11

NOTHING’S HAPPENING

I’d like to buy a vowel—the key to getting the big O back

Prior to the 1800s, it was believed that conception would not occur unless the female had an orgasm.

Then, during the Victorian era, most physicians began to assert that sexual pleasure did not exist for women in the marital bed. Intercourse was something to be “endured,” female sexual excitement did not exist, and anorgasmia was declared the norm.

By the latter part of the nineteenth century, orgasms were finally medically recognized as a normal part of sexual response, but only if they occurred during coitus between a married couple. However, in the 1918 sexual guide Married Love by Marie Stopes, the wise doctor (and one of the rare women doctors!) described the importance of female orgasm, the problem of premature ejaculation, and its effect on achieving the goal of simultaneous orgasms:

Though in some instances the woman may have one or more crises before the man achieves his, it is perhaps hardly an exaggeration to say that 70 or 80 per cent of our married women (in the middle and intellectual classes) are deprived of the full orgasm through the excessive speed of the husband’s reactions, i.e., through premature ejaculation. . . . So complex, so profound, are woman’s sex-instincts that in rousing them the man is rousing her whole body and soul. And this takes time. More time indeed than the average husband dreams of spending upon it. Yet woman has at the surface a small vestigial organ called the clitoris, which corresponds morphologically to the man’s penis, and which, like it, is extremely sensitive to touch-sensations. This little crest, which lies anteriorly between the inner lips round the vagina, erects itself when the woman is really tumescent, and by the stimulation of movement it is intensely roused and transmits this stimulus to every nerve in her body. But even after a woman’s dormant sex-feeling is aroused and all the complex reactions of her being have been set in motion, it may take from ten to twenty minutes of actual physical union to consummate her feeling, while one, two or three minutes of actual union often satisfies a man who is ignorant of the art of controlling his reactions so that he may experience the added enjoyment of a mutual simultaneous orgasm.

Today we fully agree that arousal is critical if orgasm is to occur—and orgasm, even if not simultaneous, is the ultimate goal of any sexual experience. And why not? Orgasms make us feel good. Yet, with so much emphasis on the climax, and getting to the top, the trip up the mountain is perceived as unimportant if you don’t make it to the peak.

It’s time to acknowledge that while orgasms are wonderful, a woman can have satisfying and pleasurable sex without having an orgasm. In most cases, if you make the climb more enjoyable, the peak is not only more attainable but more gratifying as well. In fact, the practice of tantric sex places essentially no value on orgasm. The pleasure is in the pre-orgasmic state that leads to a richer, more intense experience. (More on tantric sex later!)

So while some women are able to consistently orgasm, and a lucky few enjoy multiple orgasms, others may experience no orgasm at all. All of these patterns are normal and may change from time to time. That is why it is important for women to keep in mind that by tapping into how they like to be stimulated, anyone can experience sexual pleasure.

Having said that, the rest of this chapter will explore how to make it happen—or make it better.

What’s an Orgasm?

An orgasm is essentially the physical phenomenon that follows sexual arousal and stimulation. At the peak of sexual pleasure (the plateau phase) there is a muscle tension and congestion of tissues due to increased pelvic blood flow. The orgasm, which follows, consists of involuntary but coordinated rhythmic contractions of the pelvic muscles, uterus, vagina, and anus, lasting 15 to 20 seconds and resulting in an intense feeling of pleasure. Blood pressure increases, pulse quickens, and pupils dilate. Brain imaging shows that during an orgasm specific areas of the brain are activated. This intense reaction is followed by resolution, muscle relaxation, and contentment.

Dr. Streicher’s SexAbility Survey

When asked which movie title best describes their typical orgasm,

8.9 percent of women said Much Ado About Nothing

23.5 percent said Mission Impossible

35.7 percent said Swept Away

9.5 percent said Toy Story

22.3 percent said Fast and Furious

This describes an orgasm when everything is working correctly.

While some women experience fireworks during an orgasm, for others it’s more of a flickering candle. Too many women are unable to achieve any kind of an orgasm. There was great hope that Viagra would totally solve the absent orgasm issue by increasing blood flow to the clitoris and thereby increasing sensitivity and pleasure. But it’s not that simple. Yes, it’s about blood flow, but it’s also about neurology and hormones and neurotransmitters and anatomy and arousal and relationships and genetics and prior experiences and expectations.

The Four Things That Need to Happen for Orgasm to Happen

Remember the fantasy scene that opened chapter 2, when Brad Pitt entered the room and it all started getting steamy? The sexual response cycle, if all is working well, can result in orgasm. Here’s how.

1. Arousal

Arousal is triggered by both physical and emotional stimulation. While your body is better able to become aroused if both are present, it is totally possible to become aroused with just one. Just thinking about sex can sometimes cause the physical response of increased pelvic blood flow, vaginal lubrication, and hard nipples. Then again, our bodies can respond automatically in response to sexual touching. And though some women need an emotional connection for their bodies to follow suit, some women don’t.

2. Stimulation

Regardless of which combination of factors works best for them, most women need some form of physiological stimulation to achieve pre-orgasm readiness. And some women do seem to have an easier time at this than others. Studies confirm that women who are easily aroused are less likely to have orgasmic disorders than women who are difficult to arouse. If someone is psychologically ready (perhaps because she’s been reading an erotic book), she can easily become physically aroused. She will have hard nipples and wetness without any touching.

However, once a woman is aroused, there needs to be (except in rare situations) physical stimulation. Both the type of physical stimulation and the intensity of stimulation needed to induce orgasm can vary greatly throughout the life cycle. Physically touching the clitoris is usually required, but there is good evidence that orgasm can occur without clitoral provocation.

Is Clitoral Stimulation the Only Way?

Everyone agrees that clitoral stimulation in the form of pressure, massage, vibration, licking, or touching will generally trigger an orgasm. But is orgasm possible if there is no clitoral stimulation? Throughout history, there is good documentation that female orgasms can result from mental stimulation, anal stimulation, nipple/breast stimulation, cervical and vaginal stimulation . . . pretty much stimulation of any body part (including the brain!) The real proof is that women who have a spinal cord injury and cannot feel clitoral nerve touching can still achieve orgasm.

