khomeini Hospital, the fields of health and sexuality need to be sensitive and apply culturally Reyhaneh Bld, Level 3; Tehran, appropriate therapies for Iranian population. We further suggest community well Iran. defined protocols to screen, assessment and management of women’ sexual Email: [email protected] problems such as FOD in the Iranian settings. Tel: (+98) 21 66581560-1

Key words: Iranian women, Orgasm, , . Received: 8 September 2014 Revised: 19 January 2015 This review extracted from Ph.D. thesis. (Zahra Salmani) Accepted: 18 March 2015

In management of sexual problems, Introduction considerable variation exists in the therapeutic interventions. The range of different he notion that culturally competent therapeutic interventions for women's services should be available to people orgasmic problems has been growing over the who are seeking help in sensitive topics recent years, alongside an increasing interest T in orgasm related therapies to inform sexual such as sexuality has been debated for many and reproductive health related practices (4- decades. Cultural safety and cultural 6). While the term "sex therapy" is frequently competency are currently important topics for used to describe how women's orgasmic sexual health professionals (1, 2). Culturally problems are treated, far more terms are used competent services will be warranted if to describe the therapy of orgasmic problems. therapeutic interventions adapted to the given The profusion of interventions can mask some culture (3). of the basic decisive factors in therapy that the Salmani et al different therapeutic interventions share, and sexual encounters mostly is contextual and also lead to some confusion regarding which affected by their sexual scripts (23-25). It is therapy is most appropriate in a given culture necessary to pay attention to those factors at or context. the time of assessment or implementing an No question, there are number of intervention (26). This paper does not argue interventions introduced worldwide to treat that the various orgasm-related therapies are women's orgasmic problems (7). The unnecessary, but rather seeks to draw psychological and cultural valuation and together and review the full range of 'meaning' of orgasm are complex and therapeutic interventions available to assist considerably different in various societies (8). future professionals in selecting therapeutic Sometimes the interventions are not efficient intervention and adopt them into their cultures. because they are not culturally sensitive or Since the existing evidence-based therapies appropriate (9, 10). There is a need for are fused with Western norms, scholars and researchers and practitioners to be able to investigators need to determine whether such identify areas of controversy in the existing treatments are equally effective for other therapeutic interventions. cultures or whether new culturally sensitive Orgasmic problem is the second most therapies are necessary (27). common sexual complaint reported by The primary purpose of this paper is to women. The high prevalence of orgasmic critically review the existing literature problems and its consequences in one's life regarding domains of therapies such as lead researchers and professionals to study pharmacological and non-pharmacological for about etiology and find effective therapies for FODs and to explore areas of cultural these problems (11-13). According to the controversy in the contexts such as Iran. The Diagnostic and Statistical Manual of Mental secondary purpose of this paper is to suggest Disorders4th ed. (DSM-IV), Female orgasmic implications for clinical practice to be culturally disorder (FOD) is „„Persistent or recurrent sensitive and competent in Iranian settings. In delay in, or absence of, orgasm following a order to reach out the benefit of this review, normal excitement phase”. The DSM-V adds we need to answer the following important some explanations to the nature of FOD: questions: “reduced intensity, delay, infrequency or 1. What make a therapeutic intervention for absence of orgasm. The symptoms must last FOD culturally sensitive in Iranian-Islamic for at least six months and not be related to context? other physical, mental or relational problem” 2. Are the existing interventions for FOD (14). Epidemiologic research estimated adapted and/or tested in the Iranian or prevalence of orgasmic dysfunction from similar culture? approximately 20-40% (15, 16). Prevalence of 3. What possible recommendations for orgasm problem in US and Australia have culturally competent services can be made estimated between 21 to 29 percent (17, 18). for Iran or other similar contexts? Data from a study of 40-80-year-old adults in 29 countries found even higher prevalence of Materials and methods problems with orgasm among women in Asian countries (19). Iranian sexual studies have This is a narrative review of literature been restricted to prevalence and related related to interventions for FODs. This review factors of orgasmic disorders. A study with was approved by the ethic committee of 2526 Iranian women estimated the prevalence Isfahan University of Medical Sciences in of orgasmic disorder about 37% (20). Another 2014. descriptive study reported a rate of 21% orgasm disorder among a sample of 1456 Search Strategy Iranian women (21). Papers which used or discussed relevant FOD a multidimensional problem that interventions were identified by undertaking a influenced by affected personal, sociocultural, high sensitive search using Google scholar, religious and political contexts factors (22). PubMed(including Medline and CINAHL), Although genetic bases of women‟s orgasmic Embase, Psyc INFO, Cochrane, and hand- dysfunction are suggested, however, overall searching key journals and guidelines of pleasure experienced by women through their intervention from 1970-2014. We utilized

