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CHAPTER 4

Female Pleasure and Sex Ed

IT IS VERY DIFFICULT IN OUR SOCIETY to have non-sophomoric discussions about sex. Because of this, it is women who typically suffer. Female anatomy is erroneously labeled as “dirty,” and from an early age, girls are given messages about what a patriarchal society has determined a “nice” girl should and should not do.

Not knowing your anatomy, how it works and how to make it work, is disempowering and puts women at a disadvantage in a sexual relationship. Many heterosexual women learn about sex from male partners, who are often uneducated or undereducated themselves about the mechanics of female orgasms. Every OB/GYN I know has had at least one male partner ask them to point out their partner’s clitoris (meaning the clitoral glans) during an exam. On one hand, it’s great he is interested. On the other hand, “Come on, dude, you’ve been together for ten years.” Women who partner with women are less likely to have that disadvantage.

Where can women turn for accurate information about sex or to find out if what they are experiencing is normal, a technique issue, or a medical concern? In one study, only 63 percent of OB/GYNs routinely asked about sexual activity, 40 percent asked about sex problems, and 29 percent asked if a woman’s sex life was satisfying. This is a problem.

Some doctors, even OB/GYNs, find discussing sex difficult because they haven’t received much, if any, training in this type of conversation. For others, there is a time crunch in the office. Sometimes there are truly no medical therapies (think pills or injections) to recommend—some sexual problems are technique- or relationship-related. I’m not defending the lack of questioning from OB/GYNs, just explaining some of the complexities. However, doctors should be asking because then we can refer patients elsewhere when appropriate—for example, to a sex therapist, a marriage and family therapist, or a psychologist. Doctors don’t have to treat every condition; referring someone on for help with their sex life should be as natural as referring someone on for a bowel problem or headaches.

The other problem with doctors not asking about sex is women who have medical conditions that interfere with their sex life, typically conditions that cause pain with sex, end up minimized. Many women suffer for years not realizing they have a medical problem that has a diagnosis and treatment.

How Much Sex Are People Really Having?

Surveys tell us that overall satisfaction with sex life is not that high: 49 percent of heterosexual women, 47 percent of lesbian women, and 49 percent of bisexual women state they are happy with their sex life. It’s not much higher for men—although the respondents who were the happiest in this study were, no surprise, heterosexual men (but even then, only 51 percent were satisfied).

There is a lot of pressure to say sex is the most important thing. Despite many people saying publicly and privately on surveys that sex matters to them more than almost anything else in life, the reality is that the average amount of time people spend having sex is about four minutes a day. That is probably less time than most people spend grocery shopping or staring into the fridge—and I know which activity I prefer!

The key piece of information here is that dissatisfaction with your sex life seems to be a very common experience.

Why the disconnect?

Why are people having less sex than they desire? It’s possible people think they should be wanting more sex due to societal expectations, so they answer surveys with an idealized answer (hey, there are times when I have lied about my weight on an anonymous questionnaire). Admitting a truth to yourself can be very hard. We also all tend to want more of the things we enjoy. Not everyone is in a sexual relationship, and many people are in relationships that just aren’t working but they haven’t yet figured out a path forward. Most people are not good sexual communicators, and sometimes the sex is just unsatisfying. People also don’t prioritize sex, some women have medical conditions that make sex painful, and of course libido waxes and wanes.

Basically, it’s complicated.

Sexless relationships are also more common than people think. A sexless relationship, meaning no sex in the past 6–12 months, affects up to 15 percent of couples. There is less data on non-marital relationships. Society almost always lays the blame on the female partner in a heterosexual relationship, but it can often be the man.

The Sexual Response Cycle

Physically, from a pure stimulation standpoint, the clitoris is the most important anatomical structure for female sex. This doesn’t mean that some women don’t orgasm with nipple stimulation or anal stimulation; this just means the clitoris has specifically evolved for sexual pleasure, and almost always when other erogenous zones are stimulated there is also a clitoral response. Interestingly, the area in the brain that responds to nipple stimulation overlaps with the area that responds to clitoral stimulation.

