Key diagnostic points

• Persistent or recurrent delay in, infrequency of, or absence of orgasm despite adequate stimulation and desire.
• Symptoms present for at least several months and cause significant distress or interpersonal difficulty.
• Differentiate from low sexual desire disorder, sexual pain disorders, effects of substances/medications (notably SSRIs) and relationship factors.

Common causes & contributing factors

Biological

• Hormonal (hypogonadism, menopause), neurological injury, diabetes, vascular disease.
• Medications: SSRIs, antipsychotics, some antihypertensives and recreational drugs.
• Pelvic surgery, pelvic floor dysfunction, or chronic pain interfering with stimulation.

Psychological & interpersonal

• Performance anxiety, past sexual trauma, depression, body image concerns.
• Relationship issues: poor communication, mismatch in sexual scripts, partner dysfunction.
• Cultural/religious beliefs, lack of sexual education, and shame regarding genital stimulation.

Assessment checklist

1. Sexual history: onset (lifelong vs acquired), context (partnered vs solo), orgasm with masturbation vs partnered sex, frequency and situational factors.
2. Medication review: SSRIs, antipsychotics, opioids, and recent substance use.
3. Medical review: endocrine tests (testosterone, thyroid), pelvic exam, consider pelvic floor assessment and neuropathic evaluation if indicated.
4. Psychosocial screen: trauma history, mood/anxiety disorders, relationship assessment, and sexual knowledge/expectations.
5. Use validated measures (e.g., Female Sexual Function Index) to quantify domains and monitor treatment.

Treatment options — practical, evidence‑informed

Psychoeducation & normalisation

• Explain sexual response variability, encourage exploration and communication, normalise masturbation and clitoral stimulation as effective routes to orgasm.

Psychological interventions

• Sex therapy and CBT focused on sensate focus exercises, graded exposure to genital touch, reducing performance anxiety and behavioural experiments.
• Trauma‑informed therapy where sexual trauma contributes to avoidance or dissociation.

Behavioural & partner strategies

• Sensate focus (non‑goal directed touch), directed masturbation training, use of vibratory stimulation devices to enhance genital stimulation, and couples’ communication exercises.

Medical & physical therapies

• Review and modify offending medications where safe (e.g., consider switching antidepressant or dose reduction under supervision).
• PDE5 inhibitors or topical agents have limited evidence; some small studies show benefit in specific subgroups.
• Pelvic floor physiotherapy for hypertonicity or pain; referral to sexual medicine for complex cases.

Adjunctive approaches

• Mindfulness‑based therapies to enhance present‑moment sexual experience and reduce distraction.
• Address comorbid depression/anxiety with appropriate treatments which may indirectly improve sexual function.

Combine interventions—psychological, relational and medical—tailored to individual needs and preferences.

When to refer

• Suspected organic causes (neurological injury, endocrine abnormalities), pelvic pathology, or failed first‑line psychosexual therapy.
• Complex comorbidity (severe trauma, refractory depression) or medicolegal issues—refer to sexual medicine, gynaecology, urology or specialist psychiatry as appropriate.