404 Iranian Journal of Reproductive Vol. 13. No. 7. pp: 403-412, July 2015 Therapeutic Interventions and orgasmic problem in women various key combinations of words such as: conducted in a couple setting sex therapy and "orgasm" OR "orgasmic", "female orgasmic sexual skills training were the most frequently dysfunction" OR “Female anorgasmia” OR studied interventions over the years. “Female Orgasmic Disorder", “orgasmic Compared to results of this review are not dysfunction AND treatment”, “orgasm AND completely consistent, and this discrepancy intervention” selection criteria in order to be may be linked to several factors that differed included in this review, studies was required between studies, such as the meanings were (to: 1 employs clinical-based interventions, 2) used to define and operationalize the term focus on FOD. Relevant papers were "orgasm". screened and details of the interventions The results do suggest that direct extracted. All interventions were classified masturbation can be empirically valid and based on their theoretical framework. At first, effective technique for lifelong FOD. Findings we found 980 articles based on the key words from this review put emphasis on meaningful in the title or abstract. Of 980 articles, 590 effects of psychological interventions such as were selected for full review. From these marital therapy, sexual skill training and sex articles 98 were selected for the final review if therapy on severity and sexual satisfaction in they had introduced at least one therapeutic FODs. intervention. After omitting duplicated The inconsistent use of orgasm-related interventions only 25 distinct interventions concepts, for example, subjective and/or were identified. A level of evidence is given to reflexive orgasm, pleasurable or not each individual study based on guideline in pleasurable sexual encounters are found (2010) (28). important limitations of the studies had used the interventions. This does not allow one to Results reach a certain conclusion. Researcher had used several therapy techniques in FOD by Overall, the narrative review of available various outcomes implemented (28). research suggests that interventional therapy Interventional outcomes studies for the treatment of FOD have shown in Table I. of FOD are restricted and often looked Many of the interventions introduced were controversial. The studies included in this implemented in the western cultures which review have introduced non-pharmacological make broad generalizability difficult for (directed masturbation, sensate focus, practice in FOD. Limited sexual knowledge cognitive-behavioral therapy, systematic related to sexuality was found as an important desensitization, sex therapy, couple influencing factor in sexual dysfunction among communication training, educational Iranian patients (20, 29, 30). Recent Iranian intervention, sexual health model, hypnotic study examined the effectiveness of one-on- technique, anxiety reduction techniques, coital one PLISSIT (P: Permission, LI: limited alignment technique (CAT), biblotherapy, information, SS: specific suggestion, IT: kegel exercise, orgasm consistency training intensive care) model against the group-based (OCT), Sex “Aids”, Basic counseling, sexual health model in women with sexual psychotherapeutic interventions for the dysfunction. In this study PLLISIT model was individual woman, trauma therapy, modeling, significantly effective on helping to solve the role playing) and pharmacological treatments women's sexual problems. Sexual health (testosterone, , tibolone, , model was more efficient than others in bupropion, arginMax). Compared to motivating women to take action toward pharmacological treatment options, non- solving their own problems by using group pharmacological interventions have two main members' sexual experiences (31). Another advantages; that is, they do not have negative Iranian clinical trial also showed effectiveness physical , and they aim at the re- of PLISSIT model on sexual dysfunction of establishment of sexual functioning and the women in city of Zanjan (32). increase of sexual satisfaction beyond the A semi-experimental research was shown reduction of aim manifestation. on 30 Iranian females aged between 20-40 Results showed that psychological years old. The females received interventional interventions are superior to wait-list in trainings in 10 sessions within two months. improving symptom severity and sexual The obtained results revealed that sex therapy satisfaction with a significant effect size if with cognitive-behavioral approach would be

Iranian Journal of Vol. 13. No. 7. pp: 403-412, July 2015 405 Salmani et al helpful in treatment of orgasmic disorder (33). asserration training, behavioral analysis, Results have been shown the nature of most behavioral rehearsal, behavioral sex therapy, therapy necessitate that patients completing history taking, treatment cognitive therapy, assigned and exercises, maintaining anterior fornix erogenous (AFE) zone motivation and resolving sociocultural barriers stimulation, new functional-sexological between clinician visits contributes to positive treatment, sex history, group therapy, outcomes of therapy. Techniques that used sexological examination, sexological frequently with other in combination treatment interview, mindfulness and yoga practices (4, approaches methods were behavioral therapy, 34-38).

