This work aims to identify factors that contribute and those that impair the ability to experience orgasm during sexual activity. It compared women (n=96) aged 18–61 (M=38.5 years) in a stable relationship that, after a normal arousal phase, do not have an orgasm (OD) with those that do (OA) regarding sociodemographic data, sexual frequency, talking about sex with their physician, talking about sex with their partner, sexual education, masturbation, sexual desire, sexual satisfaction, depression and anxiety. We found differences between the OD and OA groups with regard to level of education (P=0.022), sex education during childhood and/or adolescence (P<0.001), masturbation (P=0.017), sexual satisfaction (P<0.001), anxiety (P<0.001) and sexual desire (P<0.001). The final model of logistic regression for orgasm problems included the variables ‘masturbation’, ‘high school’, ‘sexual desire’ and ‘anxiety’. Orgasm difficulties are influenced by personal factors, such as anxiety and low sexual desire. Increased levels of anxiety also increase orgasmic difficulties. Women who masturbate and/or have completed high school are considerably more likely to reach orgasm during sexual activity.
Woman’s orgasm is a transient peak sensation of intense pleasure, creating an altered state of consciousness usually with an induction of well-being and contentment. It is generally accompanied by involuntary, rhythmic contractions of the pelvic, striated circumvaginal musculature, often with concomitant uterine and anal contractions and myotonia that resolves the sexually induced vasocongestion.1 Orgasm can be achieved by women through different sensory mechanisms, but the two most important are: external sensory stimulation of the vulva (the clitoris in particular) and the surrounding skin and mucosal areas; and internal sensory stimulation of the pelvic area and the vaginal walls.2
In a multinational epidemiologic survey, the ability to achieve orgasm was considered important for 88% of women (52% considered it ‘very important’ and 36%, ‘somewhat important’).3 Although orgasm has been a relevant component of female sexual response, difficulty in experiencing it is very common.1 Orgasmic problems are the second most frequently reported sexual problems in women.4 In Brazil, a previous study showed that the prevalence of orgasmic dysfunction was 21%.5
According to the Diagnostic and Statistical Manual of Mental Disorders IV,6 female orgasmic disorder is defined as ‘a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase’ that causes distress or interpersonal difficulty. Simpler, the definition of the International Statistical Classification of Diseases and Related Health Problems7 states that ‘orgasmic dysfunction’ is when ‘orgasm either does not occur or is markedly delayed,’ without any additional diagnostic criteria.
Research on the etiology of orgasm difficulties combines anatomical, physiological, biological, genetic, medical and psychosocial factors.8 Physiological factors, such as endocrine or autonomic nervous system, cardiovascular factors and some medications have been associated with orgasm problems.1 However, they are more commonly associated with psychological, cognitive-affective and social aspects than with physiological aspects.9
Although the Diagnostic and Statistical Manual of Mental Disorders IV6 claims that no association has been found between specific patterns of personality traits or psychopathology and orgasmic dysfunction in females, some studies have shown associations between orgasmic problems and sexual abuse,1 depression,10 anxiety,11 psychosexual immaturity,12 lower emotional intelligence,13 poor marital communication14 and feelings of rejection during intercourse.15 Even so, there is still a lack of systematic attempts aimed at describing and mapping the components that contribute to orgasmic problems.16
It is important to highlight that cultural differences must be taken into account when studying female sexuality, as cultural norms and values influence the manner in which women experience sexuality and react to sexual dysfunction and sexual side effects.16, 17 For example, a Malaysian study showed that the prevalence of women with orgasmic difficulties was more than half, whereas in Western populations, this figure is only one-third.18 To our knowledge, no study has been conducted in Latin America comparing orgasmic and nonorgasmic women. Hence, this investigation aims to compare women who have orgasm during sexual activity with those who do not and identify personal factors that contribute and those that impair the ability to experience orgasm in Brazilian women.
Materials and method
Beck Depression Inventory and Beck Anxiety Inventory are well-established self-report scales with 21 items each. Possible scores on each scale range from 0 to 63 points. The final score is classified as ‘minimal’, ‘mild’, ‘moderate’ or ‘severe’ depression and anxiety.19, 20
The variables ‘talking about sex with physician’, ‘talking about sex with partner’, ‘masturbation’, ‘sexual education’ and ‘sexual frequency’ were assessed through a questionnaire containing the following yes or no questions:
Do you talk about sex with your physician?