The classic model of sexual response is a linear progression first presented by Masters and Johnson in 1960. It has four phases: excitement, plateau, orgasm, and resolution. This model has been criticized for not including desire (if you dislike your partner or they turn you off, getting excited may be a challenge). Another model was proposed that added desire to the sequence, but both of these models are male-centric and assume a specific, preset sex drive. This completely neglects many reasons women report wanting sexual intimacy: for example, emotionally connecting with their partner, trust, affection, safety, and respect.

A circular model has been proposed (by Dr. Rosemary Basson in 2000) that endorses the concept that a satisfying sexual encounter does not require starting with a spontaneous sexual drive or desire. This model also incorporates other factors besides physical stimulation that women report contribute to sexual arousal and satisfaction, such as feeling secure, being desired, or a sense of well-being. The circular model accepts that women may not always have a high spontaneous libido and that some women engage in sexual activity initially to feel intimacy or connectedness, and desire kicks in after arousal.

The Basson model supports the idea that sex drive can be spontaneous, but that it can also be the result of a complex interaction of many physical and emotional stimuli and that desire can be spontaneous as well as responsive. It also acknowledges that for many women, intimacy is an important sexual concept.

I often tell women to focus less on the idea of spontaneous libido and more on the idea of satisfaction (emotional and physical)—and, of course, fun and sexual pleasure. Lots of people get hung up on spontaneous libido, which to be honest seems like a response to a specific male fantasy. I prefer to think of sex as a party. It doesn’t matter if you received an engraved invitation or were invited by text. It doesn’t matter if you took a limo, drove your car, took the subway, or walked. What matters is you were at the party and you had what you consider to be a good time.

Physical changes with arousal and sex

Increased blood flow to the vagina and vulva causes clitoral engorgement, vulvar swelling, and vaginal transudate (wetness or lubrication). The lower third of the vagina may tighten, and the upper two thirds may dilate. The top of the vagina and the uterus elevate or lift slightly.

Orgasm is the rhythmic contractions of the muscles that wrap around the vagina (the pelvic floor muscles). These contractions are a reflex, meaning your nerves and muscles are coordinating the action without conscious input from your brain. This is similar in many ways to having your knee hit with a reflex hammer—your knee moves because a reflex has been triggered, not because your brain is consciously telling your knee to move. Contracting your pelvic floor muscles voluntarily (Kegel exercises) doesn’t trigger orgasm, but many women find that purposely contracting these muscles can increase arousal. I sometimes think of this as priming the pump, along the lines of warming up your legs before a run or your car on a cold day. Give it a try!

Female orgasm—the contractions of the pelvic floor muscles—typically lasts 5–60 seconds. The muscle contractions occur at approximately 0.8-second intervals (so one right after the other), and for many women each successive contraction is longer, but weaker. The general range of contractions, number-wise, is 3–15. Orgasm is accompanied by a feeling of well-being and/or release of tension. What is fascinating is that both women and men describe the feeling of an orgasm with almost identical terminology.

For some women, the clitoral glans can be too sensitive to touch directly during foreplay or sex as it has the highest density of nerves. Women who find they can’t tolerate a vibrator or direct manual stimulation against their glans may find that a tongue works fine or that they can handle the stimulation if they put a piece of soft fabric between the vibrator or fingers and their clitoris. Fortunately, as the clitoris branches around the urethra, extends into the vagina, and is beneath the labia, it can be accessed for stimulation in many creative ways that don’t involve direct contact with the glans. For example, a vibrator with a larger surface area pressed up against the vaginal opening may stimulate the crura of the clitoris. It’s fun to look at the size and location of the clitoris and think of different approaches to stimulation.

Some Sex Facts

Lesbian women are more likely to report that they usually or always orgasm during sex (86 percent) compared to heterosexual women (65 percent). This is proof that a penis is in no way required for satisfying sex, nor is it the judge of female sexual satisfaction.