Table I. Interventional outcomes studies for the treatment of female orgasmic dysfunction

Evidence Author and year N Treatment method Results grade The results indicated a 50% In vivo desensitization, sex therapy, . Cooper 1970 (39) 50 improvement in sexual functioning post- 4 No control group therapy Increase in orgasm with masturbation Primary and secondary anorgasmia Lopiccolo 1985 (40) 31 /3mo follow-up ;gains maintained - CBT sexual therapy for 5 1-hr session /improved Secondary anorgsmia Fitchenlibman 1983 No change in orgasm; increase in 23 Sexual information relaxation, kegel ex. Direct 3 (41) enjoyment of noncoital sexual caressing masturbation, sexual communication training, Orgasmic dysfunction Biblotherapy (including Van Lankveld 2001 9 communication skills, sexual education and CBT No improvement in orgasm - (42) with telephone support Sensate focus, directed masturbation, sensual There was a 64% 76% improvement in DeAmicus 1985 (43) 22 awareness, communication training, modification of sexual functioning at post-treatment, 2 sexual behaviors. No control group and this was maintained at follow-up There was a 15% to 40% improvement Cognitive behavioral therapy, communication in sexual functioning at 3 months Heiman 1983 (44) 41 training, directed masturbation, sensate focus, 2 follow-up systems conceptualization. Wait-list control group

The results demonstrated 25% Group couples communication skills & improvement in sexual functioning for Kilman 1986 (45) 55 vs. group couples sexual skills. These two groups both treatment groups at post-test. These 2 compared to a control group results were maintained at 6 months follow-up The women demonstrated significant Evaluated the effectiveness of a group CBT and improvements in their FSFI scores at Smith 2008 (46) 25 bibliotherapy program for women with sexual 3 post-therapy, as well as improvements dysfunction. No control group in most FSFI domain scores There was no control group for this Sensate focus, couples therapy, systematic study, but the success rate ranged from Masters 1970 (47) 342 desensitization, sex education and communication 3 77% - 83%. The follow-up success rate training after 5 years was 82% The results demonstrated an Systematic desensitization, directed masturbation & improvement of 95% in levels of sexual Kuriansky 1982 (48) 19 assertiveness training for the treatment condition. No 4 dysfunction a post-therapy, and 84% at control group two year follow-up Both groups of women made improvements in 2 of the 4 sexual Group intervention including orgasm training was behavior measures. The women who Hurlbert 1993 (49) 39 compared to group intervention alone for women 2 received orgasm training showed greater with HSD sensual arousal and sexual assertiveness at post-treatment and follow-up After therapy, respondents experienced Evaluated the effectiveness of individual CBT for the lower levels of sexual dysfunction, more McCabe 2001(50) 200 treatment of sexual dysfunction: 95 males, 105 positive attitudes to sex, and fewer 3 females. No control group aspects of their relationship affected by their sexual dysfunction Success rate was 65%, with few drop- Behavioral sex therapy for 365 married couples with outs. Amount of sensate focus in last Sarwer 1997(51) 370 3 a range of sexual dysfunctions. No control group week of therapy was the strongest predictor of success Pre- and postmenopausal women with and without female sexual dysfunction 6at-home sessions of 55%increased orgasm; non-female of Bilups 2001 (52) 32 - clitoral vacuum therapy; 5-15m with or without sexual dysfunction 42%increase orgasm partner CBT: Cognitive-behavioral therapy HSD: Hypoactive sexual disorder

406 Iranian Journal of Reproductive Medicine Vol. 13. No. 7. pp: 403-412, July 2015 Therapeutic Interventions and orgasmic problem in women

Table II. Therapeutic interventions and challenges

Intervention References Challenges The act of masturbation is prohibited in Islam, and must be avoided by the believers. It definitely is Directed masturbation (40, 53-59) a sin, and an evil act. Therefore Not possible or feasible to consider an intervention technique for orgasmic dysfunction in Iranian women. Systematic (54, 55, 60) In this way proposed exercises not to be consist of masturbation or other same activity that desensitization (57, 61-66) forbidden in Iranian context of religion. In Islam this method to issue fatwa from number of mojtahedes legitimate on the condition that not hypnosis (55, 65, 67-69) abused and for miss reason .this way sex therapist must be consider all of the aspect of legitimate problem and context of Iranian women in use of this technique. This way is acceptance in condition of each couple not reasonable demand and out of the traditional Couples sex therapy (47) and controversial societies from other. The use of written materials or computer programs, or the listening/viewing of audio/videotapes for Biblotherapy (42, 70-76) the purpose of gaining understanding or solving problems relevant to a person’s developmental or therapeutic needs in Iranian culturally defined. In Iranian context, sexual relationship is a private issue therefore in this technique not tolerate in Modeling (34) Iranian couple context that to be model for others and also view of film in this connection. (71) Sexual skills training (53, 77, 78) Differentiating sexual consent skill or refusal skill that matches with culturally defined (79) The part of masturbation is forbidden in religious context and must be revised and modified in Sexual health model (80) intervention treatment. Psychodynamic and (37) Not cultural restricted in use of this method in privacy condition insight-oriented therapy In this method women must be use of for masturbation or watching the kind of picture or Sex Aids (81-83) home video that those in Islam not legitimate and this behavior is haram and prohibition. Sexual stimulants are not universal phenomena and can be influenced by cultural diversity. Orgasm consistency (56) Use of masturbation as a part of this intervention is forbidden. training

