THE TREATMENT OF CHRONIC FRIGIDITY BY

SYSTEMATIC DESENSITIZATION
ARXOLD A. LAZARUS, PHD.
The term frigidity is associated with a
wide range of conditions, most of which re-
fer to female hyposexuality. Frigidity need
not necessarily imply deficient sexual feel-
ing or desire per se, since some women who
are completely frigid in all heterosexual
situations are capable of orgastic experience
during masturbation. Apart from organic
factors (which are responsible for a minor-
ity of symptoms in young women) frigidity
may generally be regarded as a learned pat-
tern of behavior, although some females are
probably genetically unequipped to respond
erotically. Frigid women may be pIaced on
a continuum extending from those who basi-
cally enjoy coitus but fail to reach orgasm,
to those for whom all sexual activities are
anathema.
Acute but shortlived episodes of frigidity
are not uncommon during or .after preg-
nancy and lactation, defloration, physical
illness, and during periods of psychological
stress. Mild or temporary frigidity may also
be due to faulty sex technique and a variety
of misconceptions which majr usually be
corrected by appropriate instruction and
information. The present paper deals with
the treatment. of recalcitrant and persistent
cases of frigidity, many of which had failed
to respond to the usual run of psychiatric
techniques. -
While the present discussion desk with
frigidity as a specific psychosexual aberra-
tion, it must be understood that several
psychopathological conditions are often
heraIded by or result in impaired sexual
functioning (e.g., endogenous depression,
schizophrenia).
The patients discussed in this paper were
Department of Psychiatry and Mental Hygiene,
IGtwatersrand University Medical School, Johan-
nesburg. South Africa.
Reprinted from THE JOURNAL OF NERVOUS AND
selected from numerous cases of frigidity
in our records. Excluded from the present
survey are all cases in whom varying de-
grees of frigidity were present as a minor
part of a much broader neurotic or psychotic
spectrum. The 16 patients who comprise the
present sample all complained of frigidity
as a monosymptomatic or primary disturb-
ance. Of the present series, five patients had
been referred by general practitioners, three
were referred by gynecologists, one was re-
ferred by a psychiatrist, and seven had been
recommended by previous patients. Cases
were only accepted for therapy when medi-
cal reports excluded organic pathology. All
were married. Their mean age was 24.6
years with a standard deviation of 3.8. Of
the 16 women, nine had been married for
two years or less, five had been married for
approximately four years, and two were
married for more than ten years. The ma-
jority had always found coitus to be mean-
ingless, somewhat unpleasant or utterly re-
pugnant.
The educational level of these patients
varied considerably and ranged from three
professional women (a doctor, a lawyer and
a grades teacher) to several housewives with
only two or three years of secondary school-
ing. The patients were reasonably homoge-
neous with regard to socio-economic status
and may be described as fairly typical of
middle class, urban, white South African
women.
Two of the women stated that they had
been highIy promiscuous pre-maritally.
They both claimed, however, that they had
never derived any sexual satisfaction what-
soever. One of these patients had also been
fairly active extramaritally. A previous
therapist had convinced her that these sex-
ual exploits were a search for erotic sensa-
MENTAL DISEASE, Vol. 136, No. 3, March, 1963
Copyright, 1963, The Williams 6 Wilkins Co. All rights reserved
SYSTEYITIC DESESSITlZATIOS OF FRIGIDITY 273
tions which had always eluded her. This
knowledge made no appreciable difference
to her condition. The remaining patients
main taintd that their sexual activities had
been confined to their marriage partners.
In atteltlpting to delineate reasonably
clt+ar-cut areas of causation, it was found
that the basic etiological factors were vkry
diverse. In Sony. cases, the problem seemed
to emanate from faulty at.titudes and mis-
pl:icetl sesual emphasis in childhood, which
resulted in conditioned avoi,Jance responses
to sexual activities. Many patients showed
c\*idence of early or recently acquired feel-
ing5 of hostility and resentment towards
mCn in gencr;iI and!or their husbands in
p:trticular. i)nl_v in one case was there evi-
dencc of a traumatic etiology. A few pa-
tient*: n-ercb complctcly unable to offer any
csplanation for their symptoms. In some,
the basic reasons were apparently uncoverdd
during therapy (these insights, although
conlforting, appeared to bear little relation-
ship to tllcrapeutic outcome:), whereas in
otlIcbr5, the pattern of causality remained
spcculati\-c or enigmatic. In one case, the
entire problem amounted to a hypersensi-
tivity to extraneous auditory stimuli and
a high degree of distractibility. During sex-
ual intercourse this patient would be exces-
sivclv ul)sct by the sound of a distant. motor
.
car, an imagined footstep, a leaking tap, or
the like, whereupon she would experience
violent dyspareunia.
