International Journal of Impotence Research (2014) 26, 177–181 & 2014 Macmillan Publishers Limited All rights reserved 0955-9930/14 www.nature.com/ijir
ORIGINAL ARTICLE
Personal factors that contribute to or impair women’s ability to achieve orgasm BB de Lucena1 and CHN Abdo2 This work aims to identify factors that contribute and those that impair the ability to experience orgasm during sexual activity. It compared women (n ¼ 96) aged 18–61 (M ¼ 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 ¼ 0.022), sex education during childhood and/or adolescence (Po0.001), masturbation (P ¼ 0.017), sexual satisfaction (Po0.001), anxiety (Po0.001) and sexual desire (Po0.001). 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. International Journal of Impotence Research (2014) 26, 177–181; doi:10.1038/ijir.2014.8; published online 20 March 2014
INTRODUCTION 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 onethird.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 Measures Beck scales. 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
1 Program of Studies in Sexuality (ProSex), Department and Institute of Psychiatry, University of Sa˜o Paulo, Sa˜o Paulo, Brazil and 2Program of Studies in Sexuality (ProSex), Department and Institute of Psychiatry, University of Sa˜o Paulo, Sa˜o Paulo, Brazil. Correspondence: Dr BB de Lucena, Program of Studies in Sexuality (ProSex), Department and Institute of Psychiatry, University of Sa˜o Paulo, Ovı´dio Pires de Campos Street, Sa˜o Paulo, SP 05403-010, Brazil. E-mail: [email protected] Received 21 March 2013; revised 7 November 2013; accepted 20 February 2014; published online 20 March 2014
Women’s ability to achieve orgasm BB de Lucena and CHN Abdo
178 Sexual questionnaire. 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?
Sexual dysfunction. 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.21–24 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 p60 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 p2 in the questions related to each dimension indicate low sexual desire, arousal problems, orgasmic difficulties and sexual dissatisfaction, respectively.
Participants 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 Sa˜o 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 ¼ 14). Thus, the orgasmic difficulty (OD) group was made up with patients who did not have orgasm after a normal arousal phase (n ¼ 22), whereas the orgasmic ability (OA) group was composed of patients with normal phases of arousal and orgasm (n ¼ 74).
Procedures 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 Sa˜o Paulo and all women provided written informed consent.
Data analysis 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.
RESULTS OD and OA groups were found to be homogenous as to age (OD: m ¼ 35.5, s.d. ¼ 8.8; OA: m ¼ 38.1, s.d. ¼ 9.5; t ¼ 1.38, P ¼ 0.175). No significant associations were revealed between the groups and psychosocial descriptors such as per capita income (P ¼ 0.099) and duration of the current relationship (P ¼ 0.276). Details of these categories are found in Table 1. Other variables, such as ‘talk about sex with physician’ (P ¼ 0.065), ‘talk about sex with partner’ (P ¼ 0.086) and ‘sexual frequency’ (P ¼ 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 (Po0.001; V ¼ 0.43), no such relation was found between depression and OD (P ¼ 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 ¼ 0.02, V ¼ 0.347). Also, significantly less of them received sexual education during childhood and/or adolescence: 13.6% against 47.2% in the OA group (Po0.001, V ¼ 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 ¼ 0.017,
Table 1. Sample characteristics: age, income and duration of current relationship OD (%) n ¼ 22
OA (%) n ¼ 74
P-value
Age 18–30 31–40 41–50 51–60
36.4 36.4 22.7 4.5
21.6 35.2 32.4 10.8
0.175
Per capita income (US$)a o250.00 250.01–375.00 4375.00
54.5 31.8 13.7
32.5 29.7 37.8
0.099
31 20.3 17.6 17.6 13.5
0.276
Categories
Duration of current relationship (years) 1–5 27.3 6–10 9 11–15 22.7 16–20 9 420 32
Figure 1. Dimensions and questionnaire items from Female Sexual Quotient (FSQ). International Journal of Impotence Research (2014), 177 – 181
Abbreviations: OA, orgasmic ability; OD, orgasmic difficulty. converted from Brazilian Reais to US Dollars.