Discussion services employ interventions "those in which the general treatment approach is determined Having outlined the range of therapeutic by the client‟s ethnicity or in which many interventions identified to address women's different features are based on cultural considerations” (84). disorgasmia, we contrasted these We identified 98 studies those had interventions with Iranian clinical culture. introduced at least one of the therapeutic Clearly, many of them come from diverse contexts with different cultures and have interventions for FOD. The studies varied in different approaches to managing orgasmic the description and assessment of this disorders. Examining these interventions problem. Few studies have indicated strong indicates the need for different and culturally impact of context and culture on sexual sensitive intervention and appropriate attitude and behavior and definition of what is approaches to treatment of Iranian women's considered sexual norms (25, 85, 86). The disorgasmia too. majority of the interventions were behavioral Recent studies and reviews have argued and cognitive-behavior basically. This finding on the effectiveness of the culturally adapted is not surprising because orgasm is subject to sexually-related interventions comparing learning and erotic behaviors must be learnt traditional un-adapted therapies. A culturally (71, 87, 88). According to Domenech sensitive intervention would change a specific Rodríguez within a pragmatist paradigm, feature of standard treatment practice (e.g. cultural adaptation models were mainly delivering therapy in the client's own developed to manipulate behavioral and language) (9, 84). Culturally competent cognitive based interventions (27).

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Many of those therapeutic interventions for interventions for FODs may happen by FODs were in practical and exercise format. seriously consideration of cultural values and The practices may be advantageous because incorporating spirituality and religion codes. they are more cost-effective, provide effective We must consider community members' care for more women, and promote self- involvement in development, taking into efficacy of clients throughout their sexual account their acculturation level, address lives. However, these interventions may be race, prejudice, and discrimination, and offer troublesome for women whose cultural values strategies to empower the clients. The related to sexuality is traditionally scripted and inclusion of community members in the may be especially unacceptable in process of adapting or developing a therapy is conservative communities. The Iranian seminal to make sexually-related interventions traditional culture of sexuality is constructed in efficient. However, none of the reviewed a typical patriarchal society, and this studies had declared community members' underpins the issues around women and involvement in the process of intervention sexuality. Analysis of this ideology shows the development. impact of men„s attitudes on women„s sexual health (89). In such contexts, women do not Recommendations for interventions talk about sex freely or never touch their own Our recommendations for therapeutic sexual organs; and women mainly perceive interventions from this review can be inspired and experience sexual behaviors in the by the Cultural Accommodation Model (CAM) context of and with their potential of counseling (94). The key component of husbands (90). CAM is to identify current culturally specific Alternatively, a few studies used concepts and models from the community to interventions in couple therapy format (4, 6, fill in the cultural gaps and accommodate the 63). It may be easier to make cultural models to therapists' working approaches. It adaptations in the process of couple therapy. sounds important to consider the practitioners' More likely some of culturally competent cultures and assumptions toward women and therapists do some adaptations already. sexuality. A range of assumptions can be However, such adaptations may be organized into a spectrum as follows: personalized by given therapist so that cultural  Social dignity of a female patient is much norms and codes can be manipulated by the more important than speaking out and therapist based on her/his beliefs and system intervening her sexual concerns. of values. Therefore, it may be difficult to  Religiosity has significant effects on Iranian assess their cultural sensitivity. women‟s sexual understandings. For example masturbation method was a  Sexually-related therapies are very open and substantial method supported by scholars. embarrass the patient. This exercise is believed to benefit women  The ways Iranian couples negotiate their with orgasmic problems for a number of sexual encounters and the process of reasons (91). Inversely some of research consent are unknown and sexual life keeps showed masturbation has a broad range of its secrecy. effects on the human psyche and  Difficulty and undesirable in questioning psychological defense mechanisms, for Iranian women about their sexual needs and example passive aggression, denial, and interests. autistic fantasy (92, 93). Although,  Iranian women scarify their sexual pleasure masturbation is forbidden in Islam; it is to satisfy their sexual duty through the possible some of even Muslim therapists marital interactions. acculturate their therapeutic approaches and Thus, in this spectrum we have highly suggest the clients‟ masturbation as the first conservative or solely medical views. Before line treatment (51). Those of culturally the 1960s, many women were abashed and competent therapists would suggest mutual anxious about seeking sexual pleasure masturbation without explicitly naming it because of the current social view that a "masturbation". 'good' woman simply tolerated her husband's The techniques that found culturally sexual advances (11, 95). Sexual dysfunction problematic showed with their challenges in in women may commonly be experienced in Table II. We argue that changes in existing the context of psychosocial issue, politics,