3. Intact Neurologic System

Clitoral stimulation results in over 8,000 nerve endings sending signals to the spinal cord and brain. This is the primary pathway by which women achieve orgasm. But there is a backup system. It appears that stimulation of some parts of the vagina and cervix can, in some women, stimulate the pelvic branch of the vagus nerve, which travels to the brain, but not via the spinal cord. The vagus nerve provides an alternate pathway and is the mechanism by which women with complete spinal cord injuries are able to climax from vaginal stimulation.

This backup system explains why women who experience both clitoral and nonclitoral orgasms report that these two kinds of orgasm are “different”—not more or less pleasurable, just different.

4. Adequate Blood Flow

In addition to being neurologically intact, a body cannot experience orgasm without adequate blood flow. An adequate blood supply is needed to lubricate vaginal walls and help in arousal, and it’s also responsible for congestion of the muscles and clitoral tissues, which is necessary for the plateau phase just prior to orgasm. Those 8,000 clitoral nerves also require adequate blood to function properly.

The Great Debate: Clitoral Orgasms vs. Vaginal Orgasms

Clearly the vast majority of orgasms not associated with intercourse are from direct clitoral stimulation. The burning question is this: Is an orgasm during intercourse a result of vaginal stimulation? Or are “vaginal” orgasms not vaginal at all, but the result of clitoral stimulation during intercourse from pressure on the clitoris?

It was in 1905 that Sigmund Freud set the stage for the notion that not only should women expect to have vaginal orgasms, but that clitoral orgasms were “immature.” This idea would cause generations of women to feel inadequate when they required clitoral stimulation to climax. This myth was propagated until the more realistic (and scientific) Kinsey team reported in 1953 that “sexual intercourse is an extremely inefficient way to stimulate the clitoris.”

In the 1960s, William H. Masters and Virginia E. Johnson took things a step further and hypothesized, based on filming subjects having intercourse in their lab, that given the vagina’s elasticity and poor innervation, orgasm could not be vaginal in origin. For that reason, they also said that penis size was irrelevant to triggering orgasm. In the often quoted Hite Report on Female Sexuality, published in 1976, Shere Hite revealed that only 30 percent of women climax during intercourse. More recent scientific studies show that 30 percent is probably a gross overestimation and that only about 5 to 10 percent of women are able to reach vaginal orgasm in the absence of clitoral stimulation.

Whether the number is 5 percent or 30 percent, plenty of scientific studies (and patients with spinal cord injuries) have shown that stimulation of many nonclitoral erogenous zones results in contraction of pelvic floor muscles, or orgasm. While the walls of the vagina have relatively few nerve endings, the roof of the vagina does have nerve endings, and either the G-spot, the internal root of the clitoris, periurethral nerves, or cervical nerves can be stimulated to result in an orgasm. There is no doubt that while clitoral stimulation is the most efficient and reliable way to orgasm, a non-clitoral-induced orgasm exists.

Orgasms and Brain Mapping

If there is any lingering doubt that clitoral and vaginal orgasms have different neurologic pathways, MRIs of the brain taken during orgasm show that different areas of the brain “light up” depending on whether the orgasm was clitoral or vaginal in origin.

Orgasmic Disorders

An orgasmic disorder is defined as either persistent or recurrent absence, reduced intensity, or delay of orgasm following a sexual excitement phase that causes distress or interpersonal difficulty. And yes, some women have satisfying, positive sexual experiences and are okay not having an orgasm.

Notice that the definition says nothing about intercourse. Not having an orgasm during intercourse not only is common but is completely normal. The definition also includes adequate stimulation: if there is no sexual excitement, it is normal to not have an orgasm. Someone who has never experienced an orgasm is described as having primary anorgasmia and also referred to optimistically as “pre-orgasmic.” Someone whose orgasms have disappeared has secondary anorgasmia, or acquired orgasmic disorder.

As you can imagine, it’s hard to know precisely how many women suffer from orgasmic issues, but somewhere between 20 and 40 percent of women report problems with orgasm at some point in their life. After hypoactive sexual desire disorder, orgasm issues are the second most common sexual complaint. Many women who have difficulties reaching orgasm also have other sexual issues, such as decreased libido, diminished lubrication, and pain with sexual activity. With all that going on too, no wonder it is difficult to do research specifically on orgasms, making it a challenge to fix the problem.

What I can say with assurance is that lack of orgasm is a common problem and has the same prevalence in both lesbian and heterosexual populations. (I guess that means we have to stop blaming it on clueless guys who need a map to find the clitoris.)

Things That Get in the Way of the Big O

Lack of Arousal

If there is no arousal, there will be no orgasm, plain and simple. Psychological, social, and physical factors all have an impact on arousal. Essentially, everyone has “excitatory” processes and “inhibitory” processes that control sexual excitement and the ability to have an orgasm. Inhibitory things include difficulties with your partner, a high stress level, and guilt about feeling sexual. Medications or medical problems that inhibit blood flow, create pain, or compromise neurologic pathways are also inhibitors. Excitatory things include neurologic stimulation, positive emotional feelings, physical stimulation, and terrific blood flow. If each of these elements represented points, it would be easy to add them all together for a winning score . . . but it isn’t so easy, right?

Limited Sexual Experience of Individual or Partner

Very often primary orgasmic disorders are a result of not knowing how to have an orgasm. Not every man and woman knows what to do. Some guys really have no idea what a clitoris is, where it is, and what they are supposed to do with it. Ditto some women. Sometimes the inability to have an orgasm has nothing to do with physiology and everything to do with education.

Anatomy—Hers and His

Intercourse is not a very efficient or effective way for most women to have an orgasm. The clitoris, while conveniently located for masturbation, is anatomically poorly positioned for stimulation during intercourse. When it comes to the guy’s anatomy, contact between a man’s pubic bone and the clitoris during intercourse seems to be a key factor. This is a consequence of his anatomy, your anatomy, and coital position.

While penis dimension has essentially no impact on clitoral orgasms, size does matter when it comes to the likelihood of a vaginal orgasm. Stimulation of the anterior vaginal wall (home of the internal part of the clitoral complex and G-spot) is dependent on the girth of the penis. Stimulation of the cervix, which fires the vagus nerve, is dependent on the length of the penis.