The ideal duration of penile penetration during heterosexual sex according to a survey of U.S. and Canadian sex therapists was 3–7 minutes (1–2 minutes was considered too short, and › 10 minutes was considered too long).

In one study, heterosexual couples reported an average of 11–13 minutes of foreplay and 7–8 minutes of intercourse, and men thought both the foreplay and the penetration lasted longer than the women did. Both men and women reported wanting more foreplay and more intercourse.

What’s the deal with vaginal orgasms and the G-spot?

It is hard to overestimate the damage done by Sigmund Freud in popularizing the myth of the vaginal orgasm. Only one third of women are capable of achieving orgasm with penile penetration alone (meaning hands off, penile thrusting only), so the idea that everyone should be having orgasms this way results in two thirds of women believing there is something wrong with their sexual wiring when really they are perfect.

Not orgasming with unassisted penile penetration is not a flaw, it’s a feature.

Further supporting this vaginal orgasm myth is the idea of the G-spot, supposedly identified by Dr. Ernst Gräfenberg in 1950. In modern lore, this is a magical spot on the vaginal wall (beneath the bladder) that when touched will drive a woman “wild.” Again, many women feel frustrated when they don’t have a G-spot.

Digging through the data, we find that Dr. Gräfenberg’s original paper did not describe a special spot. His paper is actually called “The Role of the Urethra in Female Orgasm,” and he described an “erotic zone” in the front of the vagina that was intimate with the urethra and lower portion of the bladder. Yes, he was likely describing the body, root, and bulbs of the clitoris as they envelop the urethra. As expected, multiple studies have found no macroscopic structure other than the urethra, the clitoris, and vaginal wall in the location of the so-called G-spot. The lower part of the vagina, close to the urethra, will feel great for many women because stimulation here is accessing the clitoris, but it takes the right stimulation—it is not an “on/off switch.”

It is not surprising to me when I hear of women who fake orgasms with male partners. After all, they have been led to believe that a female orgasm should be reached with a penis by way of an imaginary spot.

MRI studies looking at anatomy during heterosexual sex reveal that the clitoris can be compressed by the penis, which is why some women can orgasm with penile penetration. Ultrasound studies looking at clitoral swelling during external masturbation and during vaginal penetration indicate that both cause clitoral engorgement. This means that touching externally on your vulva or vestibule or internally with a penis, fingers, tongue, or toys are all producing the same end result—clitoral stimulation. Even nipple stimulation, which many women find erotic, triggers an area in the brain that overlaps with—yes, you guessed it—the area that interprets sensations from the clitoris. The clitoris is the pleasure aggregator and amplifier.

Basically, all pleasure roads lead to the clitoris.

It is best to do away with terms like vaginal orgasm and G-spot, as they are incorrect. The goal is female orgasm, and it can be achieved in so many ways.

Do women ejaculate or “squirt”?

The answer is yes, but not in the way the internet thinks.

If you spend any time looking at online videos of so-called female ejaculation you would come to the false conclusion that some women have a secret vaginal gland that can release a gush of fluid with the right touch. Many of these videos are labeled as “squirting.”

For a woman to ejaculate, the fluid must come from the vagina, the urethra, or a specialized gland. For reference, the male prostate releases about 5 ml of fluid with ejaculation, and there is no gland the size of a prostate in the vulva or vagina. So the idea that women can ejaculate a gush of fluid larger than 5 ml is, even without doing the research, rather doubtful.

But I’m me, so I researched it.

There is a pair of glands on either side of the urethra (the tube that drains the bladder) called Skene’s glands. These are about the size of a pea or smaller, and they are sometimes referred to as the female prostate because their secretions contain traces of prostate-specific antigen (PSA), a protein found in the male prostate. Skene’s glands can secrete a small amount of fluid, perhaps 1–2 ml at most, during sexual activity. It would be medically correct to call this ejaculate, but it will not squirt any distance or have a large volume.