a
Values
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Women’s ability to achieve orgasm BB de Lucena and CHN Abdo
179 V ¼ 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%) (Po0.001, V ¼ 0.333). Women with OD present higher levels of anxiety (68.2%) than women with OA (33.8%) (P ¼ 0.001, V ¼ 0.327). Although the majority of women in both groups have sexual desire, there is still a significant difference in the proportions found (Po0.001, V ¼ 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 (o0.1). 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 Table 2. Percentage (%) of difference of significant variables (Po0.05) between groups
High school Yes No
OD (%) n ¼ 22
OA (%) n ¼ 74
18.1 81.9
59.4 40.6
P-value
DISCUSSION 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,
0.022
Sex education in childhood and/or adolescence Yes 13.6 47.2 No 86.4 52.8
o0.001
Masturbation Yes No
9.0 91.0
35.1 64.9
0.017
Sexual satisfaction Yes No
50.0 50.0
83.7 16.3
o0.001
Anxietya Yes No
68.2 31.8
33.8 66.2
o0.001
Sexual desire Yes No
63.7 36.3
90.6 9.4
o0.001
Abbreviations: OA, orgasmic ability; OD, orgasmic difficulty. aWe considered anxious those women who scored in the ‘moderate’ and ‘severe’ categories of Beck Anxiety Inventory (BAI).
Table 3.
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.
Figure 2. Categorical principal component analysis loadings and centroids plot.
Two-dimensional categorical principal component analysis results
Dimension Eigenvalue Variance accounted for
1 2.450 30.7%
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2 1.587 19.8%
3 0.904 11.3%
4 0.851 10.6%
5 0.727 9.1%
6 0.567 7.1%
7 0.504 6.3%
8 0.410 5.1%
International Journal of Impotence Research (2014), 177 – 181
Women’s ability to achieve orgasm BB de Lucena and CHN Abdo
180 Table 4.
Final logistic regression model
Masturbation High school Sexual desire Anxiety
Coefficients
Odds ratio
2.237 2.351 1.260 0.079
0.106 0.095 0.284 1.083
Confidence interval (95%) 0.009 0.017 0.084 1.020
0.611 0.367 0.953 1.164
P-value 0.028 0.001 0.034 0.016
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%; Po0.001). 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 International Journal of Impotence Research (2014), 177 – 181
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 (Po0.001; V ¼ 0.43) between sexual dysfunction in general (FSQp60) 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. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGMENTS 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).
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181 3 Mulhall J, King R, Glina S, Hvidsten K. Importance of and satisfaction with sex among men and women worldwide: results of the Global Better Sex Survey. J Sex Med 2008; 5: 788–795. 4 Laumann E, Paik A, Rosen R. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281: 537–544. 5 Abdo CHN, Oliveira WM, Moreira ED, Fittipaldi JaS. Prevalence of sexual dysfunctions and correlated conditions in a sample of Brazilian women--results of the Brazilian study on sexual behavior (BSSB). Int J Impot Res 2004; 16: 160–166. 6 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. DSM-IV. 4th edn. American Psychiatric Association: Washington DC, 2002. 7 World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems. 10th edn. World Health Organization: Geneva, 1992. 8 Mah K, Binik Y. The nature of human orgasm: a critical review of major trends. Clin Psychol Rev 2001; 21: 823–856. 9 Mah K, Binik Y. Orgasms in the mind or the body? psychosocial versus physiological correlates of orgasmic pleasure and satisfaction. J Sex Marital Ther 2005; 31: 2000. 10 Frohlich P, Meston C. Sexual functioning and self-reported depressive symptoms among college women. J Sex Res 2002; 39: 321–325. 