Psychological, Relationship, and Communication Factors (Inhibition, Cultural Factors)

Feeling guilty about sex owing to religious beliefs, a history of sexual abuse, or anything else can create a negative emotion about achieving orgasm that can and will impact your ability to do so. In fact, many studies correlate childhood sexual abuse or a violent rape with a very high incidence of inability to achieve orgasm in a loving relationship.

Women who cannot lose control, who are unable to “be in the moment,” are often unable to focus on sensory stimuli enough to achieve orgasm. Not only do women have to feel safe and emotionally trusting, but they also cannot feel inhibited by how they may look or act during an orgasm. If a woman is worrying about her fat butt, or a funny vaginal smell, or the noise she might make when she climaxes, she is going to have a very hard time having an orgasm. And while we are talking about noises women make when they have sex, it’s not always involuntary. A small 2011 study (that focused solely on heterosexual women) found that 66 percent moan during sex to speed up their partner’s climax, while 87 percent did so to boost their partner’s self-esteem.

Women who are able to achieve orgasm through self-stimulation but not with a partner may be harboring feelings of anger, dissatisfaction, and inability to communicate. And of course there is also the issue of the partner who doesn’t know how to stimulate the clitoris effectively, and the woman who is not able to help him out because she is uncomfortable communicating this.

Medical Conditions

I hear it all the time. “I feel dead down there.” “I have no sensation.” “I can’t even tell he’s in me.” There are many medical situations in which decreased genital blood flow or neurologic damage can decrease sensation in the pelvic area. Weak pelvic floor muscles are a huge, underappreciated issue. In one study, 60 percent of women with urinary incontinence due to a weak pelvic floor were anorgasmic.

Chronic medical conditions that affect blood flow or the neurologic system include heart disease, diabetes, multiple sclerosis, and spinal cord issues, and these all have an impact on the ability to have an orgasm. Hypothyroidism, which is present in 1 of 10 women over the age of 50, is also associated with decreased genital sensation. In addition, chronic illness, even if it has no direct impact on blood flow or nerves, is associated with orgasmic disorders. In many studies, about 53 percent of women with orgasmic issues also met the criteria for depression.

Menopause

Estrogen is actually not required to have an orgasm, and many women who have estrogen and progesterone levels of zero still climax regularly. Menopause does, however, affect the ability to become aroused. Low estrogen decreases blood flow to the vagina and leads to lack of lubrication. Dry, painful intercourse is not going to lead to pleasure of any kind.

In addition, studies show that estrogen is needed to have optimal clitoral blood flow. Testosterone has been found in some studies to be involved in arousal and the orgasm experience. So while estrogen and testosterone are not absolutely essential to achieve a satisfying orgasm, they certainly help, and low levels of these hormones explain why many postmenopausal women report having a more difficult time reaching orgasm and having orgasms of shorter duration and weaker intensity than before menopause set in.

Medications

It’s often difficult to figure out if it is the medication that is causing the problem or the condition the medication is supposed to treat that is the problem. Having said that, there are some drugs that are specifically associated with orgasmic disorder. It has been well established that SSRIs not only have an impact on libido and can delay orgasm but also affect the ability to have an orgasm. (The details of the impact of SSRIs are covered in chapter 9.) The good news is that, in roughly 30 percent of cases, after taking the medication for a period of time (usually at around three months), your orgasms come back! It’s worth sticking it out for a while before you talk to your doctor to see if there is an alternative option. This appears to be a dose-related phenomenon, so sometimes lowering the amount of the SSRI that you take will solve the problem.

Other medications that are known to squelch the ability to climax are antipsychotic drugs, cardiovascular medications, hypertension drugs, and chemotherapy.

Substance Use

Alcohol

As with libido, a little alcohol gets you in the mood, a lot gets in the way. And yes, intoxication does reduce the ability to achieve orgasm.

Tobacco

Since orgasms depend on an adequate blood supply and nicotine diminishes blood flow to the penis, guy smokers have a higher incidence of erectile dysfunction. This has not been well studied in women, but since the clitoris also depends on blood flow, it follows that orgasms in women who are heavy smokers may also be diminished.

Marijuana

I know you are out there . . . don’t pretend you’re not. And during the Summer of Love, marijuana was as much a part of “make love not war” as the pill. There are a number of anecdotal reports that marijuana enhances orgasm, but it’s hard to say whether this is a direct effect of the drug or a result of women becoming more relaxed and able to let go. Large amounts of marijuana are known to decrease testosterone levels, which in turn may affect libido. There are actually no good studies looking at the effect of marijuana on female orgasm, which leaves the question wide open for some enterprising medical student.

Hysterectomy and Other Pelvic Surgeries: “It Just Isn’t the Same”

Medical studies show that long-term orgasmic function is essentially unaffected by hysterectomy. However, many of my post-hysterectomy patients have reported that things seem different; their orgasms are less intense, and some women are unable to achieve orgasm. There are three possible reasons for these changes:

•   While removal of the uterus does not change anything hormonally, some women enter menopause at the time of hysterectomy because they also have their ovaries removed. It is not the hysterectomy but menopause that creates the orgasm problem.

•   Most women are only aware of pelvic floor contractions during orgasm, but some women are aware of uterine contractions when they climax. If the uterus is gone, that aspect of their orgasm will also disappear.

•   Hysterectomy does not always include removal of the cervix. If it does, and if you are one of those women who have a vaginal orgasm from stimulation of cervical nerves, you will notice a difference. If you are going to have a hysterectomy, you may want to consider preservation of your cervix if that is an option.

My 2012 SexAbility survey of over 2,000 women who had undergone hysterectomy reported that their orgasms after hysterectomy were:

No different than before surgery (56.4 percent)

More intense and more pleasurable (21.6 percent)

Less intense and less pleasurable (15.3 percent)

Still not happening (7.1 percent)

Women who have more extensive hysterectomies because of cancer are the most likely to have problems. Survivors of cervical and vaginal cancers appear to have orgasmic problems twice as often as women in the general population, probably because of pain or damage to pelvic nerves from the surgery. Hysterectomy is not the only pelvic surgery, of course, and any operation in the pelvis can disrupt the ability to have an orgasm. These issues are usually short-term and resolve in time as tissue heals and nerves regenerate.

