Key Insights in Women's Sexuality

The more I work with women in my practice, the more I recognize that the science of human sexuality is young. For most of the last century, we assumed that men and women approach sex in roughly the same way.

Crazy. But there it is: The science is young.

Older models (Masters & Johnson, Kaplan) theorized that sex for people happens in a few neat, linear stages, beginning with desire, proceeding next to arousal, then orgasm, and finally satisfaction.

But it doesn’t always work that way, particularly for women, and especially for women over 40.

More recent researchers who focus on women’s sexuality, confirm that really, women do not experience sex in this simple, linear way. We sometimes skip phases. Our reasons to have sex are many and often complex.

We can be perfectly satisfied with sex that does not include orgasm, and we can reach orgasm without desire. We are flexible that way.

I continue to refer women to work done by Rosemary Basson, MB, FRCP, of the University of British Columbia. Basson formalized a new model of female sexuality that is now widely accepted.

She offers two key insights. First: Female sexual desire is generally more responsive than spontaneous. That is, we are more likely to respond to sexual stimuli — thoughts, sights, smells, and sounds — than we are to spark an interest in sex out of thin air (Men, on the other hand, specialize in this).

Another key insight: Emotional intimacy matters to women. That doesn’t sound like a news flash, but in the realm of the biological sciences, it’s news, trust me.

Basson's model of sexuality

So Basson drew a new model – not a linear series of steps, but a circle that includes both sexual stimuli—the thoughts that trigger a woman to take an interest in sex, and emotional intimacy—the emotional payoffs of the experience that lead her to want to come back for more. I love Basson’s model and use it every day in my practice to help my patients understand how sex really works for us.

We need to understand that it’s okay and it’s normal that we don’t always start with desire. And as we enter menopause, and our hormone levels drop, spontaneous thoughts about sex and responsiveness to opportunities for sex diminish for most of us. That’s natural and normal too.

If you don’t like the situation, and you want to feel more sexual, more responsive, Basson’s model gives us the hint: We need to stimulate our minds. The more sexual stimuli we receive, the more sexual we feel.

So, this is worth thinking about today, a worthy discussion to have with your partner: What makes you feel sexy? A juicy romance novel? A James Bond movie? Erotic art? Pretty underpinnings? A romantic dinner?  Having your partner empty the dishwasher?  Spend some time thinking about that. Maybe make a list. And then provide for these things. Sexy is as sexy does.

Where Angels Fear to Tread

Sex and religion aren’t often mentioned in the same breath. One is fleshly; the other spiritual, right? Like oil and water.

Yet, both are integral to our person and to our psyche. Both faith and sexuality are deep expressions of who we are. We can’t chuck our sexuality at the door of the church or temple or synagogue; nor can we drop whatever we believe about God at the door of the bedroom.

So I was interested to read about a recent survey conducted by psychologist Darrel Ray, who compared the behavior and feeling of nonbelievers (agnostics and atheists) to those of believers (mostly of Christian persuasions). In a nutshell, he found that both groups behave similarly. Both became sexually active at about the same age, have similar levels of sexual activity, do the same things in the bedroom. They even pursue affairs at similar levels. The significant difference was that the believers tended to feel more guilty. This was particularly pronounced in more fundamental denominations: Mormons, Jehovah’s Witnesses, Seventh Day Adventists, Pentecostals, and Baptists. But mainline Protestants and Catholics experienced higher levels of guilt, too, than atheists or agnostics. Not crippling, but noticeable.

Leaving aside for a moment serious questions about Dr. Ray’s motive and methodology (he calls religion a disease and himself a “recovering religionist”), his report raises some interesting questions. Do people who believe in God feel guilty about sex? Are certain acts, masturbation or oral sex, for example, more troubling or guilt-provoking? If so, why would this be? Does guilt derive from actual church teaching or from cultural conditioning or from something misunderstood or misapplied in childhood?

Even the religious institutions themselves struggle to honestly incorporate sex in a faith context. Yes, sex, in the context of a loving, uncoerced relationship, is a beautiful, God-given gift. Just read the Biblical Songs of Songs. However, as it’s practiced on the ground, the message isn’t all that clear, and even some church leaders admit as much.

“In the context of Catholic teaching, I would think it safe to say that the connection [between faith and sexuality] is contorted, controverted, and often confusing,” says Dr. Michael Higgins, vice-president of Mission and Catholic identity at Sacred Heart University in Fairfield, Connecticut.

“If we could only transcend the ‘forbidden fruit’ mindset, perhaps religion could evolve into a much healthier sexual ethic,” said Rabbi Howard Voss-Altman, of the Reformed Jewish tradition.