-4 direct fear of pregnancy appeared to be
the underl?ing cause of chronic frigidity
in yet anotller ca&b. The so-called safe
period is a myth . . . no contraceptive is in-
fallible and I refuse to play around with
hormones . . . I have a rheumatic heart and
doctors have warned me not to have any
children, so I regard sex as a prcttr risky
bu&zss. M-hen the therapist suggested
that the impasse might be remedied by
mc3ns of surgery, the patient revealed a
basic phobia of tloct~r~, hospit& and ant+
tllctic?. and rcrluirclcl dt5ensitizntior? along
Systematic dcscnsitizntion is a tcchniclue which
the latter dimension. She was consequent.ly
enabled to have a sall?ingectomy and subse-
quently experienG& sexual s&faction for
the first time in her life.
The sexual reluct.ance of one patient foi-
lowed a severe monilia infection which
flared up during her honeymoon. She had
irrationally attributed her illness to sexual
participation and was disinclined to expose
herself to the risk of further infection. It is
worth noting that she had other mild ob-
vious hypochondriacal tendencies, which
were treated concurrently with her sexual
problems.
The following excerpt, taken from a frigid
paGents notes, provides a graphic descrip-
tion of the attitudes of one of the most se-
vere cases :
Ii
I hate every single man on this earth,
bitterly. I think they are all pigs-some
smaller, some bigger. When one looks at me
in the street I could shoot him with a water
pistol full of vitriol. I hate women who
enjoy sex. I think they are just animals.
I hate sexy books; they are filthy. I hate to
see people kissing; it makes me feel sick. I
dont want to become one of them.
I hurt my husbands feelings whenever
I can. I think he is a pig too. I dont want
to have children. I would feel too much like
an animal. I have nightmares about men-
in my dreams they are just pigs and ani-
mals. I hate sex and everything that goes
with it.
When I have intercourse I feel like spit-
ting. I cant stand my husbands hands on
me. Nhen I have to go to bed with him and
there is no way out I feel trapped like an
animal about to be slit open with a knife.
I could strangle fiim and kick him. I hate
to see him look at other women. I want to
shout at him Animal, animal. Men are all
was developed by Dr. Joseph Wolpe (12, 13). It
consists of presenting carefully graded situations,
which are subjectiveIF noxious, to the imagination
of a deeply relascd patient until the most person-
ally distressing events no longer evoke any ansiety.
A hricf account of this technique is provided in the
section on therapy.
/-
f
\
274
ARXOLD A. LAZARUS
pig5; my father, my brothers, the WhOIe
lot !
On studying the life histories, psgchodiag-
nostic test profiles and similar detailed in-
formation which was routinely obtained in
each case? it became ob\-ious that the pa-
tients were not a honiogeneou~ group with re-
gard to temperament or personality makeul).
Marked indilvidual differences and maria-
tion,; in background, training and tempera-
ment u-we clearly noted. There xas suggc+
tivc evidence, however, that the introwrted
patients (i.e., persons with an E score of
1~s than 15 on the Naud&y Personalit)
In\.entory [3] l generally displayed straight-
forsvard a~ricty reactions to sexual situa-
tion+-- as soon as my husband approache+
me in that n-ay I literally feel tense if not
terrified --whereas the highly extroverted
patients (i.e., those with an E score of 35
or more) tended to complain of vaginismus
and similar reactions of a probable hgsteri-
cal variety.
-411 the patients had received sonle form of
treatment for t,heir condition before consult-
ing the writer. Five had received detailed
intitruction from their family doctors con-
cerning sex technique. Three were treated
by weans of hormonal injections and topical
ointments. Three other patients had con-
sulted marriage guidance counselors n-ho
had embarked on a course of reassuring
discussions with both husband and n-ifc.
suplknxntcd by a reconuncndcd list of
books on ses hygicnc. One of the patients
had undergone four years of l~sychonnaly&.
Two 1~1 visited psychiatrists -at n-tckiy
interval3 for al~proxinnitel~ six months? and
the rennknng two patients had been treated
by clinical lx~chologkt~ for one yar, and
fi1.c months respectively.