And Then There’s the Bicycle Problem . . .

Erectile dysfunction has long been linked to bike riding, but it wasn’t until a 2013 study at Yale University that it was determined that this is not just a male issue. Whether it’s frequent spin classes or 10-mile rides, prolonged clitoral pressure compresses nerve endings and blood vessels. Genital numbness, tingling, or soreness of any kind is an indication that an adjustment is in order. The position of the handlebars on your bike is far more important than the type of seat it has or the height of the seat. The lower the handlebars on your bike the more pressure on critical structures down there. Ideally, the handlebars should be as high as the seat to ensure minimal pressure.

Things That Help with the Big O

Don’t Ignore the Relationship and Psychological Aspects of Orgasm

If you have identified relational or psychological issues that are impeding your ability to orgasm, they need to be addressed. Individual and/or couples therapy is critical, even while you are exploring other medical options. A therapist experienced in sexual issues is ideal, but any good therapist can address depression, anxiety, or other inhibiting factors that get in the way of sexual health.

In addition, the inability to have an orgasm in itself causes psychological anxiety, and that distress needs to be managed. Communication is key—you need to be able not only to discuss the relationship issues with a partner but to feel comfortable directing him or her to do the things that will give you a physical response. In addition to talk therapy and cognitive therapy, mindfulness meditation and yoga have been shown in some studies to facilitate the ability to “be in the moment.”

Even if your relationship is terrific and you have no psychological issues, keep in mind that the brain is an amazing erogenous zone, not only with respect to libido but arousal as well. I rarely tell personal stories, but here goes. I love my husband. No, I adore my husband and find him to be an incredibly sexy, giving partner. But I don’t always have sex with my husband. Sometimes I have sex with Mikhail Baryshnikov. I have actually never met Baryshnikov, but I have watched The Turning Point dozens of times and feel like I know him intimately. To clarify, I am not having sex with 65-year-old Sex in the City Misha. I am having sex with the 30-year-old incredibly hot guy I saw dancing in Don Quixote when I was in my twenties. And while I am having sex with him, I am also in my twenties. I have asked my husband countless times to put on a pair of tights, but he refuses. I do however yell “Bravo!” at the end, which he really likes. Just saying.

If fantasizing about a sexy dancer doesn’t do it for you, find your own version of Misha. Erotic books, films, and fantasy go a long way toward helping with orgasm.

So let’s assume that you do not have pain, you have no relationship or psychological issues, and you are physically able to have intercourse or self-stimulate, but you just simply cannot make “it” happen. Or when it does happen it takes so much work or is so unsatisfying that not only is it hardly worth the time and effort but it leaves you feeling frustrated or in an uncomfortable state of sexual tension.

What follows are specific strategies, products, medications, and devices to heighten arousal, increase genital stimulation, increase blood flow, stimulate the nervous system, and, ultimately, facilitate the ability to orgasm. And while I do believe that a vaginal orgasm is possible, go for the low-hanging fruit and focus on the clitoris—unless, of course, you are a woman who either has no clitoris, has suffered a spinal cord injury, or has scarring that makes the clitoris inaccessible.

Faking It: “I’ll Have What She’s Having”

While not every woman fakes orgasm, and most don’t do it routinely, it’s the rare woman who hasn’t done it at least once. And if there were any doubt, the iconic scene in When Harry Met Sally is a testimony to just how convincing women can be. Why do women fake it?

•   To make their partner happy

•   To make him come faster

•   Because orgasm is unlikely and she wants him to stop trying

•   To get some sleep

•   To not feel like a failure

A 2010 Indiana University study showed that while 85 percent of the men surveyed said that their latest sexual partner had an orgasm, only 64 percent of those women said that they climaxed the last time they had sex. So not only did 21 percent of these women fake it, but 100 percent of the time the guys believed it, proving that women are better actors than they think. In another 2010 study from the University of Kansas, 50 percent of women reported pretending orgasm, but women were not the only ones who faked it—25 percent of the guys reported pretending to come as well!

Instead of working on the Academy Award for Best Performance for Faking an Orgasm, it is probably a better idea to communicate to your partner that even if you don’t have an orgasm, you are still having a really good time.

Masturbation U

While masturbation in women is still too often a taboo topic, we have come a long way from the early 1900s when doctors used to view masturbation as “self-abuse” that would “wreck” a woman’s system. Facilitating self-stimulation is now considered to be part of normal sexual health. Yet for something so natural and healthy, doctors are unlikely to bring it up and mothers aren’t exactly teaching their daughters this skill. We aren’t yet that enlightened, and young women are left to figure it out on their own . . . or not. And unlike the penis, which stands up and announces itself to a young man, a clitoris, like most buried treasure, needs to be “discovered,” so to speak.

So, if you have never had an orgasm, you are much better off eliminating the partner variable and figuring this one out on your own. Particularly in the case of primary orgasmic dysfunction (those who’ve never experienced orgasm), a technique known as “directed masturbation” solves the problem more often than not.

Directed masturbation refers to masturbation lessons, and yes, sex therapists facilitate this by telling you where to touch and how to touch. Not only does this eliminate all of the complicated dynamics that accompany a partnered sexual experience, but also it really does become “all about you.” Literally. And who is going to be less judgmental about what it takes to get you off than you? Exactly.

In one study, anorgasmic women were assigned to a masturbation education group or a wait list. The women in the education group received explicit instructions, along with a vibrator. At the end of the study, 60 percent of the women in the masturbation education group were achieving orgasm as opposed to 0 percent in the wait-listed group. Another similarly designed study resulted in a 90 percent ability to have an orgasm with directed masturbation.

So if you have never self-stimulated, it’s time to start. If you have, but have never used a vibrator, it’s time to go shopping. (See chapter 20 for the full scoop on toys.) And if you are in the 99 percent of the population who don’t have a personal sex therapist and you really aren’t sure what to do with your new vibrator, pick up a copy of Becoming Orgasmic by Julia Heiman. Once you have figured it out for yourself, you can tutor your partner.