11 Birnbaum GE. The meaning of heterosexual intercourse among women with female orgasmic disorder. Arch Sex Behav 2003; 32: 61–71. 12 Brody S, Costa R. Vaginal orgasm is associated with less use of immature psychological defense mechanisms. J Sex Med 2008 1167–1176. 13 Burri AV, Cherkas LM, Spector TD. Emotional intelligence and its association with orgasmic frequency in women. J Sex Med 2009; 6: 1930–1937. 14 Ojomu F, Thacher T, Obadofin M. Sexual problems among married Nigerian women. Int J Impot Res 2007; 19: 310–316. 15 Birnbaum G, Glaubman H, Mikulincer M. Women’s experience of heterosexual intercourse: Scale construction, factor structure, and relations to orgasmic disorder. J Sex Res 2001; 8: 191–204. 16 Graham C. The DSM diagnostic criteria for female orgasmic disorder. Arch Sex Behav 2010; 39: 256–270. 17 Dobkin RD, Leiblum SR, Rosen RC, Menza M, Marin H. Depression and sexual functioning in minority women: current status and future directions. J Sex Marital Ther 2006; 32: 23–36. 18 Sidi H, Puteh SEW, Abdullah N, Midin M. The prevalence of sexual dysfunction and potential risk factors that may impair sexual function in Malaysian women. J Sex Med 2007; 4: 311–321. 19 Beck A, Steer R, Brown G. Manual for the Beck Depression Inventory-II. Psychological Corporation: San Antonio, TX, USA, 1996. 20 Beck A, Steer R. Beck Anxiety Inventory Manual. Psychological Corporation: San Antonio, TX, USA, 1993. 21 Tozo I, Lima J, Rolim S, Gonc¸alves N, Auge A, Rossi L et al. Sexuality evaluation in women submitted to hysterectomy for the treatment of uterine leiomyoma. Rev Bras Ginecol Obstet 2009; 31: 503–507.
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22 Ribeiro M, Nakamura M, Abdo C, Torloni M, Scanavino M, Mattar R. Pregnancy and gestational diabetes: a prejudicial combination to female sexual function. Rev Bras Ginecol Obstet 2011; 33: 219–224. 23 Manganiello A, Hoga L, Reberte L, Miranda C, Rocha C. Sexuality and quality of life of breast cancer patients post mastectomy. Eur J Oncol Nurs 2011; 15: 167–172. 24 Ferreira D, Nakamura M, Souza E, Mariani C, Ribeiro M, Santana T et al. Sexual function and quality of life of low-risk pregnant women. Rev Bras Ginecol Obstet 2012; 34: 409–413. 25 Abdo C. Development and validation of Female Sexual Quotient—a questionnaire to assess female sexual function. Rev Bras Med 2006; 63: 477–482(In Portuguese). 26 Linting M, Meulman J, Groenen P, van der Koojj A. Nonlinear principal components analysis: Introduction and application. Psychol Methods 2007; 12: 336–358. 27 Lewis RW, Fugl-Meyer KS, Corona G, Hayes RD, Laumann EO, Moreira ED et al. Definitions/epidemiology/risk factors for sexual dysfunction. J Sex Med 2010; 7: 1598–1607. 28 Shaeer O, Shaeer K, Shaeer E. The Global Online Sexuality Survey (GOSS): female sexual dysfunction among Internet users in the reproductive age group in the Middle East. J Sex Med 2012; 9: 411–424. 29 Oberg K, Fugl-Meyer AR, Fugl-Meyer KS. On categorization and quantification of women’s sexual dysfunctions: an epidemiological approach. Int J Impot Res 2004; 16: 261–269. 30 Hawton K, Gath D, Day A. Sexual function in a community sample of middle-aged women with partners: effects of age, marital, socio-economic, psychiatric, gynecological, and menopausal factors. Arch Sex Behav 1994; 23: 375–395. 31 Najafabady MT, Salmani Z, Abedi P. Prevalence and related factors for anorgasmia among reproductive aged women in Hesarak, Iran. Clinics 2011; 66: 83–86. 32 Richters J, Grulich A, Visser R, Smith A, Rissel C. Sex in Australia: sexual difficulties in a representative sample of adults. Aust N Z J Public Health 2003; 27: 164–170. 