Do you talk about sex with your partner?
Do you masturbate yourself?
Did you have, throughout your childhood and/or adolescence, information/education about sex?
How many times per week, on average, do you have sex?
Desire, arousal, orgasm and sexual satisfaction were measured by the Female Sexual Quotient (FSQ), which is a scale developed and validated in Brazil that assesses multiple dimensions of women’s sexual activity and has been used in several studies conducted in Brazil.21, 22, 23, 24
The FSQ can be interpreted in terms of the total score, assessing the overall sexual functioning, or the score on the individual dimensions, as in this study. In the latter, it indicates which aspects of female sexual response are most problematic for each patient based on the last 6 months. Each question of the FSQ (Figure 1) is answered on a six-point scale: ‘never’ (0), ‘infrequently or rarely’ (1), ‘sometimes’ (2), ‘nearly 50% of the time’ (3), ‘most of the time’ (4) and ‘always’ (5). The sum of the scores multiplied by two provides the total score of the FSQ ranging from 0 to 100. Scores 60 indicate sexual dysfunction. The internal consistency, as measured by the Cronbach’s alpha coefficient, was high for the overall questionnaire and each domain (FSQ: 0.98, desire: 0.95, arousal: 0.93, orgasm: 0.95 and satisfaction: 0.96).25
Scores 2 in the questions related to each dimension indicate low sexual desire, arousal problems, orgasmic difficulties and sexual dissatisfaction, respectively.
We evaluated 110 patients (18–61 years, mean: 38.5 years) from the Gynecological Clinic of the Clinics Hospital, Medicine School of the University of São Paulo, who were there for routine well-care consultations. They had no chronic diseases and were in a stable relationship for at least 1 year with male partners. Participants under psychological or psychiatric treatment or receiving medications that affect sexual function (for example, antidepressants or antihypertensive medications) were not included.
After the data collection, patients with any problem during arousal were excluded (n=14). Thus, the orgasmic difficulty (OD) group was made up with patients who did not have orgasm after a normal arousal phase (n=22), whereas the orgasmic ability (OA) group was composed of patients with normal phases of arousal and orgasm (n=74).
Patients were invited to participate in a study on women’s sexual health during the second half of 2011 and first semester of 2012 while waiting for routine gynecological consultations. During the first contact, the study criteria were assessed by trained interviewers. Then, patients were interviewed in order to collect sociodemographic data. Finally, they were instructed to complete the sexual questionnaire, FSQ, Beck Depression Inventory and Beck Anxiety Inventory. In order to avoid missing data, the interviewers made sure that all questions were answered before dismissing the patient. This project was approved by the Ethics in Research Committee of University of São Paulo and all women provided written informed consent.
Motivated by their theoretical dependence, the association between chosen variables was tested and quantified using Fisher’s exact test and Cramer’s V. An exploratory study of the marginally significant variables was performed using the categorical principal component analysis, a nonlinear alternative to regular principal component analysis appropriate for categorical data. Finally, the relevant variables were included in a logistic regression model of OD and backward deletion was performed to obtain a reduced model fit for interpretation.
OD and OA groups were found to be homogenous as to age (OD: m=35.5, s.d.=8.8; OA: m=38.1, s.d.=9.5; t=−1.38, P=0.175). No significant associations were revealed between the groups and psychosocial descriptors such as per capita income (P=0.099) and duration of the current relationship (P=0.276). Details of these categories are found in Table 1. Other variables, such as ‘talk about sex with physician’ (P=0.065), ‘talk about sex with partner’ (P=0.086) and ‘sexual frequency’ (P=0.971) were also not considered significant. Finally, although an association between depression and sexual dysfunction in general (women who scored above 60 on the FSQ) was identified (P<0.001; V=0.43), no such relation was found between depression and OD (P=0.081).
Table 2 presents the variables found to bear a significant association with the studied groups (OD and OA). Women with OD were found to have lower education: 18.1% of the OD group completed high school education compared with 59.4% of the OA group (P=0.02, V=0.347). Also, significantly less of them received sexual education during childhood and/or adolescence: 13.6% against 47.2% in the OA group (P<0.001, V=0.289). Moreover, self-masturbation is more common in women who have orgasm during sex (35.1%) than in those who do not (9%) (P=0.017, V=0.241). Finally, sexual satisfaction exists even in women who do not have orgasm (50%), but is less frequent than in women who do (83.7%) (P<0.001, V=0.333).