Another more couples-oriented educational tool commonly used by sex therapists is “sensate focus treatment.” This is basically a series of biweekly home exercises to encourage intimacy, touch, and sensual pleasure. Intercourse is typically off the table during this treatment, and the emphasis is on touching other erogenous zones to give pleasure. While not as successful as directed masturbation, there is definitely an uptick in the number of women able to achieve orgasm with a partner after undergoing this treatment.

Anatomy Issues

If you are able to have an orgasm with self or digital stimulation but cannot during intercourse, and if having an orgasm during intercourse is something that is important to you, maximizing stimulation during intercourse by altering position may do the trick. People tend to fall into sexual patterns, and it rarely occurs to a couple that a change in position might be a game-changer.

Here are some ways to optimize clitoral stimulation during intercourse:

Option 1: In the missionary position, the guy positions his pelvic bone right above the pubic bone of the woman. The woman wraps her legs around his legs. Thrusting should be downward rather than horizontal. Intercourse isn’t as deep, but the glans of the clitoris will be stimulated more than if the guy is deep inside you. (This is known as the coital alignment technique.)

Option 2: There’s a reason many women prefer the female superior position: it allows them to position themselves in such a way as to get maximum clitoral stimulation.

Option 3: “Spooning” allows intercourse (entry from behind), but also makes it easy for a woman to receive digital or vibrator clitoral stimulation from herself or her partner.

Sometimes the clitoris is anatomically not accessible. This can occur if there is scar tissue that prevents the clitoral hood from retracting, or if the top of the labia has sealed together from atrophy or lichen sclerosus. Use a mirror and take a look down there. If you can’t see your clitoris, there may be a medical problem that needs treatment.

Hormone Therapy

Obviously, appropriate hormone therapy is going to go a long way toward making intercourse more comfortable. (See chapters 12 and 13 for more on hormone therapy.) The question in regard to orgasm is whether the addition of hormone therapy is going to specifically enhance the ability to have an orgasm.

While not consistent, there are certainly some studies that have found that supplemental estrogen alone or with testosterone in a postmenopausal woman may facilitate orgasm by increasing blood flow and increasing sensitivity to the clitoris. Studies have consistently shown, however, that hormone therapy does not help premenopausal women.

Testosterone without estrogen is often recommended, but again, there is little science to back it up. Most studies on testosterone therapy do not specifically focus on orgasm but rather on libido or “satisfying sexual experiences.”

What is known is that excess doses of testosterone result in enlargement of the clitoris, but a bigger clitoris doesn’t necessarily mean a more responsive clitoris. It’s also not clear what the best way is to deliver testosterone to enhance orgasm. Some women are advised to put testosterone cream directly on the clitoris, while others are prescribed systemic testosterone to apply to their thigh. To date, there is no data showing that one way is more effective than another.

My feeling is that while more studies are needed to determine if supplementation of estrogen and testosterone are efficacious, there is enough convincing data in postmenopausal women to give it a try.

Available by prescription from compounding pharmacies, vaginal DHEA, the precursor to estrogen and testosterone, increases vaginal lubrication. It may also help libido and orgasm, so this is also a reasonable approach.

Nonhormonal Prescription Pharmaceuticals

Going with the theory that the clitoris is just a little penis, many prescription drugs used to treat erectile dysfunction are now sometimes used for female orgasmic dysfunction. The problem is that a clitoris is not a penis, and erectile dysfunction is not the same as anorgasmia. Just because something works in guys doesn’t mean it’s going to work in women. Many of these drugs have not been adequately studied in women, and information is anecdotal, not scientific. Also, keep in mind that none of these prescription drugs are intended to be used for treatment of female orgasmic disorders, nor have they been approved by the FDA for such uses.

Phosphodiasterase (PDE5) Inhibitors (Viagra, Cialis)

It’s so tempting. His little blue pills are sitting there and certainly seem to solve his problem. Why not take one and see what happens? It did wonders for Samantha on Sex in the City, who had earth-shattering orgasms after she took her guy’s Viagra.

Not so fast.

It seems that taking a phosphodiasterase (PDE5) inhibitor would be a reasonable strategy, since these drugs are known to dilate blood vessels and increase genital blood flow. Sadly, multiple studies do not demonstrate a positive sexual effect in most women, despite increased blood flow.

There is one exception: some studies have demonstrated that women who are on antidepressants and women who have decreased blood flow because of diabetes, multiple sclerosis, or a spinal cord injury experience increased arousal and responsiveness.

Yohimbe

Erex, Testomar, Yocon, Yohimar, and Yohimbe are all brand names for a mild monoamine oxidase inhibitor (MAOI) that was originally studied as a remedy for type 2 diabetes but was found to affect sexual stimulation and is now sometimes used to treat erectile dysfunction. Yohimbe, taken one to two hours before sexual activity to enhance female orgasm, has been shown to be effective in some studies.

Amantadine/Buspirone (Symmetrel)

This is an anti-Parkinson’s and antiviral drug that increases dopamine levels. While sometimes recommended, it has not been found to be effective to treat anorgasmia in women.

Bupropion

Zyban, Wellbutrin, Budeprion, Prexaton, Elontril, and Aplenzin are all forms of bupropion, a well-known antidepressant that is also used for smoking cessation. Some studies show an increase in orgasmic responsiveness in women who use it. It is often prescribed with other antidepressants to counteract their sexual side effects.

Femprox

Femprox, a cream that is applied to the vulva and clitoris at the time of sexual activity, is another arousal-enhancing drug in development. In one very small study, it was shown to be beneficial in reaching orgasm. The active ingredient, aloprostadil (a prostaglandin), purportedly dilates clitoral blood vessels, increasing blood flow and arousal. Since it is already available for the treatment of erectile dysfunction, some women use it off-label.

Neutraceuticals

Women’s magazines, health food stores, and, of course, the companies that sell them tout nutritional supplements and botanicals such as L-arginine, ginseng, and ginkgo biloba as products that enhance orgasm. None of these products require FDA approval to make their claims, and so, not surprisingly, none have been the subject of the kind of long-term, controlled study to prove efficacy that is required for prescription products.

