The Nature of The Female Orgasm

Cindy M. Meston, Elaine Hull, Roy J. Levin, and Marca Sipski have written an article in Sexual Medicine about the nature of the female orgasm and female sexual dysfunction.

In their summary review, they start with a rather formal definition, in which they refer to the characteristics of the female orgasm that we would all recognize: they define it as a sensation of great pleasure which creates a state of altered consciousness and which is accompanied by contractions of the created muscles around the vagina, vulva, anus and uterus, together with contraction of other pelvic muscles.

These contractions and the myotonia that accompanies them resolve the vasocongestion which has been induced by sexual activity, the whole experience being succeeded by a sense of great contentment and well-being.

Unfortunately female orgasmic dysfunction (anorgasmia) appears to be comparatively common: in a random sample of 1749 women in the United States, 24% had some kind of orgasmic dysfunction. It's clearly helpful for women addressing the question of how to have an orgasm during sex to understand exactly what type of orgasmic dysfunction they might be experiencing, and it's helpful for clinicians to understand how such dysfunctions might be classified, to assist them in treating and managing these conditions.

A committee of four experts worked at the International Conference On Sexual Disorders mentioned in the paper currently under review to produce a suitable classification and definition of the disorders which women might experience in relation to sexual function and orgasm.

Research has shown that the second most common sexual problem reported by women is difficulty in reaching orgasm, or not being able to reach orgasm at all, even after a period of normal sexual activity with a level of sexual arousal which would normally be sufficient for orgasm.

In expanding upon their original definition, the authors observe that a woman's orgasm is not consistent from one experience to another, but generally involves a transient sense of intense pleasure accompanied by involuntary contractions of various muscles in the genital and pelvic region.

These contractions serve to relieve the vasocongestion and the myotonia which are associated with sexual arousal, and this relief is accompanied by a sensation of satiation and well-being.

There is great variability in how women achieve orgasm although stimulation of the clitoris and vagina are by far the most common methods of achieving peak sexual pleasure. Despite this, orgasm can be achieved by stimulation of the periurethral glands, the breasts or nipples, and even by the use of erotic imagery or mental fantasy.

Orgasms can also occur during sleep, a fact which emphasizes the interaction of mind and body in the experience of orgasm. Although reports are rare there have also been a few recorded cases of "spontaneous orgasm" where there is no obvious sexual stimulation.

Oddly enough, the mechanism by which orgasms are triggered are still not fully understood. However, the use of positron emission tomography and MRI scans have enabled scientists to identify the areas of the brain that are associated with orgasmic activity: these include part of the hypothalamus [the paraventricular nucleus], part of the gray area of the midbrain [the periaqueductal area], the cerebellum and the hippocampus.

However, these studies have not demonstrated whether there are in fact specific areas of the brain which have a crucial role in triggering orgasm in women, and if so which they are.

Much more observable, and possibly much more interesting for the average person, are the psychosocial factors which affect orgasmic ability in women. Correlations have been discovered between women's ability to reach orgasm and age, social class, personality factors, religious affiliation, level of education, and quality of relationship.

Unfortunately research in this area has been sparse, and there are no definitive studies which demonstrate that one factor or another is fundamental to the achievement of orgasm. This is rather surprising in view of the fact that orgasmic problems have been reported by women as the second largest area of concern in relationship to sex.

The National Social and Health Life Research Survey demonstrated that in a sample of 1749 women from the United States almost exactly one quarter reported being unable to reach orgasm - and this state had persisted for several months at least during the preceding 12 months. Similar findings have been made in sexual clinics.

Admittedly, the situation is complicated by the fact that there have been comparatively few well conducted studies in this area, and the definition of female orgasmic disorder varies from one researcher to another. The DSM IV defines the condition of female orgasmic disorder as follows: "Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase that causes marked distress or interpersonal difficulty."

But the problem of definition is complicated by the fact that women are so individually variable in the amount of stimulation which they require to achieve orgasm. Indeed, the judgment as to whether or not a woman has female orgasmic disorder is actually based in practice on the practitioner's judgment about her orgasmic ability and capacity; the key question would be whether or not it was actually lower than would be expected among an "average" group of women of her age, level of sexual experience and sexual responsivity to stimulation.