408 Iranian Journal of Reproductive Medicine Vol. 13. No. 7. pp: 403-412, July 2015 Therapeutic Interventions and orgasmic problem in women economics, social class, cultural background, References relationship conflicts, and shame or embarrassment about sexuality due to 1. Polaschek N. Cultural safety: A new concept in religious beliefs or familial inhibitions (4, 11, nursing people of different ethnicities. Journal of 26, 35, 96). Advanced Nursing-Institutional Subscription 1998;27:452-457. A study comparing multiple ethnic groups 2. Betancourt JR, Green AR, Carrillo JE, Ananeh- revealed that Asian women report more Firempong O. Defining cultural competence: a sexual complaints and higher instances of practical framework for addressing racial/ethnic anorgasmia (4). Religiosity has significant disparities in health and . Reports 2003; 118: 293. effects on Iranian women‟s sexual 3. Merghati-Khoei E, Richters J. Concepts of sexuality understandings; and that experts working in and health among Iranian women in Australia. Aust the fields of treatment of orgasm problem Fam 2008; 37: 190-192. need to be sensitive to the notion that some 4. IsHak WW, Bokarius A, Jeffrey JK, Davis MC, Muslim women may not speak out their Bakhta Y. Disorders of orgasm in women: A literature review of etiology and current treatments. The sexuality as an indicator of submission to Journal of Sexual Medicine 2010; 7: 3254-3268. religious codes, of and of being an 5. Opperman E, Braun V, Clarke V, Rogers C. “It Feels idealized Muslim wife (97). So Good It Almost Hurts”: Young Adults' Experiences of Orgasm and Sexual Pleasure. Journal of Sex Research 2013; 1-13. Conclusion 6. Frühauf S, Gerger H, Schmidt HM, Munder T, Barth J. Efficacy of psychological interventions for sexual In this paper, we described a range of dysfunction: a systematic review and meta-analysis. therapeutic interventions implemented to Archives of Sexual Behavior 2013; 42: 915-933. 7. Meston CM, Bradford A. Sexual dysfunctions in address women's disorgasmia. We have women. Annu Rev Clin Psychol 2007; 3: 233-256. examined whether the existing interventions 8. Graham CA. The DSM diagnostic criteria for female are culturally sensitive or applicable in the orgasmic disorder. Archives of Sexual Behavior Iranian contexts. We found that, while the 2010; 39: 256-270. 9. Fabes RA, Martin CL. Gender and age stereotypes interventions are profoundly effective in of emotionality. Personality and Social various contexts, there can be clear Bulletin 1991; 17: 532-540. differences in effectiveness and 10. Shirpak KR, Ardebili HE, Mohammad K, Maticka‐ appropriateness of them in the given contexts Tyndale E, Chinichian M, Ramenzankhani A, et al. such as Iran, where women's sexuality is Developing and testing a sex education program for the female clients of health centers in Iran. Sex socially constructed and culturally regulated. Education 2007; 7: 333-349. Since many therapeutic interventions are 11. Lavie-Ajayi M, Joffe H. Social representations of introduced to inform sexually-related female orgasm. Journal of Health Psychology 2009; practices, it is important to select an 14: 98-107. 12. Redelman M. A general look at female orgasm and intervention that will be culturally appropriate anorgasmia. Sexual Health 2006; 3: 143-153. and sensitive to religion. Professionals 13. Harris JM, Cherkas LF, Kato BS, Heiman JR, working in the fields of health and sexuality Spector TD. Normal Variations in Personality are need to be sensitive and apply culturally Associated with Coital Orgasmic Infrequency in appropriate therapies for Iranian women. We Heterosexual Women: A Population‐Based Study. J Sex Med 2008; 5: 1177-1183. suggest community well defined protocols to 14. Widiger TA, Simonsen E. Introduction to the special screen, assessment and management of section: The American Psychiatric Association's women‟s sexual problems such as FOD in the research agenda for the DSM–V. Journal of Iranian settings. Personality Disorders 2005; 19: 103-109. 15. Hayes RD, Bennett CM, Fairley CK, Dennerstein L. ORIGINAL RESEARCHEPIDEMIOLOGY: What can Acknowledgments Prevalence Studies Tell Us about Female Sexual Difficulty and Dysfunction? J Sex Med 2006; 3: 589- We thank the Isfahan university of Uedical 595. Sciences for the Approval of this Research 16. Bancroft J, Loftus J, Long JS. Distress about sex: A national survey of women in heterosexual with the Ethical code of 393377. relationships. Arch Sex Behav 2003; 32: 193-208. 17. Laumann E, Glasser D, Neves R, Moreira E. A Conflict of interest population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of The authors have no conflict of interest to America. International Journal of Impotence declare. Research 2009; 21: 171-178.