It also should be noted that most of these products instruct the user to massage them onto the clitoris. Beyond the placebo effect, one has to assume that a nice long clitoral massage maybe—just maybe!—has a little something to do with “efficacy.”

Zestra is a botanical massage oil made of biological ingredients such as borage seed oil, evening primrose oil, angelica extract, coleus extract, and vitamins C and E. According to the company that makes it, Zestra “naturally stimulates the body’s own sensory nerve conduction, heightening sexual sensation and pleasure.” It was first developed for patients with multiple sclerosis who, because of reduced sensation, were unable to have orgasms. While Zestra does increase blood flow, it primarily helps by sensitizing nerves to stimulation. Results are variable. In one study, there were statistically significant improvements in level of arousal, level of desire, satisfaction with arousal, genital sensation, and the ability to have orgasms. A temporary genital burning sensation (experienced by 15 percent of study participants) was the main side effect.

ArginMax is a dietary supplement capsule that contains ginseng, ginkgo, damiana, and L-arginine. In a small, randomized control study (of only 77 women), 73.5 percent of the ArginMax group reported improved satisfaction in overall sex life, compared with 37.2 percent of the placebo group. Improvement of clitoral sensation and orgasm was specifically noted.

Lubricants That Promise More Than Wetness

Vibrel, HerSolution, Sliquid Stimulating O Gel, KY Yours and Mine, KY Intense Arousal Gel, Intimate Organics Clitoral Stimulating Gel . . . a plethora of lubricants are available that promise to make things not only more slippery but also more orgasmic. None have been tested scientifically, but you wouldn’t know that from the testimonials that populate the product websites. Most, at a minimum, cause the clitoris to “tingle” or cause a sensation of warmth or coolness, which evidently some women find stimulating.

Wet wOw is an example of a lube that promises lots of extra benefits. The active ingredient, methyl nicotinate (also used as a lip plumper, as in your face lips), creates a temporary inflammatory reaction that causes slight swelling and increased sensation. Vanillyl butyl ether has a warming effect. A dash of peppermint extract gives a cooling sensation. It sounds like there’s a lot going on, and hopefully the poor little clit won’t panic from feeling warm, cold, swollen, and excited all at the same time. On the other hand . . . that sounds a lot like love. In any case, the rave reviews the company touts are purely anecdotal at this point.

While additional studies are needed to determine the efficacy of herbal and other non-FDA-approved substances for treatment, neutraceuticals and lubes are low-risk options with potentially high return. If they work for you—lucky you! If they don’t, you haven’t lost much beyond the cost of the product. So, good luck!

Devices to Induce Orgasm

In Woody Allen’s 1973 hit movie Sleeper, one simply has to enter the “Orgasmatron” to efficiently induce a mind-blowing orgasm. Alternatively, simply holding a cantaloupe-sized orb can induce an orgasm in seconds without the bother of having to remove clothing or touch genitals.

The evil Dr. Durand in the 1964 film Barbarella invents the “Excessive Machine,” which uses constant stimulation with a paddle device as a form of torture that induces death by orgasm. Barbarella survives with a smile.

Flesh Gordon, the 1974 parody of Flash Gordon, utilizes a “Sex Ray” to cause earthlings to become aroused. The Coneheads (remember them?) use “Sensor Rings” to give their partners pleasure.

Until someone invents an actual Orgasmatron, Excessive Machine, Sex Ray, or Sensor Rings, this is what is out there that you can try.

Pelvic Physical Therapy and Pelvic Floor Strengthening Devices

As you saw in chapter 6, pelvic floor strengthening and other techniques done with a pelvic physical therapist can do wonders for sexual response. Not only will these techniques help you have an orgasm, but they may also help make your orgasms stronger. This makes sense since a healthy orgasm requires a contraction and release of pelvic floor muscles. That is the premise behind many of the SexAbilitators discussed in chapter 6, including the Magic Banana and a variety of weighted balls, cones, and, yes, barbells. All of these products promise better orgasms when used regularly. No scientific studies have actually been conducted to prove this, and currently none are planned.

Intensity

Intensity is the newest and one of the more promising devices specifically designed to treat orgasmic dysfunction. At first glance, it looks like a giant rabbit-type vibrator, but unlike a vibrator, Intensity utilizes electrical muscle stimulation to strengthen pelvic floor muscles. The inflatable vaginal probe (designed to fit every vagina) ensures close contact with pelvic floor muscles.

And yes, there is also a clitoral stimulator with an ultra-intense vibration. Scientific studies on Intensity are in progress, and they are promising. Most of my patients, though, don’t care about the studies. They just want to know where they can get it—right now this device is only available online (Pourmoi.com).

EROS

The EROS Clitoral Therapy Device was approved by the FDA in 2000 for the treatment of orgasmic disorders and female sexual dysfunction. This battery-powered device is applied to the clitoris and works by applying a gentle vacuum to increase blood flow and enhance engorgement. A number of well-designed studies on the EROS device have been published by sexual health experts, and they have demonstrated effectiveness, with up to 60 percent of women finding their ability to achieve orgasm enhanced. The device has also been studied and found to be effective in diabetics and in women who have had pelvic surgery or received radiation to the pelvis.

Slightest Touch Electro Sex

Best. Sex. Ever. That’s what the company that makes Slightest Touch promises you, along with a “spectacular orgasm or your money back.” Slightest Touch is a battery-operated device that stimulates nerve pathways to the genital area. Essentially a TENS (transcutaneous electrical nerve stimulation) unit, it requires that you apply electrode pads to the top of the foot, above the ankles, and on the buttocks. The premise is that stimulation of nerves in the back will trigger an orgasm. No studies have been published, but I did find a number of people on the Internet who were (unsuccessfully) trying to get their money back.

InterStim

This is a pelvic nerve stimulation system that must be surgically implanted. It is used to help treat urinary incontinence, but has also been found to increase women’s orgasmic ability.

Vielle

This is a female massager. Designed for a single use, it is worn on a finger when providing digital stimulation. The company claims this will improve orgasm. Essentially, it adds little bumpy projections to the end of the stimulating finger. I’m skeptical, but it can’t hurt to try.