Women with OD present higher levels of anxiety (68.2%) than women with OA (33.8%) (P=0.001, V=0.327). Although the majority of women in both groups have sexual desire, there is still a significant difference in the proportions found (P<0.001, V=0.311).
An exploratory study was performed using categorical principal component analysis and involving all marginally significant variables found above: ‘high school’, ‘sexual education during childhood and/or adolescence’, ‘talk about sex with partner’, ‘talk about sex with physician’, ‘sexual desire’, ‘masturbation’, ‘depression’, ‘anxiety’ and ‘orgasm’. All variables were scaled as nominal except for ‘high school’ (ordinal) and ‘depression’, ‘anxiety’ and ‘orgasm’ (multiple nominal). The variables ‘talk about sex with partner’ and ‘talk about sex with physician’ were excluded because their correlations to the components were low (<0.1). One, two and three component analyses were then studied to determine the best number of dimensions (different analyses must be run as categorical principal component analysis models are not nested.26 A two-dimensional decomposition was selected using both scree and eigenvalue less than one criteria (see Table 3 for details).
From the components loadings and centroids plot (Figure 2), it is clear that the second dimension relates predominantly to anxiety and depression (affective states), whereas the first dimension accounts for all other variables (background factors). Furthermore, the impact of the affective states on orgasm difficulty appears to be lower than other factors, such as desire and masturbation. The use of multiple nominal scaling for the affective states allows us to see that the impact of anxiety and depression on OA is asymmetric, that is, although not having depression or anxiety has little effect on OA, depressive or anxious women have increased OD.
So as to characterize the impact of the above factors, a logistic regression was performed modeling OD based on the significantly associated variables: ‘high school’, ‘sexual education in childhood and/or adolescence’, ‘masturbation’, ‘sexual desire’ and ‘anxiety’. Despite the statistically significant association found between orgasm ability and sexual satisfaction, it was not included in the logistic regression model owing to the fact that sexual satisfaction is likely to also be a result of orgasm rather than only a cause.
During the variable pruning (backward deletion) procedure, only ‘sexual education in childhood and/or adolescence’ was removed from the regression (see Table 4). In the final model, only anxiety (odds ratio (OR): 1.083; 95% confidence interval (CI): 1.020–1.164) was found to be positively associated with OD, whereas sexual desire (OR: 0.284; 95% CI: 0.084–0.953), masturbation (OR: 0.106; 95% CI: 0.009–0.611) and high school education (OR: 0.095; 95% CI: 0.017–0.367) are negatively associated with it, therefore contributing to OA.
As far as we are aware, this is the first study from Latin America comparing women who have orgasm during sexual activity with those who do not. The proportion of women with orgasm problems (23%) is consistent with the literature from both Brazil (21%)5 and other Western countries. In the United States of America, Canada, Australia and Sweden, for example, the prevalence of orgasmic dysfunction ranges from 16 to 25%.27 Although these rates are higher in Eastern countries,14, 18 our numbers can be considered alarming, especially in this work, where only women with no chronic diseases and under no medications were included.
In many surveys considering female sexual functioning, contradictory findings appear across demographic variables, such as education and age. For instance, although many studies have shown a positive association between education level and female sexual dysfunction,4, 18, 28 others report that there is no relation,29 even specifically between orgasm and education.11, 13 In contrast, our results, as well as those in Ojomu et al.,14 have shown that higher levels of education have an important role in OA. Although further investigation is required owing to the lack of consensus in the literature, the magnitude and significance of our results suggest that an association exists, at least in our population. This relation may be explained by the fact that women with higher education may be more knowledgeable about their bodies and their inner workings. More education may also lead to more access to information about sex and general health.
The Diagnostic and Statistical Manual of Mental Disorders IV6 notes that orgasmic capacity in females increases with age and orgasmic difficulties may be more prevalent in younger women. Some studies have confirmed this statement,30 whereas others reveal the opposite: orgasm problems are more common in older women.31, 32 Our research found no association between age and orgasm problems, such as the findings of Fugl-Meyer et al.,2 Laumann et al.,33 and Oberg et al.29 It is possible that older women and younger women have different advantages with respect to achieving orgasm. Although older women may have more sexual experience and greater knowledge of their own body, younger women have more sexual desire,34, 35 which, according to our study, is an important factor for achieving orgasm. Thus, it is difficult to claim that any age group is more affected than the other with regard to OA.