Iranian Journal of Reproductive Medicine Vol. 13. No. 7. pp: 403-412, July 2015 409 Salmani et al

18. Richters J, Grulich AE, Visser RO, Smith A, Rissel 34. Almas E, Landmark B. Non-pharmacological CE. Sex in Australia: Sexual difficulties in a treatment of sexual problems–A review of research representative sample of adults. Australian and New literature 1970–2008. Sexologies 2010; 19: 202-211. Zealand Journal of Public Health 2003; 27: 164-170. 35. Meston CM, Hull E, Levin RJ, Sipski M. Disorders of 19. Laumann EO, Nicolosi A, Glasser DB, Paik A, orgasm in women. J Sex Med 2004; 1: 66-68. Gingell C, Moreira E, et al. Sexual problems among 36. Pereira VM, Arias-Carrión O, Machado S, Nardi AE, women and men aged 40–80 y: prevalence and Silva AC. Sex therapy for female sexual dysfunction. correlates identified in the Global Study of Sexual Int Arch Med 2013; 6: 37. Attitudes and Behaviors. International J Impot Res 37. Bitzer J, Brandenburg U. Psychotherapeutic 2005; 17: 39-57. interventions for female sexual dysfunction. Maturitas 20. Safarinejad M. Female sexual dysfunction in a 2009; 63: 160-163. population-based study in Iran: prevalence and 38. Heiman JR. Sexual dysfunction: Overview of associated risk factors. Int J Impot Res 2006; 18: prevalence, etiological factors, and treatments. J Sex 382-395. Res 2002; 39: 73-78. 21. Goshtasbi A, Vahdaninia M, Rahimi Foroushani A, 39. Cooper AJ. Frigidity, treatment and short-term Mohammadi A. Reproductive correlates of female prognosis. J Psychosom Res 1970; 14: 133-147. sexual dysfunctions in Kohgilouyeh-Boyerahmad 40. LoPiccolo J, Stock WE. Treatment of sexual Province: a population-based study. Payesh 2008; 1: dysfunction. J Consult Clin Psychol 1986; 54: 158- 67-73. 167. 22. Philpott A, Knerr W, Boydell V. Pleasure and 41. Fichten CS, Libman E, Brender W. Methodological prevention: when good sex is safer sex. Reprod issues in the study of sex therapy: effective Health Matters 2006; 14: 23-31. components in the treatment of secondary orgasmic 23. Dunn KM, Cherkas LF, Spector TD. Genetic dysfunction. J Sex Marital Ther 1983; 9: 191-202. influences on variation in female orgasmic function: 42. Van Lankveld JJ. Bibliotherapy in the treatment of A twin study. Biol Lett 2005; 1: 260-263. sexual dysfunctions: A meta-analysis. J Consult Clin 24. Gagnon JH. The explicit and implicit use of the Psychol 1998; 66: 702-708. scripting perspective in sex research. Annual Review 43. De Amicis LA, Goldberg DC, LoPiccolo J, Friedman of Sex Research 1990; 1: 1-43. J, Davies L. Clinical follow-up of couples treated for 25. Parker R. Sexuality, culture and society: shifting sexual dysfunction. Arch Sex Behav 1985; 14: 467- paradigms in sexuality research. Cult Health Sex 489. 2009; 11: 251-266. 44. Heiman JR, LoPiccolo J. Clinical outcome of sex 26. Mah K, Binik YM. Are in the mind or the therapy: effects of daily v weekly treatment. Arch body? Psychosocial versus physiological correlates Gen 1983; 40: 443-449. of orgasmic pleasure and satisfaction. J Sex Marital 45. Kilmann PR. The treatment of primary and secondary Ther 2005; 31: 187-200. orgasmic dysfunction: A methodological review of the 27. Rodríguez MMD, Baumann AA, Schwartz AL. literature since 1970. J Sex Marital Ther 1978; 4: Cultural adaptation of an evidence based 155-176. intervention: From theory to practice in a Latino/a 46. Smith WJ, Beadle K, Shuster EJ. The impact of a community context. Am J Community Psychol 2011; group psychoeducational appointment on women 47: 170-186. with sexual dysfunction. Am J Obstet Gynecol 2008; 28. Montorsi F, Basson R, Adaikan P, Becher E, Clayton 198: 697. e1- e7. A, Giuliano F, et al. Sexual medicine: Sexual 47. Lewis RW, Fugl‐Meyer KS, Bosch R, Fugl‐Meyer AR, dysfunction in Men and woman.Paris: Health Laumann EO, Lizza E, et al. Epidemiology/risk Publications Ltd 2010;10-11. factors of sexual dysfunction. J Sex Med 2004; 1: 35- 29. Shokrollahi P, Mirmohamadi M, Mehrabi F, Babaei 39. G. Prevalence of sexual dysfunction in women 48. Kuriansky JB, Sharpe L, O'Connor D. The treatment seeking services at centers in of anorgasmia: Long-term effectiveness of a short- Tehran. J Sex Marital Ther 1999; 25: 211-215. term behavioral group therapy. J Sex Marital Ther 30. Shirpak KR, Chinichian M, Maticka-Tyndale E, 1982; 8: 29-43. Ardebili HE, Pourreza A, Ramenzankhani A. A 49. Hurlbert DF, Apt C. The coital alignment technique qualitative assessment of the sex education needs of and directed masturbation: A comparative study on married Iranian women. Sexuality & Culture female orgasm. J Sex Marital Ther 1995; 21: 21-29. 2008;12:133-150. 50. McCabe MP. Evaluation of a cognitive behavior 31. Farnam F, Janghorbani M, Raisi F, Merghati‐Khoei therapy program for people with sexual dysfunction. E. Compare the Effectiveness of PLISSIT and J Sex Marital Ther 2001; 27: 259-271. Sexual Health Models on Women's Sexual Problems 51. Sarwer DB, Durlak JA. A field trial of the effectiveness of behavioral treatment for sexual in Tehran, Iran: A Randomized Controlled Trial. J dysfunctions. J Sex Marital Ther 1997; 23: 87-97. Sex Med 2014; 11: 2679-2689. 52. Billups KL, Berman L, Berman J, Metz ME, Glennon 32. Rostamkhani F, Ozgoli G, Khoei EM, Jafari F, Majd ME, Goldstein I. A new non-pharmacological vacuum HA. Effectiveness of the PLISSIT-based Counseling therapy for female sexual dysfunction. J Sex Marital on sexual function of women. Journal of Shahid Ther 2001; 27: 435-441. 53. LoPiccolo J, Lobitz WC. The role of masturbation in Beheshti School of Nursing & Midwifery 2012;22:1-9. the treatment of orgasmic dysfunction. Arch Sex 33. Gudarzi S. Female Orgasmic Disorder Treatment Behav 1972; 2: 163-171. Using Cognitive-behavioral Approach. Advances in 54. Andersen BL. A comparison of systematic Life Sciences 2014; 4: 196-199. desensitization and directed masturbation in the