Vibrators, aka “BOB” (Battery-Operated Boyfriend)

My advice is to start with what works for most women and is the most accessible. Even corner drugstores and airport gift shops (Come fly with me!) are selling vibrators these days. Over the years I have found that when the majority of my patients who have never had an orgasm try a vibrator, something wonderful happens. For many normal women, the intensity of a vibrator makes it the only way they are able to climax. A woman in her fifties who has lost the ability to have an orgasm may require a vibrator to get the same response that she easily achieved with digital stimulation in her thirties. And when I refer to a “vibrator,” I’m not talking about that battery-operated long hard thing you got as a gag gift in 1982. Toss it and go shopping. But read chapter 20 first.

Surgery?

Every once in a while you will see a claim that a procedure such as G-spot augmentation with collagen injections, clitoral hood reduction, an injection in the clitoris, or a cosmetic procedure will facilitate orgasm. Don’t do it.

Tantric Sex

Another approach is to forget the destination (orgasm) and focus on the journey (great sex). Tantric sex, which dates back 5,000 years, promises amazing climaxes that last longer than the average O. But that’s actually not the point of the experience. While most only experience a transcendent state during an orgasm, people who engage in this ancient Eastern spiritual practice aim to extend arousal throughout the entire sexual experience. Much like yoga, the key to a tantric experience is in your breath.

If you hone in on your breathing, you can rid your mind of all things mundane and truly focus on how you’re feeling. This can be applied to activities outside the bedroom as well. But during sex the participants add reverence to sex, taking time to appreciate each other’s arousal. While you may have heard rumors about tantric sex lasting for hours and hours (I’m looking at you, Sting), that’s not necessarily the goal. The objective should be to get yourself into the right frame of mind. How can you get there? For starters, spend time talking about having sex, enjoy just kissing, or give each other a sensual massage. If and when that orgasm happens, it will be worth the wait.

When Having the Orgasm Itself Is the Problem

While anorgasmia is the most common orgasmic disorder that plagues women, some have no problem climaxing but may experience orgasmic headache, pain with orgasms, incontinence, or a relatively rare but very distressing condition known as persistent genital arousal syndrome.

Not Tonight, Honey, I’m About to Get a Headache

The first time a patient came to me and told me that every time she had an orgasm she experienced a terrible headache, I advised her to see her internist, or maybe a neurologist. Quite frankly, I thought she suffered from migraines and the correlation with her orgasm was simply a coincidence.

Wrong! Now I know there is a specific phenomenon known as “orgasmic headache.” Let me be clear, though: headache associated with sexual activity is not the same as headache before sexual activity, as in, “Not tonight, honey, I’ve got a headache.”

This is an uncommon issue, affecting only about 1 percent of the population, but even if only one in 100 women experience a headache during sexual activity, that’s significant. Fortunately, 75 percent of the time orgasmic headache is a onetime event.

I learned more about sexual headache when I heard a lecture by Dr. Robert Cowan, the director of the Headache Program at Stanford University. He emphasized that there are two very distinct categories of sexual headaches. Pre-orgasmic headaches occur during arousal and usually start as a mild dull ache in the head and neck. Many women describe a throbbing, pressure-like sensation in the head accompanied by a muscle contraction in the neck or jaw. Pre-orgasmic headaches get worse with increased sexual excitement and can last up to three hours. While a real romance killer, these sexual headaches are generally not an indication of anything serious. You can take a nonsteroidal anti-inflammatory drug (NSAID) like indomethacin 30 minutes prior to sexual activity (I know, it’s not like you have a schedule for intercourse), and if that doesn’t work, see your doctor for further evaluation and a prescription remedy.

A true orgasmic headache is a sudden explosive headache that is simultaneous with orgasm. It starts in one spot and quickly spreads. This is the important part. A true orgasmic headache has a very high correlation with a more serious problem, such as stroke or brain hemorrhage. In fact, 4 to 12 percent of patients with a sub-arachnoid brain hemorrhage report that their first indication that something was wrong was experiencing an excruciating headache during sex.

The bottom line is this: if you have a severe explosive headache simultaneous with orgasm, put on your clothes and get yourself to an emergency room immediately. A head CT scan or MRI will determine whether there is something serious going on. In many cases, it will turn out to be nothing serious. But if you have a ruptured aneurysm, your orgasm will have literally saved your life.

Incontinence

If you have no problem with your orgasms other than you wet the bed anytime you have one, you are not alone. Occasionally, it is not urine at all, but female ejaculation from a vestibular gland in the vagina. In most cases, however, an orgasmic pelvic floor contraction has combined with a penis pushing on the bladder to cause an involuntary loss of urine that is distressing to say the least. (Incontinence is covered in more detail in chapter 15.)

Painful Orgasms

It’s bad enough to have pain in any circumstance, but to have pain when you are expecting pleasure is the equivalent of thinking you are about to get into a nice warm shower only to discover that there is no hot water.

Most women who have pain with orgasm are experiencing painful intercourse that continues or worsens if there is an orgasm. Since an orgasm is essentially a contraction and release of pelvic floor muscles, most pain with orgasm is a result of a hypertonic pelvic floor. Eliminating the source of the pain with pelvic floor physical therapy will alleviate this problem.

Pain-free pleasurable intercourse that culminates in a painful orgasm is a different matter.

The first step is to determine what hurts.

If the clitoris hurts, it may be that the nerves have continued to fire after orgasm. This is a likely scenario if the first orgasm is fine but during additional orgasms things get progressively more painful. You may need to just give it a rest!

Sometimes, if there is clitoral pain, there may be scarring from an old infection, or potentially a current infection. I once found that a patient who had excruciating orgasmic pain had an active herpes sore right on the tip of her clitoris. Sometimes the clitoral hood has adhesions from an old infection, or inflammation and engorgement of the clitoris causes the hood to “pull” on the clitoris, resulting in pain. Women from developing countries that still perform genital cutting also often have scarring that results in pain. In these cases, surgically removing the adhesions eliminates the pain.