As we did not specifically investigate the distress criteria from the Diagnostic and Statistical Manual of Mental Disorders IV, the orgasmic dysfunction group cannot be diagnosed with female orgasmic disorder,6 but only with orgasmic dysfunction.7 Our focus was not the distress caused by lack of orgasm, but whether there was sexual satisfaction in women with and without orgasmic difficulties. From this perspective, our findings are in agreement with the end of sexual response by the circular model of Basson,36 which states women can be sexual satisfied although not reaching orgasm. However, our study reveals that sexual satisfaction is more common in women who do have orgasm (83.7 vs 50%; P<0.001).
An American study from 197837 found that although 63% of married women reported arousal or orgasm problems, 85% of this ‘problem group’ said that they were satisfied with their sexual relationship. More recent studies30, 38 have shown a positive association between women who did not experience orgasm and distress about sexual relationship. Although these studies did not use the same method, these findings may reflect a cultural change through time of the meaning attributed to female orgasm. It is possible that today, owing to greater dissemination of sexual topics and validation of sexual health as an important aspect of quality of life, women give more importance to orgasm and consider it more relevant to sexual satisfaction.
Regarding masturbation, it is possible that for some women orgasm is a motivation for masturbating. Thus, women who have difficulty in reaching orgasm may have no interest in masturbation. On the other hand, women who masturbate can acquire more awareness of their bodies, knowing the intensities, frequencies and places the partner must stimulate in order for them to reach orgasm. From this viewpoint, masturbation and orgasm would have a bidirectional relation in which one influences the other.
Although we found no association between depression and orgasm difficulties, there was a significant association (P<0.001; V=0.43) between sexual dysfunction in general (FSQ60) and depression, as other studies have shown.10, 17, 39 This suggests that depression is an impediment to the female sexual response in general and probably the impediment is greater in the previous phases to orgasm (desire and arousal). Once a satisfactory level of arousal is obtained, women may have no problems reaching orgasm, even if they are depressed.
Anxiety, however, is an obstacle to achieving orgasm, as other studies have already shown.11, 39 Here, it is clear that increased levels of anxiety also increase the odds of OD. Anxiety can cause women to turn their focus to sexual performance concerns (for example, their ability to reach orgasm), which acts as a distraction that disrupts the processing of erotic cues.1 Thus, the difficulty to reach orgasm in anxious women can lead to a problematic cycle: the less a woman focuses on sex due to anxiety, the less frequently she will achieve an orgasm due to distraction, thus becoming even more anxious and even less likely to climax. Our exploratory analysis, nevertheless, reveals that, although anxiety increases OD, the absence of anxiety may not necessarily improve OA. Further studies are required to determine the nature of this asymmetric relation.
Limitations of the current research include the relatively small sample size and lack of psychosocial variables, such as quality of the relationship and the specific forms of partner’s stimulation that leads to orgasm (for example, in the vagina or clitoris; by hand, mouth or penis). Nonetheless, the sample and variables studied in this work enabled findings of considerable relevance, especially for those working with female sexuality issues. First, they suggest that masturbation can be beneficial to the improvement of OA. Second, they set anxiety as an important factor in cases of orgasm difficulties. When anxiety is present, strategies must therefore be proposed to address it, as this alone could improve orgasm capacity.
In summary, OD is a complex phenomenon of multiple etiologies. Identifying the factors involved in orgasm problems is an intricate task, but necessary in order to manage patients to whom orgasmic difficulties are a concern. Women differ in how important orgasm is to their sexual satisfaction, although for most, it represents a relevant component of sexual response. Future works include the impact of medical conditions and specific psychological aspects of orgasm, such as personality traits, beliefs and other sexual behaviors.
We would like to thank Professor Edmund Chada Baracat for making the Gynecological Clinic available for our study. This work was partially supported by the Coordination for the Improvement of Higher Education Personnel (CAPES, Brazil).
About this article
International Journal of Impotence Research (2015)