Dr. Sheema Khan, a practicing Muslim, said that “…sexuality forms part and parcel of [Muslim] spirituality. There are even prayers prior to sexual intercourse, and… foreplay is encouraged (as part of religious teachings).” But she also condemned the Muslim preoccupation with the “purity of women,” which could result in the ritual killing of a woman suspected of having sex outside of marriage.

So it would seem that if we aren’t sure how to feel about sex or some sexual behaviors, or if some indefinite guilt is associated with sex, we aren’t alone. Our religious institutions are grappling with the same issues.

But isn’t this the nature of life—to honestly articulate and wrestle with our inconsistencies? And in the end, to become more mature and integrated?

I remember the advice a wise old pastor gave my mother when she was trying to reconcile church teaching with the expression of sex in her marriage. “I don’t think that anything a loving couple does in the bedroom to give each other pleasure can possibly be sinful,” said this man of God. Amen to that.

Q: Should I throw in the towel on trying to experience orgasm?

First, know you're not alone! About 25 percent of us report difficulty achieving an orgasm.

The most commonly used approach to treat ‘primary anorgasmia’ (the medical term for a woman who has never had an orgasm) is what is called ‘directed masturbation.’ The amount and intensity of stimulation is variable from person to person, as well as the time required. Ninety-five percent of women are successful--which means, unfortunately, five percent are not. The women who are most successful masturbate at least once a week; for some women it can take up to 10 weeks to experience an orgasm. The majority of women use additional stimulation by way of erotic DVDs (or other visual erotica) and/or vibrators.

Many of my patients, especially as they get older, find they cannot have an orgasm without a vibrator. Yesterday I had a patient in the office who has never had an orgasm without a vibrator.

Using vaginal estrogen can improve sensation to the area (assuming you are menopausal); a warming lubricant or oil can help, too. Start with applying only a small amount of warming lubricant to test your reaction, because if the tissues are thin and sensitive, you might feel some uncomfortable burning.

There are also physical reasons some women can’t have an orgasm or have weaker orgasms: neurological disorders (Parkinsons and MS, for example), surgical conditions (having had pelvic surgery), clitoral adhesions, medical disorders (diabetes, vascular disease) and medication side-effects (antidepressants, antihypertensives, and others).

I understand your frustration. I encourage you to keep practicing--and to experiment with resources available to you!

When an Orgasm Is Not an Orgasm

This topic comes up more often with girlfriends than with patients. But it comes up often enough with girlfriends that I know it’s on my patients’ minds, too! The question is whether it’s sometimes okay to fake an orgasm.

I think it depends on how you define “sometimes” — and what your reasons are for faking. Let’s start by acknowledging that, by some estimates, as many as one in ten of us has never achieved an orgasm. Among those of us who orgasm, we might do so in only about half of our sexual encounters. And, just to dispel one widespread myth, only about a third of us achieve orgasms with heterosexual intercourse alone.

All that said, I think you get to decide when you signal your partner that you’ve achieved orgasm when you haven’t. Maybe you’re getting tired but you don’t want to break the intimate mood. Maybe you want to satisfy or boost your partner’s confidence. Studies show that nearly 80 percent of women will fake orgasm at some point.

But making a habit of it isn’t fair to you or to your partner, even though, with our busy, fast-paced lives, it can be an easy pattern to fall into. It’s worth it to spend some time—alone and with your partner—learning more about your body and its paths to orgasm. Even if you’ve had a lot of experience, changes in hormone levels, circulation, and tissue health can mean your needs have changed.

If you’re faking more than once in a great while, there may be something else going on that needs attention. Do you feel like it takes too long to reach orgasm? Does your partner know exactly what to do to help you achieve an orgasm? Is there something on your mind that’s making it hard to relax when you’re having sex? There are lots of ways to increase your mindfulness, sensation, and response.

We like sex for lots of reasons, and orgasm doesn’t have to be one of them. If you’ve never learned to have an orgasm, or if you don’t have them regularly, don’t consider yourself a sexual failure! But if you’re finding yourself pretending more than you used to, it’s never too late to learn or relearn our bodies.

Couples Pornography: What’s In It for You?

An article in The New York Times last week reports that, come January, Playboy TV will begin “shifting from traditional pornography toward a higher-quality, female-friendly slate of of reality shows,” called “TV for 2.” Designed to appeal to women’s preferences for “contextualized sex” -- intimate scenes that are part of realistic stories that feature believable characters -- the new programming will have an emphasis on intimacy and “learning as a couple.”