In one study, 38 women masturbated to orgasm (confirmed by monitors that measured pelvic floor muscle contractions), and no ejaculate was seen coming from the vagina or the urethra. However, if the incidence of squirting or ejaculation was 1 in 50, say 2 percent of women, this study might not be large enough to identify them.

Another study looked specifically at a small group of women who reported squirting, meaning they said that they release a large amount of fluid during orgasm. They were screened to make sure they did not have incontinence. The women emptied their bladders and stimulated to orgasm. The amount of urine in their bladder at baseline, while aroused, and after orgasm was measured by ultrasound. Their urine was collected and analyzed before stimulation and after orgasm, and the “squirted” fluid was analyzed as well.

The results? The women’s bladders filled remarkably fast during sexual stimulation. There was urine before orgasm and their bladders were empty after squirting. The squirted fluid was identified in the lab as urine.

Why does this happen? It is possible when women report squirting that they are simply having an orgasm strong enough for the pelvic floor muscles to empty their bladder, which is why it is associated with heightened pleasure. It is also possible that a more intense sexual response could result in a faster filling of the bladder.

It is also possible that some women have a lot of transudate—meaning they get very wet—during sex. When they orgasm, that fluid could come out all at once.

I looked at enough squirting videos to categorize most as either women who had inserted water (or another fluid) vaginally and were now releasing it for the video—meaning they were acting—or fluid clearly coming from the urethra and, hence, urine. There were some that showed secretions from Skene’s glands, and as expected there were just a few drops of white liquid.

The reason we need to be medically accurate about the source of female ejaculation and squirting is that some women feel they are inadequate if they can’t squirt, and there are already enough sex myths that reduce a woman’s pleasure to a male metric. If you have urine leakage during sex and it is bothersome to you, then see a bladder specialist (a urogynecologist is a good place to start). If you are having fun and are not bothered, then it doesn’t really matter what is coming from where.

A good sexual encounter is not about optics that make a man (it’s usually a man in this scenario) feel as if he has achieved something. A good sexual encounter is about pleasure. As long as you are having an orgasm or two, who cares about anything else?

If arousal is partly due to increased blood flow, can special vibrators or medications that increase blood flow help?

Sexual arousal causes increased blood flow to the clitoris. There are several devices on the market that specifically provide suction to the clitoris to draw in blood—think a small suction cup placed over the glans—based on the idea that more blood flow may help physical arousal. There are inexpensive hand pumps, vibrators that fit over the clitoral glans, as well as more expensive devices, like the Fiera Arouser and the Eros Clitoral Therapy Device. Studies on the Eros device are very small, of low quality, and made up of self-selected patients. Having more options for clitoral stimulation and sexploration can be fun and a device that delivers a more suction-like sensation to the clitoral glans—the part of the clitoris with the most nerve endings—may also be an option to try for women who have difficulty achieving orgasm or who have never had an orgasm. However, we don’t know if expensive devices like the Fiera and Eros are better for sexual arousal than receiving oral sex, masturbating, or a more traditional vibrator. Everyone is different, and whether these devices appeal could be very personal.

Studies have looked at medications that increase blood flow to see if they improve female sexual response—after all, the class of drugs that includes sildenafil (VIAGRA) works for men by increasing blood flow to the penis. One study indicated that these medications do increase clitoral blood flow for women who report difficulties feeling aroused, but that did not translate into a feeling of sexual arousal. One possibility is the feeling of arousal is not just dependent on blood-flow-induced changes, but the brain needs to perceive that sensation as sexually pleasurable.

What about anal sex?