33 Laumann E, Nicolosi A, Glasser D. Sexual problems among women and men aged 40–80 years: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res 2004; 17: 39–57. 34 Abdo CH, Valadares ALR, Oliveira WM, Scanavino MT, Afif-Abdo J. Hypoactive sexual desire disorder in a population-based study of Brazilian women: associated factors classified according to their importance. Menopause 2010; 17: 1114–1121. 35 Woods NF, Mitchell ES, Julio KS. Sexual desire during the menopausal transition and Early Postmenopause: Observations from the Seattle Midlife Women’s Health Study. J Womens Health 2010; 19: 209–218. 36 Basson R. Women’s sexual function and dysfunction: current uncertainties, future directions. Int J Impot Res 2008; 20: 466–478. 37 Frank E, Anderson C, Rubinstein D. Frequency of sexual dysfunction in ‘normal’ couples. N Engl J Med 1978; 299: 111–115. 38 Bancroft J, Loftus J, Long JS. Distress about sex: a National Survey of Women in Heterosexual Relationships. Arch Sex Behav 2003; 32: 193–208. 39 Laurent SM, Simons AD. Sexual dysfunction in depression and anxiety: conceptualizing sexual dysfunction as part of an internalizing dimension. Clin Psychol Rev 2009; 29: 573–585.
International Journal of Impotence Research (2014), 177 – 181
ORIGINAL ARTICLE
Personal factors that contribute to or impair women’s ability to achieve orgasm BB de Lucena1 and CHN Abdo2 This work aims to identify factors that contribute and those that impair the ability to experience orgasm during sexual activity. It compared women (n ¼ 96) aged 18–61 (M ¼ 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 ¼ 0.022), sex education during childhood and/or adolescence (Po0.001), masturbation (P ¼ 0.017), sexual satisfaction (Po0.001), anxiety (Po0.001) and sexual desire (Po0.001). 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. International Journal of Impotence Research (2014) 26, 177–181; doi:10.1038/ijir.2014.8; published online 20 March 2014
INTRODUCTION 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 onethird.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 Measures Beck scales. 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
1 Program of Studies in Sexuality (ProSex), Department and Institute of Psychiatry, University of Sa˜o Paulo, Sa˜o Paulo, Brazil and 2Program of Studies in Sexuality (ProSex), Department and Institute of Psychiatry, University of Sa˜o Paulo, Sa˜o Paulo, Brazil. Correspondence: Dr BB de Lucena, Program of Studies in Sexuality (ProSex), Department and Institute of Psychiatry, University of Sa˜o Paulo, Ovı´dio Pires de Campos Street, Sa˜o Paulo, SP 05403-010, Brazil. E-mail: [email protected] Received 21 March 2013; revised 7 November 2013; accepted 20 February 2014; published online 20 March 2014
Women’s ability to achieve orgasm BB de Lucena and CHN Abdo
178 Sexual questionnaire. 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?
Sexual dysfunction. 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.21–24 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 p60 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 p2 in the questions related to each dimension indicate low sexual desire, arousal problems, orgasmic difficulties and sexual dissatisfaction, respectively.
Participants 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 Sa˜o 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 ¼ 14). Thus, the orgasmic difficulty (OD) group was made up with patients who did not have orgasm after a normal arousal phase (n ¼ 22), whereas the orgasmic ability (OA) group was composed of patients with normal phases of arousal and orgasm (n ¼ 74).
Procedures 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 Sa˜o Paulo and all women provided written informed consent.
Data analysis 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.