It will be interesting to see how their new market responds.

Sexual advisors and therapists frequently recommend watching sexy movies together as a way for couples to stimulate or improve or add spice to monogamous sex. But finding “explicit sexual content” that appeals to both partners can be tricky.

As the Playboy Channel has (rather belatedly) learned, women are not typically turned on -- and many of them are downright turned off -- by the purely visual, graphic sex that men find arousing to watch. More than a few of my patients have told me that they felt less (sometimes much less) sexually attracted to their husbands after viewing pornographic material their partners had inadvertently left open on shared computer screens.

And for a woman in her 40s or 50s who may be starting to feel less confident about her own body and its appeal, the air-brushed young women who appear on the covers of men’s magazines can make it even harder to conceive of herself as someone who’s still  got what it takes to be a desirable partner in bed.

Of course, watching X-rated movies together -- even ones that don’t appeal to both (or either) of the people watching -- can help a couple communicate about what each of them likes or doesn’t like and what they both might be interested in and willing to try. And anything that helps a couple talk about sex has the promise of increasing their erotic connection and their understanding of each other’s pleasures and desires.

What do you think? Will the business of producing “porn aimed at couples” be a good thing for women who want to have an active and satisfying sex life in their middle years? What role, if any, does sexually explicit media play in your own relationships? Are you planning to check out “TV for 2?” We’d love to hear what you think!

The Third Component of Great Sex: Deep Sexual and Erotic Intimacy

What's the difference between "connection" (number two of the "eight components of optimal sexuality") and "deep sexual and erotic intimacy" (number three)? That stumped me for a bit while I was digesting the study published last year in The Canadian Journal of Human Sexuality.

Then I read this quote from one of the study’s participants, describing a type of intimacy that goes beyond intense connection in the moment: “It’s part of the way you act with each other long before you’re actually engaged in any kind of, you know, technical sex.”

I like that. I think that “the way you act with each other” before, after, and during “technical sex” is essential to deep erotic and emotional intimacy. Trust, respect, and real admiration and acceptance build the foundation for a truly intimate relationship. These are things that take time, that come with knowing each other in a profound way.

And, in my experience, you can tell if a couple has this kind of intimacy just by observing the way they interact at the grocery store or a dinner party. Do they laugh at each other’s jokes? Do they exchange quick touches and knowing glances? Do they refrain from criticizing each others’ tastes in breakfast cereal?

According to study participants, a deep sense of caring for one’s partner is a key characteristic of sexual intimacy. One woman mentioned that her need to feel solicitude and concern had become more important to her with age: “I don’t know that I’m capable of having great sex anymore without really caring about a partner.”

The study’s authors noted that “almost every participant identified a deep and penetrating sense of trust as characteristic of the intimacy that was part of great sex for them.” They needed to trust that their partners cared for them and that the relationship was secure.

This kind of trust and intimacy doesn’t just happen. It takes time and openness and communication. Especially at midlife, when our bodies and needs are changing, it’s important for partners to talk with each other, to stay up-to-date on feelings and desires. Honest and caring talk about sex can be erotic in itself, and can go a long way toward creating and maintaining the deep intimacy that makes for sex that is “better than good.”

More on this next week, when we look at component number four: Extraordinary Communication!

Q: How can I increase sensation and more readily orgasm?

There is no doubt that the ability to achieve an orgasm becomes more difficult as we age, and the orgasm itself is often briefer and less intense. As we age, we need more time for every step of the process, starting with foreplay. Sometimes our partners need to hear a clear message about what's changing for us! We hope our website can make it easier to have those discussions with a partner.

Using a warming lube, like Oceanus G Stimulating or Sliquid Organics Stimulating O Gel, can improve sensation for some women. Warming lubes include a minty or peppery ingredient, which increases circulation and sensation in genital tissues.

You mention occasional orgasm success with a vibrator. Not all vibrators are alike: Some don't provide the intensity of vibration that our tissues need in midlife. We offer vibrators by Emotional Bliss that are more powerful than average, designed for those who specifically need more stimulation, more intensity. I’ve seen some amazing results with these in women who previously were unable to have an orgasm because of neurologic diseases or medications that are known to interfere with orgasm.

You might also talk to your health care provider to see whether vaginal (or localized) estrogen is a good option for you. Lack of estrogen to vaginal tissues results in a decrease in circulation, which leads to less sensation, which is why you may not sense penetration as you did before.

Do talk to your partner and explore your options. Sexual satisfaction comes in many forms, but if you're missing orgasms, there's no reason to leave them behind.