410 Iranian Journal of Reproductive Medicine Vol. 13. No. 7. pp: 403-412, July 2015 Therapeutic Interventions and orgasmic problem in women

treatment of primary orgasmic dysfunction in 72. Zeiss RA. Self-directed treatment for premature females. J Consult Clin Psychol 1981; 49: 568-570. . J Consult Clin Psychol 1978; 46: 1234. 55. Anderson BL. Primary orgasmic dysfunction: 73. Glasgow RE, Rosen GM. Behavioral bibliotherapy: A Diagnostic considerations and review of treatment. review of self-help behavior therapy manuals. Psychol Bull 1983; 93: 105-136. Psychol Bull 1978; 85: 1-23. 56. Hurlbert DF, White LC, Powell RD, Apt C. Orgasm 74. van Lankveld JJ, Everaerd W, Grotjohann Y. consistency training in the treatment of women Cognitive‐behavioral bibliotherapy for sexual reporting hypoactive sexual desire: An outcome dysfunctions in heterosexual couples: A randomized comparison of women-only groups and couples-only waiting‐list controlled clinical trial in the Netherlands. groups. J Behav Ther Exp Psychiatry 1993; 24: 3-13. J Sex Res 2001; 38: 51-67. 57. Munjack D, Cristol A, Goldstein A, Phillips D, 75. Jack SJ, Ronan KR. Bibliotherapy practice and Goldberg A, Whipple K, et al. Behavioural treatment research. School Psychology International of orgasmic dysfunction: a controlled study. Br J 2008;29:161-182. Psychiatry 1976; 129: 497-502. 76. Leiblum SR. Becoming Orgasmic. By Julia R. 58. Trudel G, Laurin F. The effects of bibliotherapy on Heiman and Joseph LoPiccolo. J Sex Educ Ther orgasmic dysfunction and couple interactions: An 1997; 22: 52-53. experimental study. Sex Marital Ther 1988; 3: 223- 77. Hartman WE, Fithian MA. Treatment of sexual 228. dysfunction. Am J Fam Ther 1974; 2: 68-80. 59. Hoseini SS. Masturbation: Scientific Evidence and 78. Kilmann PR, Boland JP, Norton SP, Davidson E, Islam‟s View. J Relig Health 2013: 1-6. Caid C. Perspectives of sex therapy outcome: a 60. Auerbach R, Kilmann PR. The effects of group survey of AASECT providers. J Sex Marital Ther systematic desensitization on secondary erectile 1986; 12: 116-138. failure. Behav Ther 1977; 8: 330-339. 79. LoPiccolo J, Miller VH. Procedural outline: Sexual 61. Everaerd W, Dekker J. Treatment of male sexual enrichment groups. Couns Psychol 1975. dysfunction: Sex therapy compared with systematic 80. BeatriceBean'E R, Bockting WO, Rosser BS, Miner desensitization and rational emotive therapy. Behav M, Coleman E. The sexual health model: application Res Ther 1985; 23: 13-25. of a sexological approach to HIV prevention. Health 62. Kockott G, Dittmar F, Nusselt L. Systematic Educ Res 2002; 17: 43-57. desensitization of erectile impotence: A controlled 81. Westheimer RK, Lopater S, Westheimer, Lopater. study. Arch Sex Behav 1975; 4: 493-500. : A psychosocial perspective: 63. Mathews A, Bancroft J, Whitehead A, Hackmann A, Lippincott Williams & Wilkins; 2002:88. Julier D, Bancroft J, et al. The behavioural treatment 82. Leiblum SR, Wiegel M. Psychotherapeutic of sexual inadequacy: A comparative study. Behav interventions for treating female sexual dysfunction. Res Ther 1976; 14: 427-436. World J Urol 2002; 20: 127-136. 