This is clearly unsatisfactory since it introduces such a subjective element into the diagnosis, a fact which is backed up by the observation that a very high proportion of women who are diagnosed with female orgasmic disorder - also known as anorgasmia - appeared to be diagnosed with female sexual arousal disorder as well.

If you refer back to the DSM-IV definition given above, you will see that the implication of this is that perhaps the criterion of "normal sexual excitement sufficient to reach orgasm" appears to be ignored in many cases.

Furthermore, DSM-IV classifies female orgasmic disorder into sub-categories of lifelong or acquired, and situational or generalized. By contrast, the International Statistical Classification Of Diseases (ICD-10) adopts a much simpler approach by simply describing orgasmic dysfunction as a condition in which "orgasm either does not occur or is markedly delayed".

This means of course that women who can achieve orgasm during masturbation but who are anorgasmic during intercourse alone would not be defined as having any kind of dysfunction, which which seems a sensible conclusion, since penile thrusting during intercourse does not generally provide enough stimulation to either the clitoris or vagina for a woman to reach orgasm.

So if a woman actually does have difficulty reaching orgasm, during both sex and masturbation, how is this to be remedied? Unsurprisingly, approaches over the years have been very varied, including cognitive behavioral therapy, psychodynamic psychotherapy, psychoanalytic therapy, sexual therapy, behavior modification and more.

CBT has focused on attempting to change attitudes and sexual thought processes, as well as decreasing levels of anxiety, and also providing more information about masturbation and other sexual techniques. Where relationship issues may be affecting a woman's treatment of orgasm, communication skills and relationship training is often added to the mix of therapies.

Any therapist working in this field will be well aware that some of the major issues associated with anorgasmia are lack of knowledge and understanding of sexual arousal and sexuality, and a high degree of sexual inhibition or repression.

These are all matters that can be dealt with by a gradual process of sexual education and training that allows a woman to become more familiar with her body and its sexual responses. So-called "directed masturbation" skills training has been used alongside a variety of other therapies with considerable success. Indeed, it's been demonstrated as a valid and effective treatment for women who have experienced lifelong anorgasmia with all their sexual partners. It's also helpful for women who have an aversion to touching their own genitals.

Needless to say, the approach is very different where a woman can masturbate to orgasm on her own but has difficulty reaching orgasm in a sexual situation which involves her partner.

This kind of problem is much more about relationship issues such as a lack of communication skills, lack of a sense of trust or safety, lack of knowledge of sexual techniques on the part of either the woman herself or her partner, or lack of knowledge around the fundamentals of sexual attraction between heterosexual couples (and especially the fact that most women do not achieve orgasm during intercourse).

Education about the sexual positions which may be used during sexual intercourse to maximize sexual stimulation may be useful here, including the so-called coital alignment technique.

But since the achievement of orgasm is so dependent on the sensory and psychological processes that accompany sexual arousal and stimulation, it's always necessary to investigate whether or not anxiety is acting as a distraction that is preventing a woman from achieving orgasm. The same can be true of concerns around sexual performance, guilt, shame or embarrassment.

Sensate focus was originally developed by Masters and Johnson to serve as a means of reducing anxiety during sexual interactions by exposing a couple to step-by-step sequence of touching each other on their bodies with increasing levels of intimacy. Throughout the sequence the couple maintain a low level of anxiety and a high level of relaxation and intimacy.

Evidence for a connection between the level of anxiety that a woman is experiencing and her inability to ejaculate during sex is inconclusive, but it might be logical to expect that one would affect the other since anxiety can be extremely distracting during sexual stimulation and arousal.

The evidence for an improvement in orgasmic capacity is inconclusive as far as almost any individual component of therapy is concerned, which suggests that a variety of approaches in combination is the best method of achieving greater orgasmic capacity and ability in women, This is precisely the approach which the current treatment program for anorgasmia adopts.

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