THER.WI-
The present thcralwutic lwogrt~n WE
b:i~cd on the as5uinl)tion tlntt frigidity is
USU:tll!- tllr result of lC?i\l*IlC.Yl liabits of ans-
icty relating to .wiual particil>ation. AS in
chewy effccti\*e system of tlwraly, tlw bask
curative mechanism would then depend on
unlearning the primary neurotic stimulus
configuration.
The desensitization procedure (12, 13.J
has proved high!y effective in treating di-
verse neurotic reactions where specific
ratlrcr than free-Aoating anxiety is pres-
ent l.5,~. This technique has also been used
in groups t.7) and adapted for child therapy
programs (6, 8 t . Bond and Hutchinson (1 ,J
have successfully employed systematic de-
scwitization in the treatnlent of exhibition-
kin, and Lazovik and Lang ( 10 1 have scru-
tinized the value of dc~cnsitization therap!
under controlled laboratory conditions.
Rachwan ( 11.1 has provided an account, of
a 24-year-old female n-ho had a phobia for
injections, a fear of using internal sanitary
pads: and who experienced pain and anxiety
in sexual situations. The elimination, by
desensitization, of her sanitary pad anxiety
and the injection phobia effected an iln-
provenlent in her sexual adjustment,
Briefly, the dcscn~itization method in-
vol\-es the following three separate sets of
operations:
1 I The patient is taught the essentials of
Jacobson?c (4) progressive relaxation. Thi::
relaxation training program seldom extends
o\*cr niorc than six interviews. (During the
past ywr, ho\vcvcr, the writer has rclicd ex-
tcnGwl\- on a long playing l~honogral~l~
record of which he iti the co-author f93. I
21 Gratl~~cl lists arc dran-n up of all the
definable tlwnw into which the patients
anxictics may be grouped. This construction
of anxiety hierarcliic~ iinplic,~ that. a11 iin-
portant thcinatic clcnwnt~ which engender
neurotic anxiety in the patient will be iden-
tificd and prolwly ranked according to the
dtgrcacl of subjccti\e disturbance aroused.
3r The anxiety-evoking items from the
hieritrcll~ are prcwntcd wrbally to the
iniagination of the deeply relaxed patient,
coniinencing with the weakest stimuli and
grwdu;tliv lwocecding up the hierarchy to
c
progreA~*ely stronger anxiety-arou$ng
situations. Sew items arc introduced onl?-
I :
; : *.
,
. . I
.
SYSTEMATIC DESEX3ITIZATIOK OF FRIGIDITY 275
when patients are able to picture their pre-
ceding scenes without experiencing anxiety.
It is impressed upon patients that, if any
item proves upsetting or disturbing they
must raise their left forefinger.
The easiest cases to handle were those in
which the normal erotic interchange be-
tween male and female constituted the es-
sential anxiety component. 3ly mother
warned me to keep away from boys so often
that I even feel guilty when my husband
kisses me. A patient who depicted less
generalization along this theme said, I
actually quite enjoy kissing and necking,
but when it gets more serious than that I
just feel myself freezing up. Desensitiza-
tion in these cases proceeded along a hier-
archy of more and more intimate physical
and sexual interchanges. In the most severe
cases, the graded repertoire of noxious situ-
ations had to commence with the most
casual and innocent contacts between the
sexes. The thought of a flirtatious glance-or
an ephemeral embrace initially produced
observable anxiety reactions in two of the
patients. The mildest case along this
dimension was a patient who could accept
coitus in the normal position, but whose
husbands erotic gratification depended on
varying the sexual positions. Frankly, I
think that my husband needs treatment. He
behaves just like an animal.
This patients aversion to postural varia-
tions during coitus apparently emanated
from feelings of fear and disgust when, as a
-young girl on the farm, she had on occasion
been forced to witness animals copulating.
She reported that ever since then, t.he sight
of animals doing it in the street upset her
undufy. Systematic desensitization was ac-
cordingly administered along dimensions of
distance and size-the nearer the animals
the worse; the larger the animals the worse.
As soon as she became impervious to sexual
activities in animals, her own behavior
underwent a change. She became free from
peared to have consolidated her marriage
and according to her husband, saved a
worthwhile marriage in the nick of time.
The patient whose sex life was under-
mined by real or imagined extraneous
sounds responded well to desensitization
methods. While hypnotically relaxed, she
was asked to imagine increasingly disturb-
ing sounds while conditions for sexual rela-
tions became less and less ideal. (As an ex-
ample : I want you to imagine that you
and your husband are in Cape Town on
holiday. While having intercourse you can
clearly hear people walking and talking in
the hotel corridor.) After 14 desensitization
sessions she reported that she was able to
get lost in sex. At the time of writing, she
has not experienced dyspareunia for over
fifteen months.