64. O'Gorman EC. The treatment of frigidity: a 83. Leiblum SR. After sildenafil: bridging the gap comparative study of group and individual between pharmacologic treatment and satisfying desensitization. The Br J Psychiatry 1978; 132: 580- sexual relationships. J Clin Psychiatry 2002; 63: 17- 584. 22. 65. Sotile WM, Kilmann PR. Treatments of psychogenic 84. Sue S, Zane N, Hall GCN, Berger LK. The case for female sexual dysfunctions. Psychol Bull 1977; 84: cultural competency in psychotherapeutic 619-633. interventions. Annu Rev Psychol 2009; 60: 525-548. 66. Sotile WM, Kilmann PR. Effects of group systematic 85. Hatfield E, Rapson RL. Passionate love/sexual desensitization on female orgasmic dysfunction. Arch desire: Can the same paradigm explain both? Arch Sex Behav 1978; 7: 477-491. Sex Behav 1987; 16: 259-278. 67. Sotile WM, Kilmann P, Follingstad DR. A sexual- 86. Baumeister RF, Twenge JM. Cultural suppression of enhancement workshop: Beyond group systematic female sexuality. Rev Gen Psychol 2002; 6: 166. desensitization for women's sexual anxiety. J Sex 87. Laan E, Rellini AH. Can we treat anorgasmia in Marital Ther 1977; 3: 249-255. women? The challenge to experiencing pleasure. Sex Relation Ther 2011; 26: 329-341. 68. Brown JM, Chaves JF. Hypnosis in the treatment of 88. Sanchez DT, Kiefer AK, Ybarra O. Sexual sexual dysfunction. J Sex Marital Ther 1980; 6: 63- submissiveness in women: Costs for sexual 74. autonomy and arousal. Pers Soc Psychol Bull 2006; 69. Gilmore LG. Hypnotic metaphor and sexual 32: 512-524. dysfunction. J Sex Marital Ther 1987; 13: 45-57. 89. Ahmad-Nia S. Women's work and health in Iran: a 70. Marrs RW. A meta-analysis of bibliotherapy studies. comparison of working and non-working mothers. Am J Community Psychol 1995; 23: 843-870. Soc Sci Med 2002; 54: 753-765. 71. Barbach LG. Group treatment of preorgasmic 90. Merghati-Khoei E, Whelan A, Cohen J. Sharing women. J Sex Marital Ther 1974; 1: 139-145. beliefs: what sexuality means to Muslim Iranian

Iranian Journal of Reproductive Medicine Vol. 13. No. 7. pp: 403-412, July 2015 411 Salmani et al

women living in Australia. Cult Health Sex 2008; 10: 94. Leong FT. Cultural accommodation model of 237-248. counseling. J Employ Couns 2011; 48: 150-152. 91. Laumann EO, Paik A, Rosen RC. Sexual dysfunction 95. Tepper MS. Sexuality and disability: the missing in the United States. JAMA, 1999; 281: 537-544. discourse of pleasure. Sex Disabil 2000; 18: 283- 92. Brody S, Costa RM. Sexual satisfaction and health 290. are positively associated with penile-vaginal 96. Tiefer L. Female sexual dysfunction: A case study of intercourse but not other sexual activities. Am J disease mongering and activist resistance. PLoS Public Health 2012; 102: 6-7. 93. Brody S, Weiss P. Vaginal orgasm is associated with Med 2006; 3: e178. vaginal (not clitoral) sex education, focusing mental 97. Merghati Khoei E, Whelan A, Cohen J. Sharing attention on vaginal sensations, intercourse duration, beliefs: What sexuality means to Muslim Iranian and a preference for a longer penis. J Sex Med women living in Australia. Cult health sex 2008; 10: 2010; 7: 2774-2781. 237-248.

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