What Do Breasts Do for Us?

Recently I treated a patient who’d had elective breast reduction surgery. Nerve damage during the procedure had caused her to lose all sensation in her nipples. She found herself unable to have an orgasm without the extra stimulation those nerves had provided. That was a consequence she hadn't thought to ask about!

Changes in nipple sensation are possible side effects of any type of breast surgery, including elective surgery to increase or reduce breast size. Sometimes the effects are temporary, but they can be permanent. It’s important to understand these risks -- and the role your breasts play in sexual arousal and satisfaction -- when choosing breast surgery for cosmetic reasons. I don't know if my patient would have made a different choice, but she may have.

How do breasts contribute to orgasm? Some women (not most) can reach orgasm through nipple stimulation alone. Others rely on intense breast and nipple fondling to “put them over the top” during oral sex or vaginal penetration.

Like the clitoris, nipples are bundles of nerve endings that respond to touch by releasing certain hormones in the brain. One of these hormones, oxytocin, is sometimes referred to as the “cuddle hormone”: It makes us feel warm and open toward the person whose touch initiated its release in our bodies. Other hormones, including testosterone and endorphins, combine to create a surge of sexual arousal that increases blood flow to the clitoris and stimulates vaginal lubrication.

For most women, sexual foreplay is essential to getting us interested in and ready for intercourse or penetration. And for most women (82 percent in one study) breast and nipple stimulation are an essential ingredient of foreplay.  We talk a lot about clitoral stimulation and vaginal maintenance for maintaining our sexual satisfaction, but other parts of our bodies also play a part in arousal and orgasm, though.

For those of us fortunate enough to retain the pleasant sensations our breasts can provide, remembering these important sites of arousal during foreplay and intercourse (warming and massage oils can work wonders here) will enhance our readiness for and enjoyment of sex -- at any age. Let's not forget to raise our focus -- to our breasts.

Why We Love Rosemary

Rosemary Basson's model of female sexual response

The science of human sexuality is young. For most of the last century, we assumed that men and women approach sex in roughly the same way.

I know: Crazy. But as I said, the science is young.

Older models (Masters & Johnson, Kaplan) theorized that sex for people happens in a few neat, linear stages, beginning with  desire, proceeding next to arousal, then orgasm, and finally satisfaction.

But it doesn’t always work that way, particularly for women, and especially for women over 40.

More recent researchers who focus on women’s sexuality, confirm that really, women do not experience sex in this simple, linear way. We sometimes skip phases. Our reasons to have sex are many and often complex.

We can be perfectly satisfied with sex that does not include orgasm, and we can reach orgasm without desire. We are flexible that way.

Enter Rosemary Basson, MB, FRCP, of the University of British Columbia. Basson formalized a new model of female sexuality that is now widely accepted.

She offers two key insights. First: Female sexual desire is generally more responsive than spontaneous. That is, we are more likely to respond to sexual stimuli — thoughts, sights, smells, and sounds — than we are to spark an interest in sex out of thin air (Men, on the other hand, specialize in this).

Another key insight: emotional intimacy matters to women. I know, that doesn’t sound like a news flash, but in the realm of the biological sciences, it’s news, trust me.

So Basson drew a new model – not a linear series of steps, but a circle that includes both sexual stimuli — the thoughts that trigger a woman to take an interest in sex, and emotional intimacy — the emotional payoffs of the experience that lead her to want to come back for more.

I love Basson’s model and use it every day in my practice to help my patients understand how sex really works for us.

We need to understand that it’s okay and it’s normal that we don’t always start with desire.  And as we enter menopause, and our hormone levels drop, spontaneous thoughts about sex, and responsiveness to opportunities for sex diminish for most of us. That’s natural and normal too.

If you don’t like the situation, and you want to feel more sexual, more responsive, Basson’s model gives us the hint: We need to stimulate our minds. The more sexual stimuli we receive, the more sexual we feel.

So, this is worth thinking about today, a worthy discussion to have with your partner: What makes you feel sexy? A juicy romance novel? A James Bond movie? Erotic art? Pretty underpinnings? A romantic dinner?  Having your partner empty the dishwasher?  Spend some time thinking about that. Maybe make a list. And then provide for these things. Sexy is as sexy does, friends.

And, hey, if you’d like to help a sister find some sexual motivation, use the comment field below to share. What sights, sounds, scents, scenes help you get in the mood?

Here's more:

Theories of Female Sexual Response

Sex:Desire, Chicken:Egg

Why Women Have Sex