A more detailed case presentation should
lend greater clarity to some of the points
outlined above.
Mrs. -4, aged 24 years, had been married
for two and one-half years, during which
time she claimed to have had coitus on less
than two dozen occasions. She always ex-
perienced violent dyspareunia during inter-
course as well as disgust and anxiety at
the whole messy business. She could toler-
ate casual kissing and caressing without
anxiety and at times found these experi-
ences mildly pleasant. The background to \
her problem was clearly one of puritanical
upbringing, in which much emphasis was
placed on the sinful qualities of carnal de-
sire. Mrs. As husband had endeavored to
solve their difficulties by providing his wife
with books on sex techniques and practices.
Mrs. A had obligingly read these works
but her emotional reactions remained un-
changed. She sought treatment of her own
accord when she suspected that her husband
had developed an extramarital attachment.
After diagnostic interviews and psycho-
metric tests, systematic desensitization was
administered according to the following
unnecessary inhibitions which had upset her hierarchy (the most disturbing items being
sexual relationships. Significantly, this ap-
at the head of the list): )
.A
AXNOLD A. LAZARUS
276
2)
4)
6)
7)
13)
14)
15)
16)
17)
18)
19)
20)
211
Having intercourse in the nude whiIe
sitting on husbands lap.
Changing positions during inter-
course.
Having coitus in the nude in a dining
room or living room.
Having intercourse in the nude on
top of a bed.
Having intercourse in the nude un-
der the bed covers.
Manual stimulation of the clitoris.
Husbands fingers being inserted into
the vagina during precoital love play.
Caressing husbands genitals.
Oral stimulation of the breasts.
Naked breasts being caressed.
Breasts being caressed while fully
clothed.
Embracing while semi-clothed, being
aware of husbands erection and his
*
desire for sex. _
Contact of tongues while- kissing.
Having buttocks and thighs caressed.
Shoulders and back being caressed.
Husband caresses hair and face.
Husband kisses neck and ears.
Sitting on husbands lap, both fully
dressed.
Being kissed on lips.
Being kissed on cheeks and forehead.
Dancing with and embracing hus-
band while both fully clothed.
Variations in the brightness of lighting
played a prominent part in determining the
patients reactions. After four desensitiza-
tion sessions for instance, she was without
anxiety able to visualize item 14 (having
her buttocks and thighs caressed) if this
was occurring in the dark. It required sev-
eral additional treatments before she was
able to tolerate this imagined intimacy unr
der conditions of ordinary lighting.
The therapist asked Mrs. As husband to
make no sexual overtures to his wife during
the period of treatment (to avoid tesensiti-
zation). Mrs. A was desensitized three times
a week over a period of less than three
months.
.
.
When item 7 on the hierarchy had been
successfully visualized without anxiety,
Mrs. A seduced her husband one evening
and found the entire episode disgustingly
pleasant. Thereafter, progress was ex-
tremely rapid, although the first two items
were slightly troublesome and each required
over 20 presentations before the criterion
(a 30-second exposure without signaling)
was reached. A year later Mr. and Mrs. A
both said that the results of therapy had
remained spectacularly effective.
BESULTS
Of the 16 patients, nine were discharged
as sexually adjusted after a mean of 28.7
sessions. (The mean time was somewhat in-
flated by one patient, who required more
than 40 sessions.)
- The remaining cases were regarded as
failures. Patients were usually seen once a
week, so that the average time period for
successful therapy was just over six months.
The majority of patients listed as failures
usually terminated therapy on their own
initiative after less than six sessions. It can
safeiy be said that treatment was successful
for every patient who underwent more than
15 sessions.
The nine recoveries were all cases in
whom reasonably clear-cut areas of inhibi-
tion could be discerned, while the seven
patients who reported no improvement were
nearly a11 individuals in whom abstruse,
pervasive. or extreme attitudes prevailed.
Some of them-were inadequately motivated
for therapy. Others, although evidently
eager to overcome their sexual difficulties,
were unable to produce sufficiently vivid
images-an essential prerequisite for effec-
tive desensitization. It is worth noting that
all the successful cases were undoubtedly
dysthymic in character (i.e., having high
scores on neuroticism and low scores on
extraversion 121.)
The criterion for cure was an affirma-