Anal sex has been increasing since the 1990s, according to surveys in the United States, United Kingdom, Sweden, and Croatia. It is unknown if this is a true increase, meaning more women are truly practicing anal sex, or if more women feel comfortable reporting it due to changes in sexual mores. Currently, 30–46 percent of women report at least one lifetime experience with receptive anal sex, and 10–12 percent report it is a regular part of their sexual repertoire. Reasons women give for engaging in anal sex include pleasing their partner (the most common reason), their own pleasure, vaginal sex is painful, and to maintain their virginity. Some people report seeing anal sex in pornography as a reason to try it, just as some have drawn inspiration from the food scene in the movie 9½ Weeks. Remember, sex in mainstream movies, pornography included, is often as realistic as the driving in car-chase scenes in action movies. According to one study, anal sex featured in 55 percent of scenes in the most commonly viewed pornography, which could lead to false beliefs about its frequency in heterosexual relationships.

Some women report coercion regarding anal sex, as well as so-called “accidental” but actually planned anal penetration by their male partner. It is important when we discuss anal sex as a society that we do not trivialize or normalize this behavior.

Anal sex is often promoted as “better” for men because the anus is a “tighter” orifice. This plays on tired tropes that a vagina is “too loose” for male enjoyment, especially after a woman has been sexually active vaginally or after pregnancy.

Women should try anal sex if the idea appeals to them and they want to explore their sexuality, not because their male partner thinks everyone is doing it or is obsessed with the imagined size of his penis.

WHAT DOES ANAL SEX FEEL LIKE? Studies indicate that approximately 50 percent of women who have anal intercourse find it arousing, although pain is often an issue. At least 50 percent of women report their first episode of anal sex was painful enough that they needed to stop, so it is important to ensure your partner is willing to go slow and abandon the effort if required. Only 27 percent of women who are sexually active anally report little or no pain, so whether the pleasure payoff is worth it for you will be an individual choice.

A good lubricant is essential for anal sex. This will reduce pain, as well as microtrauma to the tissues. Anal sex is the most efficient way to sexually transmit HIV (human immunodeficiency virus), due to the combination of microtrauma and the specific cells in the anus being more susceptible to infection with the virus.

If you are not in a mutually monogamous relationship or there is a concern about HIV transmission, then it is essential to use condoms, whether a male condom for your partner or a female condom in your anus (see chapter 25 for more on condoms). If you plan to also have vaginal sex, you need one condom for anal and another for vaginal penetration. Even if you are in a mutually monogamous relationship, having a condom for anal sex can help you transition between anal and vaginal penetration without needing your partner to clean his penis.

Another reason for using a condom with anal sex is to reduce the risk of transmission of the human papilloma virus (HPV), as this virus also causes anal cancer, and the data is conflicting regarding whether receptive anal intercourse is a risk factor or not. Currently, we have no screening programs for anal precancer and cancer for women, so protection is even more important.

For women interested in anal play, either during masturbation, with a female partner, or with men, there are a multitude of anal toys, such as anal beads and plugs, for experimentation. About 4 percent of women report they used anal plugs and toys regularly in their sexual practice. This is also a good way for women who may wish to try anal intercourse with a male partner to see how they like anal stimulation when they are in control of the situation. An anal vibrator or dildo should have a flared base so it cannot move up inside the rectum. Every general surgeon I know has taken someone to the operating room to remove toys that have become lodged—this can result in very serious bowel injury, so choosing a medically safe anal vibrator is essential.

Some women wonder about anal injury with anal penetration. There is no data to suggest that receptive anal intercourse or anal play can damage the muscles of the anus, but one study (women with an average age of 46) did report that women who had receptive anal intercourse in the past month reported a higher incidence of fecal incontinence—28 percent for women who had anal intercourse versus 14 percent who did not. Whether this was an isolated incident immediately related to the sex or something that happened later on in the month was not described. There was no association of fecal incontinence with anal toys.

BOTTOM LINE

• About 50 percent of women are satisfied with their sex lives.

• A penis is not the most reliable way to achieve female orgasm.

• There is no specific G-spot; the sensitive area that many women describe just inside the vagina is part of the clitoral complex.

• Female ejaculation is tiny drops of fluid, not “squirting” as depicted in most online videos and porn.

• For women interested in anal play or anal sex, starting with a vibrator designed for anal stimulation is a safe, noncoercive way to begin.