RESULTS OD and OA groups were found to be homogenous as to age (OD: m ¼ 35.5, s.d. ¼ 8.8; OA: m ¼ 38.1, s.d. ¼ 9.5; t ¼ 1.38, P ¼ 0.175). No significant associations were revealed between the groups and psychosocial descriptors such as per capita income (P ¼ 0.099) and duration of the current relationship (P ¼ 0.276). Details of these categories are found in Table 1. Other variables, such as ‘talk about sex with physician’ (P ¼ 0.065), ‘talk about sex with partner’ (P ¼ 0.086) and ‘sexual frequency’ (P ¼ 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 (Po0.001; V ¼ 0.43), no such relation was found between depression and OD (P ¼ 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 ¼ 0.02, V ¼ 0.347). Also, significantly less of them received sexual education during childhood and/or adolescence: 13.6% against 47.2% in the OA group (Po0.001, V ¼ 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 ¼ 0.017,
Table 1. Sample characteristics: age, income and duration of current relationship OD (%) n ¼ 22
OA (%) n ¼ 74
P-value
Age 18–30 31–40 41–50 51–60
36.4 36.4 22.7 4.5
21.6 35.2 32.4 10.8
0.175
Per capita income (US$)a o250.00 250.01–375.00 4375.00
54.5 31.8 13.7
32.5 29.7 37.8
0.099
31 20.3 17.6 17.6 13.5
0.276
Categories
Duration of current relationship (years) 1–5 27.3 6–10 9 11–15 22.7 16–20 9 420 32
Figure 1. Dimensions and questionnaire items from Female Sexual Quotient (FSQ). International Journal of Impotence Research (2014), 177 – 181
Abbreviations: OA, orgasmic ability; OD, orgasmic difficulty. converted from Brazilian Reais to US Dollars.
a
Values
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Women’s ability to achieve orgasm BB de Lucena and CHN Abdo
179 V ¼ 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%) (Po0.001, V ¼ 0.333). Women with OD present higher levels of anxiety (68.2%) than women with OA (33.8%) (P ¼ 0.001, V ¼ 0.327). Although the majority of women in both groups have sexual desire, there is still a significant difference in the proportions found (Po0.001, V ¼ 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 (o0.1). 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 Table 2. Percentage (%) of difference of significant variables (Po0.05) between groups
High school Yes No
OD (%) n ¼ 22
OA (%) n ¼ 74
18.1 81.9
59.4 40.6
P-value
DISCUSSION 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,
0.022
Sex education in childhood and/or adolescence Yes 13.6 47.2 No 86.4 52.8
o0.001
Masturbation Yes No
9.0 91.0
35.1 64.9
0.017
Sexual satisfaction Yes No
50.0 50.0
83.7 16.3
o0.001
Anxietya Yes No
68.2 31.8
33.8 66.2
o0.001
Sexual desire Yes No
63.7 36.3
90.6 9.4
o0.001
Abbreviations: OA, orgasmic ability; OD, orgasmic difficulty. aWe considered anxious those women who scored in the ‘moderate’ and ‘severe’ categories of Beck Anxiety Inventory (BAI).
Table 3.
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.
Figure 2. Categorical principal component analysis loadings and centroids plot.
Two-dimensional categorical principal component analysis results
Dimension Eigenvalue Variance accounted for
1 2.450 30.7%
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2 1.587 19.8%
3 0.904 11.3%
4 0.851 10.6%
5 0.727 9.1%
6 0.567 7.1%
7 0.504 6.3%
8 0.410 5.1%
International Journal of Impotence Research (2014), 177 – 181
Women’s ability to achieve orgasm BB de Lucena and CHN Abdo
180 Table 4.
Final logistic regression model
Masturbation High school Sexual desire Anxiety
Coefficients
Odds ratio
2.237 2.351 1.260 0.079
0.106 0.095 0.284 1.083
Confidence interval (95%) 0.009 0.017 0.084 1.020
0.611 0.367 0.953 1.164
P-value 0.028 0.001 0.034 0.016
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%; Po0.001). 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 International Journal of Impotence Research (2014), 177 – 181
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 (Po0.001; V ¼ 0.43) between sexual dysfunction in general (FSQp60) 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. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGMENTS 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).
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