If there is generalized pelvic pain and cramping in addition to the pain you experience during orgasm, it may indicate there is something amiss in your pelvis, such as endometriosis, an ovarian cyst, or other gynecologic problems. (See chapter 9 for more information on the possibilities.) In any case, an orgasm shouldn’t be painful, and if the pain persists, a visit to your gynecologist is in order.

Persistent Genital Arousal Disorder: Too Much of a Good Thing?

What could be better! Constant orgasms! Constant pleasure! Your first thought might be, Where can I get some of that? Well, not so fast. For the women who have persistent genital arousal disorder (PGAD), there is nothing pleasurable about what they are experiencing.

I still remember my first exposure to persistent genital arousal syndrome. I had just completed the exam of a new patient. Everything was normal, but when I asked her if she had any issues she wanted to discuss, she began to weep. “I’m excited all the time, and I keep having . . . actually orgasms. All day long. Constantly.”

I must have looked puzzled, because she went on to say, “I mean, even when I am not sexually excited, like when my boss, who I can’t stand, gives me extra work. It’s constant, and I can’t make it stop. Sitting on the bus, having my morning coffee. I don’t know what to do.” She wept harder.

I was at a loss. Didn’t orgasms feel good? I saw patients all day who were desperate to have orgasms. Was she crazy? So I did what every doctor does when confronted with something they don’t know. I told her to get dressed and I tried to look it up. The problem was that I didn’t know how to look it up. The phrase “persistent genital arousal syndrome” didn’t yet exist. I put “too many orgasms” in my computer’s search engine. You can only imagine what came up. Constant orgasm? Even worse.

I gave up on the Internet and turned to my medical textbooks. My gynecologic textbook didn’t even have “orgasm” in the index, much less “constant” or “too many.” I was stuck.

So I did the other thing doctors do when they have no clue. I referred her to someone else, who probably didn’t have a clue either. I don’t even remember what specialty I picked. I think I probably considered that my patient might have been a little crazy, but she seemed so normal, so ordinary.

Fast-forward. Today I know a lot about this very real, very distressing syndrome.

PGAD has been around forever but was not described in the medical literature until 2001, as a condition in which there is constant genital arousal in the absence of sexual desire. The absence of desire is important and differentiates the person suffering from PGAD from someone who is hypersexual and feels desire all the time. It has been known to affect teens, young women, and postmenopausal women.

Pretty much anything that causes even slight clitoral pressure can trigger the symptoms. Sexual activities such as intercourse or masturbation can initiate an episode. Nonsexual situations such as bike riding, tight jeans, vibrations from a car, or even sitting can also set off feelings of arousal that last for hours, days, or weeks. Orgasms, when they do occur, do not always give relief; sometimes they can be painful.

Here are the specific criteria required to make the diagnosis:

1.  Having feelings of sexual arousal (pre-orgasmic genital fullness and swelling) that last for a minimum of hours.

2.  Having orgasms does not make the symptoms go away. In spite of constantly feeling like you are on the brink of an orgasm, there is no pleasure or relief when it happens.

3.  Sexual arousal is unrelated to any subjective sense of sexual excitement or desire—for example, feeling pre-orgasmic while your smelly, overweight boss is yelling at you.

4.  The symptoms are intrusive and unwanted. The moment when you are about to take an important test is not when you want to be thinking about your clitoris.

5.  Having the symptoms causes distress. This seems a bit redundant, since anyone experiencing symptoms 1 to 4 is not going to be happy, but this criterion is meant to differentiate someone with this syndrome from a person who finds these symptoms pleasurable.

Even if they don’t meet all these criteria, some women may still experience some of the symptoms, such as persistent vasocongestion, tingling, wetness, throbbing, and genital contractions.

Proposed Causes of PGAD

What causes PGAD is highly controversial, and in many cases it has multiple roots. While it is associated with a number of conditions such as depression, anxiety, sexual abuse, and panic attacks, “associated with” (and exacerbating the symptoms) is not the same as “causing.” Many researchers believe that treating any underlying depression or anxiety is an appropriate first step. Other conditions linked to PGAD include cysts on the sacral bone that impinge on nerve endings, increased soy intake, and various medications. One theory is that PGAD is the female clitoral version of priapism, a condition in men who have a persistent erection caused by engorgement of blood vessels.

Neurologic problems such as epilepsy, overactive bladder, restless leg syndrome, brain arteriovenous fistulas, or stroke have also been described as potential causes of PGAD. Increased vascularity to the pelvis, as seen in pelvic varicose veins, is another possible link. Antidepressants such as SSRIs have been implicated in triggering PGAD, but obviously women who are starting SSRIs also have high levels of anxiety and depression.

Whatever the source of this condition—vascular, hormonal, physical—there is an inappropriate triggering and hypersensitivity of the nerve, or a branch of the nerve, that supplies the clitoris.

Therapy for PGAD

While having an orgasm will not eliminate the symptoms, sometimes multiple orgasms will relieve the discomfort. But women quickly discover that, in addition to providing only incomplete relief, going to the bathroom to masturbate multiple times before giving a presentation to one’s colleagues is no way to live.

Most women go to several doctors before they find someone who can help. Sexual health programs that routinely treat PGAD are the best bet. These programs utilize a team approach that includes gynecologists, pelvic physical therapists, and psychologists.

The first step is to identify any potential causes that are reversible, such as a physical nerve entrapment, a sacral cyst, or a medication issue. Most pelvic examinations are normal, but they still should be done to determine if there is clitoral engorgement. A pelvic ultrasound will determine if there are any pelvic masses, and an MRI will show if there is a nerve entrapment, varicose veins, or a sacral cyst. Therapies to “quiet” the clitoral nerve include medications that alter neurotransmitters, nerve blocks, topical anesthetics, and ice. If pelvic varicosities are present, embolization can be considered.

Cognitive behavioral therapy has been a useful treatment, along with distraction techniques such as exercise.

Clearly, much research still needs to be done on this issue, but at least now the problem is recognized, it’s been given a name, and therapies have become available that in fact often work.

And by the way, I would like to say to that first patient of mine, I’m so sorry I didn’t help you. I am so sorry I didn’t take your problem seriously enough to do additional research. I hope you found the help you needed.